Whose fault is it that homebirth is not safe?

who is to blame question

Imagine if smokers blamed cancer and emphysema deaths on pulmonologists. If only those lung doctors would invent a safer tobacco cigarette many fewer people would die of lung cancer, right?

Imagine if vaccine rejectionists blamed the pertussis deaths in children who are unvaccinated on pediatricians who won’t treat unvaccinated patients. If only the parents could have taken their coughing, vomiting, whooping baby to the local pediatrician instead of the hospital ER, the chances of the baby surviving might have been increased, right?

Imagine if the survivors of people who shun conventional cancer treatments claimed that oncologists were responsible for the deaths of those who chose alternative treatments. After all, if oncologists had created chemotherapy that was gentler, the person who refused chemotherapy might have accepted it, right?

We recoil from those claims for very good reasons:

Pulmonologists have no responsibility for improving the safety of cigarettes. The people who bear the ultimate responsibility for tobacco caused lung cancer are the people who choose to smoke.

It’s not the job of pediatricians to improve the safety of vaccine refusal. The people who bear the ultimate responsibility for a vaccine preventable death are those who refused vaccines.

It is not the job of oncologists to make chemotherapy as pleasant as alternative “treatments” (although they are indeed trying to do so). The people who bear ultimate responsibility for dying a chemotherapy preventable death are the people who refuse chemotherapy.

Now tell me: whose fault is it that homebirth is not safe?

Yesterday I wrote about Elizabeth Heineman, currently publicizing a book long apologia on her son’s death at homebirth. Where does Heineman place the blame? On everyone but herself. Indeed, in an especially creative attempt to avoid responsibility for choosing homebirth, Heineman actually blames “politics.”

I believe that after decades of successful practice and no bad outcomes, Deirdre made the wrong judgment call in not referring me to a doctor once I was a week postdate. I believe that judgment call resulted in Thor’s death.

I believe the likelihood of her making the wrong judgment call was heightened by the fact that she felt under siege. I believe the warfare between the medical profession and out-of-hospital midwives made her reluctant to refer a low-risk pregnancy with no sign of trouble to a doctor …

It’s those obstetricians! They are responsible for her baby Thor’s death because they refuse to collaborate with homebirth midwives.

No, they’re not responsible for Thor’s death any more than pulmonologists are responsible for tobacco related deaths, or pediatricians are responsible for vaccine-preventable deaths or oncologists are responsible for the deaths of those who refuse chemotherapy. They are not responsible because they offer a safer alternative to the unsafe choices that people make. They are under no moral obligation to mitigate the danger of unsafer choices, beyond counseling against them.

Homebirth is the same. If you choose homebirth and your baby dies as a result, you bear responsibility.

You are not the only one who bears responsibility; there is an entire industry of natural childbirth and homebirth “professionals” feeding you lies about homebirth safety and they should be held accountable, too. But there is not a homebirth advocate alive who does not recognize that her choice is a rejection of conventional medical advice and a transgressive choice. Indeed many homebirth mothers choose homebirth precisely BECAUSE it is a rejection of conventional medical advice and a transgressive choice.

To the extent that homebirth midwives attempt to obtain informed consent, they almost always declare that in the event of disaster, they are not responsible. The consent forms often require the mothers to specifically accept responsibility for any bad outcomes. And indeed, when the inevitable tragedies occur, they turn in anger toward homebirth loss mothers who dare to expect accountability of homebirth midwives. The was NEVER part of the plan. The mother always knew that she was rejecting conventional medical advice and she is supposed to shoulder the responsibility for that decision, not those selfless “birth workers” who were merely giving her what she asked for.

When it comes to responsibility, homebirth is a game of musical chairs. There are lots of people and chairs at the beginning of the game: the midwife, the doula, the cranio-sacral therapist, all the providers of homebirth services start out with chairs. The minute a woman starts labor at home, the homebirth midwives and mothers pull out all the chairs, but one, the obstetrician’s chair. You remember the obstetrician. He or she is the one the mother ignored as not evidenced based, profit hungry, and driven to perform unnecessary C-sections just to get to his golf game. THAT obstetrician, the one the mother didn’t trust, it the ONE person she expects will save her baby and her if anything goes wrong.

The ultimate problem, though, is that American homebirth is not and can never be as safe as hospital birth. It is simply impossible because it is the hospital and the expert personnel and safety equipment that makes hospital birth safe. When you reject the safest choice, doctors are not ethically obligated to make your preferred unsafe choice safer.

When a person dies of a tobacco related illness, he or she is ultimately responsible, not the doctors who didn’t make cigarettes safer.

When a baby dies of a vaccine preventable illness after a parent rejects vaccines, the parent is responsible, not the pediatrician who advised against it and refused to care for the child thereafter.

When a person dies of cancer after refusing cancer treatment, he or she is responsible, not the oncologist who advised against it and refused to administer the alternative “treatment.”

And when a baby dies at homebirth, the mother is responsible, not the obstetrician who advised against it and refused to collaborate with a midwife he did not trust.

Homebirth mothers are very happy to claim credit when they dodge a bullet by refusing conventional care. If they are willing to claim credit, they are responsible when things go wrong. Homebirth is INHERENTLY unsafe and American homebirth will NEVER be as safe as hospital birth. Obstetricians are not responsible for making unsafe choices safer. Mothers are responsible for making unsafe choices.

Heineman’s midwife deliberately chose to ignore standard obstetrical practice, not because she didn’t know any better, but because she thought she could get away with it. After all, she had gotten away with it in the past.

Politics did not kill baby Thor. His mother’s decision led to his death. Had she chosen to accept conventional obstetrical care, Thor would almost certainly be alive to day. Heineman bears the ultimate responsibility, and her efforts to avoid that responsibility, while understandable, are shameful nonetheless.

  • Mr.G

    There is one additional piece of information: Ms.Heinemann was 45-years old or so. If she did not have an egg-donor IVF pregnancy (likely), then it was an IFV pregnancy. So much for not liking interventions! These IVF pregnancies in “older” women are really, really high risk and she should have never, ever seen a midwife and more importantly should have known to never deliver at home.
    “…the frequency of intrauterine deaths are much higher than the average for all pregnancies…”
    http://www.ncbi.nlm.nih.gov/pubmed/23095186

  • yentavegan

    Rage, The normal emotion Elizabeth Heinman ought to be experiencing any day now. She has been hoodwinked, manipulated, mesmerized, and lied to by the Natural Childbirth Industry and their “amen” squad of believers. And b/c Ms. Heinman is an intellectual with an advanced degree, the NCB Industry won her over by using code words and jargon that all sounded official and hefty with gravitas. Those of us who are speculating that her baby would not have survived even if she laboured and delivered in a hospital are missing the point of being in a hospital and under the care of an OB. Ms. Heinman would have had at the very least fetal heart monitoring, a sonogram and an OB that would not be advising a mother in her 40′s to go post date.

    • The Bofa on the Sofa

      She has been hoodwinked, manipulated, mesmerized, and lied to by the Natural Childbirth Industry and their “amen” squad of believers.

      No, she WAS (and apparently still IS) one of the “amen” squad.

      And in writing this book she is trying to hoodwink more.

      See the excerpt from her book posted below – she thinks that HB is “evidence-based medicine” and “the scientific method.”

      • Anj Fabian

        She is part of the culture. Reading the book first time, I saw what she wanted to present – a woman who explored all options and made a responsible choice.

        Once I got to the end of the book, I noticed how subtle tropes and memes kept showing up in the second half of the book. Not in the first half, where they would have revealed her to be a believer in those memes. In the second half, after the narrative of a well educated, responsible, careful woman had been established.

        My conclusion was that instead of doing her due diligence and exploring ALL of her options, what she did was to decide to have the home birth. The only things that she needed to do after that decision is to plan exactly how and to consult with the hospital based CNMs. What did she want from the hospital CNMs? Reassurance that she wasn’t really high risk and to ask about the HB CNM she wanted to use. She was not seriously exploring the option of a hospital birth.

  • LMS1953

    We obstetricians are being forced into birth as performance art (versus the goal of a healthy, live baby) as well. Joint Commission doesn’t give a shitty tub of water about waterbirth standards, but by golly they let loose the hounds of hell on <39 week deliveries. Here is a good "evidence-based" study that proves that such a policy is killing babies. But who cares about that?

    Quote:"

    RESULTS: We identified 12,015 singleton live births before
    and 12,013 after policy implementation. The overall
    percentage of deliveries occurring before 39 weeks of
    gestation fell from 33.1% to 26.4% (P<.001); the greatest
    difference was for women undergoing repeat cesarean
    delivery or induction of labor. Admission to the neonatal
    intensive care unit (NICU) also decreased significantly;
    before the intervention, there were 1,116 admissions
    (9.29% of term live births), whereas after, there were
    1,027 (8.55% of term live births) and this difference was
    significant (P.044). However, an 11% increased odds of
    birth weight greater than 4,000 g (adjusted odds ratio
    1.11; 95% confidence interval [CI] 1.01–1.22) and an increase in stillbirths at 37 and 38 weeks, from 2.5 to 9.1
    per 10,000 term pregnancies (relative risk 3.67, 95% CI
    1.02–13.15, P.032), were detected.
    CONCLUSION: A policy limiting elective delivery before
    39 weeks of gestation was followed by changes in the
    timing of term deliveries. This was associated with a small
    reduction in NICU admissions; however, macrosomia
    and stillbirth increased.

    ….."Although all deliveries at 37 or more weeks of
    gestation are categorized as term births, recent observational
    studies have documented progressive improvement
    in neonatal outcomes with each completed
    week of gestation until 39 weeks.4–8 These
    findings have stimulated a national effort to reduce
    elective delivery before 39 weeks through increased
    adherence to the American College of Obstetricians and
    Gynecologists recommendations.9 The Joint Commission
    recently adopted rate of elective delivery before 39
    weeks as a institutional quality measure….."

    (Obstet Gynecol 2011;118:1047–55)

    DOI: 10.1097/AOG.0b013e3182319c58

    LEVEL OF EVIDENCE: III

    • Young CC Prof

      So preventing 89 NICU admissions (probably short ones) caused an additional 8 term stillbirths, and presumably a few more emergency c-sections for overly large babies. (And probably a few elective RCS converted to emergency RCS due to spontaneous labor at 2 am).

      That actually doesn’t sound like a good tradeoff at ALL.

      Did the paper note any reduction in serious complications requiring long NICU stay or potential long-term problems, or in neonatal death?

      • lawyer jane

        Wow. So how exactly would those stillbirth risks have been prevented by earlier delivery before 39 weeks? Can those risk factors be identified?

        • Young CC Prof

          I read through the article and one baby did have IUGR, probably should have been delivered earlier or monitored more closely. I don’t think the IUGR was diagnosed prenatally, but presumably it could have been. (If I hadn’t just happened to have that extra 32-week ultrasound, that might have been my son, just dead inside me at 38 weeks with no sign beforehand as our crappy placenta finally gave out.)

          Most of them, though, were either cord accident or “cause unknown.” Unpredictable and unpreventable, so apparently sudden death is an unavoidable hazard of being a fetus.

        • LMS1953

          The one thing you can trust as regards pregnancy is that EVERY fetus is potentially a victim of drowning. The stillbirths would have been iatrogenic saves were it not for 39 week Nazis who prohibited them from being plucked from the pool electively (because of swollen feet, backache, tired of being pregnant, stat tee/supper time) before they drowned. The rarely seen “law of unintended benefits” is now being trumped by the law of unintended consequences when so-called evidenced-based medicine takes complete precedence over any notion of experience-based medicine.

          • Young CC Prof

            The problem isn’t evidence-based medicine. The observation that 37-38 week babies were more likely to experience medical problems during the first few days of life was indeed an important piece of evidence. If nothing else, it’s a reason for hospitals to observe those newborns a bit more carefully, no matter why they came early.

            But the enthusiasm with which the 39-week rule was rolled out had nothing to do with evidence. Real evidence-based medicine considers cost-benefit analysis, for one thing.

            Give me a few days, depending on Baby Prof’s temper, and I’ll make a little graph. See if you like it.

      • LMS1953

        So, for every 11 short-term NICU admits we are preventing, we are killing one baby. Such collateral damage would be unconscionable in any other medical calculus. For example, in the era prior to laparoscopy, surgeons were taught that they should have 10 negative laparotomies for every hot appendix they take to surgery or else they are showing they do not have a high enough index of suspicion. The 39 week Nazis do not show a high enough index of suspicion for the risk of 38 week stillbirth – nor the risk of emergency C-sections necessitated by the spontaneous onset of labor in the 38th week of a planned repeat C-section. Babies are being killed and mothers are suffering unnecessary morbidity because of that.

  • stenvenywrites

    Wait, what? She is blaming the doctors whom she refused to consult? IT’s THEIR fault that she refused to listen to them because they’re just big old nagging buzz-kills who’d just say “if you do that, something awful could happen,” and it’s THEIR fault that when she did as she pleased, something awful happened? And she’s over seventeen? She really didn’t grow out of that? That’s … really discouraging.

  • lawyer jane

    So how would this have gone down in a hospital? It was placental abruption, right? Could that have been detected in time for a c-section?

    • LMS1953

      The doctor would have had a vacation scheduled and nobody could imagine anyone else but him delivering the baby. So he would have brought her in at 38 weeks on a Friday before he left that weekend. Her cervix would have been green and she would have “failed to progress” so a “five o’clock” C-section” would have been scheduled. And Thor would have been born alive and perfectly healthy and everyone would have lived happily ever after. Oh, the humanity……

      • LMS1953

        Seriously, I don’t buy her sequence of pathophysiology. The process was the chronic insult of utero-placental insufficiency. There is progressive hypoxia and acidosis. The scale tips and the baby dies. This is what pisses me off about midwives of every stripe. They think everything is fine (they trust birth) until it isn’t fine and they keep a monkey on a leash to come do a C-section without having collaborated earlier which would have prevented the catastrophe in the first place. The point of the scientific/medical practice of obstetrics is to use one’s training and judgment to anticipate risk factors and adverse events and intervene before the cascade of pathophysiology begins. This is otherwise known as the “art of medicine” – which at times conflicts with “evidence-based medicine” because it is next to impossible to do studies the efficacy and benefit of experience. Hence the common sense notion that waterbirth is non-physiologic and dangerous is met with all the pushback the forces of woo can muster.

        • Trixie

          I’m not sure if you saw this downthread, but Heineman’s CNM, who still practices, has an assistant CPM who recently got a PhD in Women’s Studies from the same department where Heineman teaches at the University of Iowa.

          • LMS1953

            In New England, in the late 17th century, they would have been considered a coven of witches who practiced infanticide and medicinal witchcraft with a cauldron of evening primrose and kale and garlic and raspberry tea and moxibusted toes. You know, they were probably on to something there.

          • The Bofa on the Sofa

            However, Heineman was not her adviser, nor even on her thesis committee

          • Trixie

            No, but they clearly all know each other.

    • LMS1953

      A placental abruption usually presents with very painful uterine bleeding. The uterus often is rock hard to palpation with a tetanic contraction. If the mother has continuous fetal monitoring, often signs of fetal distress can get picked up. An unusual form of abruption is the “occult” or hidden abruption which does not present with bleeding since it is trapped behind the placenta that is separating. I don’t think she suffered an abruption because she would not have missed the extreme pain and bleeding. She mentioned nothing about that. But it is a handy “throw down” diagnosis – hard to predict, catastrophic, it was nobody’s fault, etc. Another throw down diagnosis is amniotic fluid embolism – it has the same characteristics. They are handy diagnoses to help deflect guilt and liability – like when insurance companies evoke “acts of God”.

  • Ash

    Good lord. The author’s accusation that medical staff stopped the midwife from providing care. LOL. Because the OBs are sooooo mean that the midwife was unable to recommend the author call a OBGYN clinic or even present to the emergency department. And of course, this event ccouldn’t be predicted…oh wait…it was based on due dates which were known months ago. And the author wrote a book but did not interview medical experts about risks for stillbirth and contributing factors. All due to OB/GYN practices. They are just so mean.

  • anh

    I think I’ve been reading this site too much. I dreamt last night I was pregnant and had a cord prolapse but somehow delivered the baby on the floor of my mother’s kitchen. Then I wanted to go to the hospital but my mom made me wait and charge my kindle.

    • realitycheque

      “Then I wanted to go to the hospital but my mom made me wait and charge my kindle.”

      Love those priorities!

  • Sullivan ThePoop

    Has anyone read this, I found it while looking for a link. It is kind of old but interesting http://www.bmj.com/content/346/bmj.f108/rr/630974

    • Dr Kitty

      Pauline Hull is a very sensible woman.
      She makes excellent points.

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

        Agreed on your assessment of Pauline Hull – such sensibilities are very needed to bring the conversation on birth back to some kind of balance.

  • Amazed

    OT: Would someone PLEASE inform this gorilla that she ISN’T supposed to bond to her c-section baby because interventions and so on?

    http://www.dailymail.co.uk/new

  • areawomanpdx

    I disagree that it is the mother’s fault. I think it is the fault of the homebirth midwives who reject the idea that they should get actual education and spend all their time fighting to keep their right to ignorantly attend births while hiding just how ignorant they are from prospective clients. It is the fault of natural birth advocates who publish scads of books, magazines and websites that seem legitimate. It is the fault of the American educational system which does not teach young women how to think critically and evaluate evidence so that they are sucked in by all the flowery bullshit. I mean, Lamaze and Childbirth Connection and Mercola all seem legitimate and backed by “experts” and “evidence.” If you don’t have the skills to evaluate it, you can’t tell it’s false.

    • areawomanpdx

      Perhaps Heineman has more responsibility than most parents, since she is well educated. But I still believe the greatest responsibility lies with homebirth midwives and their advocates.

      • attitude devant

        areawoman, she IS one of their advocates.

        • Anj Fabian

          She is definitely one of their advocates. In the beginning of the book, I had hope that she would understand that home birth is a risky business best left to those who willingly embrace those risks. (It’s possible to argue that she was one of those people.)

          But her personal revelation wasn’t about risk and the consequences, but how women deserve personal midwifery care and how the hospitals and insurance companies make that care more risky than it needs to be.

          Home births are risky. Home births take place in a low resource environment. The only mitigating factor is the midwives who choose to attend them – and their decision to accept more risks (AMA, postdates) can only lead to an increased rate of poor outcomes.

          The variable in the home birth equation is the attendant.

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

      I agree to an extent, but Heineman has crossed the line from reading those books to writing them and contributing to the entire problem.

      • areawomanpdx

        That is true.

    • fiftyfifty1

      This one was a CNM. She had a real education.

      • areawomanpdx

        Those CNMs are worse than uneducated lay midwives in my opinion. They *know* standards of practice and ignore them.

      • Anj Fabian

        She had an online education apparently.

    • AmyP

      “It is the fault of the American educational system which does not teach young women how to think critically and evaluate evidence so that they are sucked in by all the flowery bullshit. I mean, Lamaze and Childbirth Connection and Mercola all seem legitimate and backed by “experts” and “evidence.” If you don’t have the skills to evaluate it, you can’t tell it’s false.”

      I think that “critical thinking” is not really what’s needed. “Critical thinking” is part of the problem, actually–these women have critically thought themselves right out of reality. You just need to be convinced that having babies hurts and is dangerous without medical help–if you know those two things, you’re pretty safe from the brainwashing.

  • Amy Tuteur, MD
    • fiftyfifty1

      “Heineman seems at least consoled that her brief time with Thor was spent on her terms.”

      I did it MYYYYYYYY way!

      • Laura

        Rather gruesome, don’t you think?!

        • fiftyfifty1

          Actually I wasn’t referring to the time after his death. She can do whatever she wants then without harm to anyone. Seems to me that the brief time that she actually had with Thor was the prenatal period. And that time, most certainly, was spent on her terms.

          • Laura

            I thought that comment quoted was referring to her postpartum time with the deceased, embalmed Thor. Any way you look at it, her time with her son was tragically cut short. It didn’t have to be that way, either, which just compounds the sadness. I don’t think she’s ready to really wrestle with that yet, though.

        • LMS1953

          Sorry, but I just can’t get this image out of head when I think of Thor’s superterranean existence.

        • Jessica S.

          No, b/c she’s talking about her choice for home birth, not what she did after the fact.

    • LMS1953

      Quote: “These choices grew from conscientious thought and research, not from inclination or whimsy: “I chose home birth because I believe in evidence-based medicine,” she writes. “Because I believe in scientific method.” She does not, in other words, believe in the unquestioned authority and the assumed omniscience of doctors in hospitals. Yet Thor died. – See more at: http://www.literarymama.com/reviews/archives/2014/03/a-review-of-ghostbelly-a-memoir.html#sthash.OouPvE5w.dpuf
      I call bullshit on the “evidence-based medicine” that says there is no benefit in improvement of fetal outcome when comparing continuous maternal/fetal monitoring versus intermittent auscultation and palpation – except to increase C-sections by the cascade of intervention. There is a TWELVE FOLD increase in crappy APGARS with the no EFM approach with HB and a FOUR to NINE FOLD increase in neonatal death. It is time we call the prior studies a canard that has hidden the common sense benefit of continuous EFM.

      • The Bofa on the Sofa

        “I chose home birth because I believe in evidence-based medicine,” she writes. “Because I believe in scientific method.”

        Wait a minute. Just yesterday, we were hearing about how she was a victim of a bad provider, and how could she know that she was high risk, and oh, her doctor said it was ok.

        That’s a nice defense, however, she doesn’t agree. By her own account, she claims she knew exactly what she was doing. In fact, not only was she not some dupe at the hands of an incompetent midwife, she thought she was smarter than the doctors.

        She’s not a victim of someone else’s incompetence. She chose her path with full knowledge. She denied the risks, and convinced herself that she was smart in doing so.

  • Amy Tuteur, MD
    • Laura

      Sad and beautifully written. I couldn’t help imagine what a stranger would have thought upon congratulating her on her new baby in the sling at the park and realizing that it was a dead, embalmed baby. I hope she finds peace on her journey.

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

        WHAT

        • Laura

          Yeah, it’s kind of creepy. And I don’t want to pass judgment on how people grieve. God knows if that happened to me I’d probably lose my mind. But walking around with a dead baby for however long she did IS disturbing.

          • Anj Fabian

            It’s denial, from what I can tell. On the first year anniversary, she conjures up what it would have been like to be sitting down and having breakfast with a one year old Thor. In detail.

            It’s odd.

          • Dr Kitty

            I found it…unusual.
            It isn’t how I would choose to grieve, mostly because I, personally, think dead bodies are empty vessels which no longer contain the essence of the person, but I understand why she found it comforting.

            I would have found her undertaker’s language and demeanour to be really, really creepy and inappropriate rather than warm and reassuring, but that is probably cultural. The Irish undertakers I have met are very formal, professional and polite, which I know most people here find a comfort.

          • Mishimoo

            When my husband’s stepmum passed away, we immediately drove down to support his dad and stepsister and say a final goodbye. We arrived between the doctor certifying her death and the undertakers coming to collect her. One of which was slightly creepy, because he insisted on telling us how he’d had a near-death experience but was sent back specifically to look after deceased persons and the families that they’d left behind.

          • SuperGDZ

            It’s different when it’s a newborn and you are simultaneously trying to get to know her and let her go. Grieving is not the same when you can’t bring to mind a face, a voice, a smile, a touch.

  • attitude devant

    Let’s try this one: Steve Jobs had pancreatic cancer, widely known as a killer, caught very early, early enough where he had a good chance with conventional therapies. Smart guy, our Steve, but he decided to treat it with alternative therapies. And the cancer advanced and did not respond well to the conventional treatment he eventually agreed to. And he’s dead now.

    Whom do we blame for this? We don’t blame the alt med guys—-after all, Steve had all the information and money he could want at his disposal. We blame Steve. How foolish of him–he had a chance and blew it.

    Well, I’m sorry, but Elizabeth Heineman is no idiot. She’s a professor of history at a major university, and the cultural history of motherhood is one of her areas of special expertise. For her to claim that, pregnant at 45, she had no idea childbirth was risky for her and for her baby is ridiculous.

    Sadly, she is unlikely to conceive spontaneously again. She too had a chance and blew it.

    • Sullivan ThePoop

      Put in that context it looks pretty bad.

    • The Bofa on the Sofa

      On the other thread, I asserted that her choice of HB was probably because she was trying to be “edgy.” I didn’t realize she was actually a history professor.

      Now I go with the other explanation: she really does think that she’s smarter than all those sheep who unthinkingly go to the hospital.

      What are the chances she is a regular at “Thinking Moms Revolution”?

      • Guestll

        Doubt it. Heineman doesn’t strike me as stupid (a word I’d certainly apply to members of the TMR) or even ignorant. I just think she disregarded the odds because she thought they wouldn’t apply to her. She could not have been unaware of the risks, given her profession. She’s arrogant, not dumb or ignorant.

        • The Bofa on the Sofa

          eineman doesn’t strike me as stupid (a word I’d certainly apply to members of the TMR) or even ignorant.

          There ARE PhDs on TMR

          And they are all in some humanities

          • Guestll

            So? They’re still largely stupid and ignorant, particularly on the topics upon which they expound.

          • Laura

            The humanities, of which I majored in, don’t require much science at all! It’s a very different way to look at the world. And in the US most birth outcomes are excellent, so if you’re not exposed to the ugly details of death and devastating birth outcomes in third world countries, you have blind spots in your understanding of childbirth. This is dangerous when you only read NCB info.

          • Guestll

            Fair enough, but this doesn’t apply to Heineman, given her job and field of expertise.

          • Laura

            Yes it does, if she doesn’t have a background in medicine and intimate knowledge of the medical aspects of childbirth.

          • Guestll

            No, it doesn’t. You don’t need background in medicine and intimate knowledge of the medical aspects of childbirth to know that giving birth at 45 is not low risk.

          • Laura

            I was referring to her unwillingness to see where she had given into a philosophy of childbirth that is not rooted in evidence based outcomes. Her midwife was willing to take her on and not risk her out nor encourage her to get induced at 41 weeks because of the midwife’s philosophy that probably went something like: “She’ll be fine. The odds are low that there will be a problem.” For Heineman not to acknowledge that this laissez faire thinking is rooted in a philosophy that she bought into, but instead blames the medical system, shows her lack of understanding of the medical aspects of childbirth. She gambled on odds that “it wouldn’t happen to me” because she apparently knew the odds and didn’t appreciate the risk. How would you describe this thinking and the BOOK SHE PUBLISHED arriving at the conclusions that she did?

          • Guestll

            Arrogance and denial. The odds wouldn’t apply to her. Insert your rationale here.

          • The Bofa on the Sofa

            Arrogance and denial

            The hallmark of the folks at TMR.

            Arrogance? They run around calling themselves “thinking moms” with the implication that others are not.

            I don’t know how you can think that “arrogant” is at all at odds with the morons at TMR.

          • Thankfulmom

            History reveals the high death rate of moms & babies at home before births began to regularly take place in hospitals where life saving interventions could be done.

            She talked about walking through the graveyard showing her dead baby tombstones of other babies who “died in a flash.” A visual reminder that moms & babies commonly died. Her study of history should have showed her the past is littered with dead babies. Maybe she thought it was okay to take a chance because the hospital was only 10 minutes away.

          • Laura

            I agree. The whole scene she wrote about was terribly sad and disconcerting.

          • The Bofa on the Sofa

            So why do you think Heineman is any different? She has clearly demonstrated herself to be ignorant of midwifery.

    • Laura

      And her take on who’s to blame seems more rooted in her pride and unwillingness to take personal responsibility than some personal attachment to her midwife, as I had suggested before. Although, it’s probably a combination of both. In this area of modern medicine she seems sadly ignorant and unexposed to the truth, regardless of her professional course of study and expertise.

    • Are you nuts

      And Steve Jobs admitted that he had regret over postponing traditional medicine in favor of alternative medicine: http://www.forbes.com/sites/alicegwalton/2011/10/24/steve-jobs-cancer-treatment-regrets/
      Days and weeks matter a lot in the fight against cancer, just like seconds and minutes matter a lot during birth.

      • Amy Tuteur, MD

        One of my favorite homebirth memes: When every second matters, the hospital parking lot is “only” minutes away!

  • Ellen Mary

    You are failing to recognize something fundamental about birth: being transported during labor is just not ideal. On many levels, so we get car births, we also get arrested labor. I always said I could have a hospital birth as long as I had time to adjust to the space. I don’t want to labor at home as long as possible, which is the other ‘fix’ to the problem. When I attempted to show up early, it was explained to me that insurance makes them give a reason for keeping me (like they have to do something to me) even though my water was broken & the Ward was empty & fully staffed.

    There is even a bio basis for this phenomenon, which is why humans also do not sleep well on their first night away from home.

    Mothers choose HomeBirth for a variety of reasons in our society, but amongst them is the desire to give birth in what our primal brain perceives is a safe space.

    • Guestll

      Are you saying that transport during labour causes arrested labour?

      Do you have citations for the claims you’ve made?

      • Trixie

        Apparently it both speeds up and slows down labor, because it results in car births too (never mind that the car birth would be been an unassisted home birth if the mom stayed home, since the midwife wouldn’t have made it in time either).

        • Ellen Mary

          I don’t think being transported in labor could speed it up, not at all, but when a society has a policy of regularly transporting laboring women, some are not going to make to correct call about when to leave & babies are going to be born in transit.

          • Trixie

            You’re right. I think I’ll renovate my home so I can have a full OR on site and pay a full staff of doctors and nurses to be on standby in case I ever have another child. It’s much better than sitting in a car for 20 minutes.

        • OBPI Mama

          My exmidwife told a friend that the transport ambulance ride to the hospital LOOSENED up her baby enough from a shoulder dystocia to be born 12 minutes after her arrival there (forget the suprapubic pressure and whatnot!). So apparently, car rides loosen the babies out. (face palm).

      • Sullivan ThePoop

        Speaking of transporting during labor. My friend who is an OB had two horrible home birth transfers two days in a row. One the mother labored for 4 days, apparently the baby’s head was out for some 12 hours and then they decide to get in the car and go to the hospital. Well, the baby was gone because its neck was broken. She could not understand how four people could have thought that was a good idea.

        • Are you nuts

          My goodness.

        • Karen in SC

          I wonder if that birth was crowd sourced on MDC or BWF?

          • Sullivan ThePoop

            It made the paper.

          • areawomanpdx

            Do you have a link??

          • Sullivan ThePoop

            No I tried to look for it and couldn’t find it, it was still a really small couple of paragraphs in the local paper.

        • Dr Kitty

          That poor, poor baby.
          The mother will be lucky if she doesn’t have a fistula.

    • Amy Tuteur, MD

      That’s baloney! Women in low resource countries walk miles in labor to get to real obstetric providers. There is no primal urge to give birth at home; that’s just imagined “noble savage” nonsense.

      Homebirth advocates are a fringe group; they don’t represent anyone other than themselves.

      • Karen in SC

        I think that “safe space” originates with cats. Don’t they hide when giving birth?

        • Amazed

          My grandmother’s yard cat hid to give birth… under my bed. Later, she carried her kittens one by one to an old storage room and deposited them in the baby carriage that we had, of course, outgrown. Grandma carried them out – and the cat took them right back in.

          Had a fondness for man made things, this one.

          • AmyP

            When I was a kid, our kitty pulled exactly the same stunt with birthing her litter of kittens under my mom and dad’s bed.

          • Amy M

            But aren’t cats fearing for the safety of the kittens? Not the arrest of labor, but that something will come along and threaten them while they are incapacitated or more likely, come along and eat the helpless kittens while mom is out hunting or whatever. I thought that is why they hide them?

        • Jessica S.

          And if they were able to reason like we do, they might walk several miles to the vet clinic. Ha! :)

        • me

          One of our cats had a litter (her first) right out in the open in the yard. My mom and I stayed with her (no, our presence didn’t appear to impede her progress) because we lived in a very rural, desert environment at the time and we were worried about predators coming upon her (coyotes, owls, hawks, rattlesnakes, etc). When she was done, we moved her and her kittens to a safer place (a shed). Every litter after that, she just went to the safer place to begin with. She was a FTM and apparently didn’t have those alternative ‘ways of knowing’, despite being an outdoor cat her whole life…

      • pburg

        The resurgence of Rouseauian naturalism is absurd and annoying. Applied to certain instances, like homebirth, even dangerous. But most every movement has some truth to it. And like other extreme movements is a reaction to an opposing extreme. There is nothing more natural and naturally dangerous as childbirth. So Naturalism is appropriately applied in general, but does not apply in specific ways concerning most every pregnancy.

        On the other hand we know that environment and relationship to/attitude of observers psychologically effect human sports performance. Elderly people (no not pregnant moms over 35) are more likely to die when they move to a new place. Mice who become slowly accustom to drugs like morphine will die of OD when placed in a new cage, but not before. I believe environment plays a role in instincts, physical ability, and overall outcome. But is a baby with a prolapsed cord going to require a sterile surgical environment? Heck yeah. So, while I do think most women and babies are better served at home for a multitude of reasons, birth is dangerous business and I only hope we can make it a more sensible option for women who desire it.

        • NoLongerCrunching

          >So, while I do think most women and babies are better served at home for a multitude of reasons… birth is dangerous business”

          Dont you see the contradiction here?

        • Amy Tuteur, MD

          Does maternal environment affect the outcome of labor? There’s absolutely no evidence that it does. It’s not like this can’t be studied or hasn’t been studied. No matter how much you wish to believe that environment is crucial and no matter how many analogies to make to other medical conditions and other species, we KNOW that maternal environment has no impact on labor or labor outcomes.

          • The Bofa on the Sofa

            I like the recent study that found that POSITION of labor doesn’t even matter.

            Talk about a whole premise of NCB that sounds good falling apart.

          • Sullivan ThePoop

            I know it kind of depends on what is going on with you and what feels most comfortable.

          • The Bofa on the Sofa

            Does it?

            IIRC, it was a randomized trial of position, where one set was done in the normal “on their back” and the other allowed to do what they felt most comfortable.

            There was no difference in outcomes.

            Now, the one moving around might have felt more comfortable, particularly without an epidural, but it did not have an actual effect on labor.

          • Sullivan ThePoop

            I didn’t mean for labor to progress. I just meant sometimes it feels good to walk, to lay, to sit. I guess I didn’t really read your comment that it was about labor progression. I never thought that would have much effect. I always thought that whole strapped to the bed crap was nonsense anyway. No one ever kept me strapped to the bed.

          • fiftyfifty1

            “was done in the normal “on their back” ”

            Small quibble here. The NCB crowd may say it’s “on your back”, but women are actually encouraged NOT to labor on their backs in the hospital because the weight of the baby presses on the abdominal aorta in that position. The most common position to push in in the hospital is actually a semi-reclined position, half way between sitting upright and lying down. It’s also the position most commonly chosen spontaneously by women at home as any search through Youtube birth videos will show.

          • Captain Obvious

            We used to get incarcerated women who go into labor in prison be brought to L&D and get cuffed to the hospital bed and deliver without any arrest of labor or difficulty.

          • pburg

            “Does maternal environment affect the outcome of labor? There’s absolutely no evidence that it does.”

            Just because there is no evidence doesn’t not mean that we cannot make a reasonable assumption based on experience or commonly understood notions of how the human person operates. 

            “It’s not like this can’t be studied or hasn’t been studied.”

            Outcome based on maternal environment CAN NOT be studied with adaquate precision.  We can not know exactly what would have been the outcome in an alternative environment involving a particular birth.  No mother is the same, no labor is the same, and none of the external circumstances involved in a particular labor & delivery can be identically repeated.

            “we KNOW that maternal environment has no impact on labor or labor outcomes.”

            We do not KNOW this.  Some studies may indicate one way or the other, but this type of statement perpetuates the lack of nuanced thinking among your readers and does not put into perspective the fact that these types of studies rarely “prove” anything.

          • Amy Tuteur, MD

            Sorry, you lost me at “just because there’is no evidence.”What science teaches us, above all else is that we CAN’T make assumptions based on our experience.

            The earth is a sphere even though we experience it as flat. Bacteria exist even though we experience them as invisible. Time is relative even though we experience it as absolute.

            If you want to ignore science when it does not comport with your cherished beliefs you are entitled to do so. Just don’t expect anyone who respects the scientific method to follow you.

          • pburg

            If there is little, conficting, or simply no evidence available, but need to make a decision, we use what other information is at our disposal. Experience should not be undervalued.

            Regardless, med research can be informative but is often lacking and has been known to be completely wrong. Eg. doctors told moms to put babies to sleep on their tummies in order to avoid SIDs. Would you judge moms who didn’t because their decision was not based on the current evidence at that time? The scientific method is a tool which, when used well, can point to the truth. It is not truth. You cannot respect the scientific method if you idolize it.

          • Young CC Prof

            Are you familiar with the hierarchy of evidence? Anecdotes and “common sense” are the lowest form, but better than nothing. People rely on anecdotes when no other evidence is available.

            We HAVE evidence that the maternal environment or emotional state has little effect on the progress of labor, higher levels of evidence.

          • pburg

            Interesting that you put “common sense” as the lowest form of evidence.  Pls cite your source for this. How disturbing that common sense (aka logic, wisdom, prudence) would be relagated into a sphere of any hierarchy, let alone, to the bottom of it! It is not a type of evidence but the ability to inform our decisions or, for instance, interpret whether a study was conducted properly, if the information was compiled properly, and if the conclusion accurately reflected the outcome data.  It is also central to how evidence is applied to medical care practice.  Medical practitioners need common sense in order to properly incorporate a patient’s values with that of their clinical experience and the best evidence at their disposal.  I suppose this is what seperates “evidence based medicine” from “evidence informed health care.” common sense.

            “We HAVE evidence that the maternal environment or emotional state has little effect on the progress of labor”

            I mentioned earlier why adaquate research is lacking here. Even if we had better studies on the specifics of how sensory surroundings impact L,D & R, we are unable to determine ethical quality of care by means of control studies.  If it wasn’t for the ethical component, I don’t think that many women would choose homebirth.  Its not about being in charge, a cozy experience, or damning the man.  It’s about human dignity, woman’s rights, parental rights, and conscientious objection to medical practices which infringe on these things. Since the risks are small (and negligible under certain conditions) women who choose homebirth should not be treated like pariahs.

          • Young CC Prof

            http://www.ijstd.org/viewimage.asp?img=IndianJSexTransmDis_2012_33_1_49_93829_u1.jpg

            See if that link works for you. That’s one example of the “hierarchy of evidence” pyramid.

            “for instance, interpret whether a study was conducted properly, if the information was compiled properly, and if the conclusion accurately reflected the outcome data.”

            Perhaps we differ in our definition of common sense. To me, it’s, “Well, there haven’t been ANY studies about what to do in this circumstance, but this idea seems to make sense, so let’s try it.” Interpreting studies and deciding whether they were done well is another issue entirely.

            “Since the risks are small (and negligible under certain conditions) women who choose homebirth should not be treated like pariahs.”

            The probability of a baby dying either during labor or shortly after delivery as a direct result of home birth is about ten times as high as the probability of a newborn child dying in a car crash at any time up to the age of 15. Serious injury to the baby is also not uncommon.

            Negligible risk? Really?

          • pburg

            Yes. Negligible compared to hospitals, and, as I mentioned, under certain conditions:

            “For multiparous women, there were no significant differences in the incidence of the primary outcome by planned place of birth.” -birthplace study

            “homebirth might be AS SAFE AS THE HOSPITAL for multips.” -dr. amy [her emphasis]

            The homebirth multips studied were low risk (no vbac) and were under the care of uk midwives.

            To make broad claims regarding the dramatic difference between home v hospital risk is unfair to those who aren’t taking more of a risk than they would be in the hospital. They involve different types of risk. But it is the right of the patient to make those calls.

            http://skepchick.org/2012/01/nuance-of-risk-and-homebirth/

          • Young CC Prof

            I grant you the UK birthplace study, however, it does not apply to US women. For two reasons:

            1) Home birth providers in the USA regularly fail to perform appropriate prenatal testing

            2) Studies of home birth in the USA do find a dramatic increase in risk, including among multiparous women. (The risk is lower among multips than among primips, but still excessive)

          • pburg

            “I grant you the UK birthplace study, however, it does not apply to US women. For two reasons:1) Home birth providers in the USA regularly fail to perform appropriate prenatal testing”

            And many US homebirth midwives will perform these test.  There is a local CNM homebirth midwifery practice which also offers a birth center option, work with OBs, and they have hospital privileges.  For low risk multips, a homebirth with them would be a reasonable option. No? There not many practices like theirs.  Maybe if the birth wars calm down, there might be.

            “2) Studies of home birth in the USA do find a dramatic increase in risk, including among multiparous women. (The risk is lower among multips than among primips, but still excessive)”

            I’m very interested in these studies you refer to. Would you mind pasting a link for me? In terms of US studies comparing low risk multips hombirth outcomes to comparable hospital outcomes… I found nothing. 

          • Young CC Prof

            No one has done a controlled home vs hospital study, but we have:

            http://www.ajog.org/article/S0002-9378%2813%2900641-8/abstract

            And other work by Gruenbaum.

            MANA’s own study: http://onlinelibrary.wiley.com/doi/10.1111/jmwh.12172/full

            Note that although the conclusion claims that MANA STATS shows home birth is safe, in fact it proves exactly the opposite. MANA’s sample size was almost identical to the number of home births in the UK Birthplace study. The Birthplace study found 6 intrapartum deaths, MANA found 22, 8 of them in multiparous women with no history of prior cesarian birth.

            In order to make US home birth safer, we would need to:

            1) Develop a strict set of risk-out guidelines and consequences for providers who ignore them, including loss of license. (Primip should be a risk-out criteria. In fact, I think that well over 50% of pregnant women in the US would be disqualified if reasonable risk-out criteria were used.)

            2) Require providers to carry malpractice insurance. (Currently this is basically impossible. The insurance would be insanely expensive because the insurance companies know home birth is unsafe.)

            3) Develop strict guidelines for transfer during labor, including meconium staining, labor proceeding slower than predicted by WHO partograph, etc.

            4) Require home birth providers to associate with a hospital and pre-register women, so that emergency transfers can proceed smoothly. (This is done in Canada, Britain, Australia and the Netherlands, everywhere home birth is recognized. Currently our entire healthcare system is not set up for it.)

            5) Make it a crime in all states to attend home birth without the appropriate license and credentials. (In many states, just about anyone can call themselves a midwife. In a few states, it’s literally anyone.)

            So, you’d basically have to redesign large parts of our health care and legal systems. And evidence from Canada and Britain shows that building this kind of safety net around home birth may in fact be MORE expensive than just delivering all babies in the hospital. But that’s how it has to be done.

          • pburg

            “The Birthplace study found 6 intrapartum deaths, MANA found 22, 8 of them in multiparous women with no history of prior cesarian birth.”

            Overall intrapartum death rate went from 1.3 to .85 when adjusted to exclude all high risk factors. The multip rate when from .84 to .66 when adjusted to only exclude vbac. But the only risk factor shown in the study which is exclusive to multips is vbac. Where does the study differentiate the other risk factors based on parity? The birthplace study ruled out all high risk miltips, not just vbacs. It also studied certified midwives integrated into the hospital system. This may account for the striking disparity in death count. Point being: some woman are able to qualify for a reasonably safe homebirth. We shouldn’t vilify US homebirth simply because studies haven’t been sophisticated enough to account for certain combinations of variables. The birthplace study seems to be the only study containing data on the more rigorous qualifications. Some US woman fit those qualifications. What critics seem to be saying is that we cannot trust women to make informed decisions. And this may be true for some women, but certainly not all. Low risk women shouldn’t be deprived of a safer homebirth experience because of it.

            As for the Gruenbaum study

            It is difficult for me to believe that a zero apgar was over ten times as prevalent at home births. This is far more extreme than other studies I’ve looked into. 5 of the 7 authors of the study published a professional opinion regarding hombirth which even Dr. Amy thought was absurd and poorly reasoned. I’m not accusing them of blandly falsifying data, but it does make me wonder if their bias blinded them to certain critical details. Regardless, in order to make the study more comparable to the birthplace study it might be more helpful to look at the “freestanding Birthcenter midwive’s” stats and not the homebirth midwives. Birthcenters are just births in someone else’s home. What women usually get is a more medically-minded mentality among providers, which can also be found in some HB midwives. Like the practice I mentioned in my previous post.

            Regarding your guidelines for safer homebirth– I agree that primips should be considered high risk. Why is it not ok for any medical professional to forgo malpractice insurance as long as they are upfront about it? It seems that the hospital association and registration everyone can agree on. I’m not so convinced regarding the criminalization of midwives practicing without a licence. That’s a tricky one. CNMs and OBs refuse many high risk women the option to deliver vaginally. A lay midwife or CPM maybe a woman’s only option. No woman should be forced to choose between an unattended high risk homebirth or a surgery which she may believe to be even more dangerous. Homebirth midwifery is a particular profession involving a basic human right.

            I know several women who found themselves in this situation. A cesarean due to breech or multiples may not be that big a deal to some women. But, my friends are now grandmultips, and maybe soon greatgrands. The surgery would have had more serious implications on subsequent pregnancies than for moms planning smaller families. They made an informed decision and everything turned out fine for them. Perhaps they were playing the wrong side of risk assessment. But, if something did go wrong, it would be vicious to exploit the death of their children to defend hospital birth.

          • Young CC Prof

            “It is difficult for me to believe that a zero apgar was over ten times as prevalent at home births.” It is absolutely unbelievable how dangerous home birth is compared to hospital birth! It’s utterly outrageous. If you don’t believe the Gruenbaum APGAR study, repeat it yourself. It is 100% based on CDC public records.

            “No woman should be forced to choose between an unattended high risk
            homebirth or a surgery which she may believe to be even more dangerous.”

            Well, then she believes wrongly. I’m sorry, but that’s just all there is to it. There is no possible circumstance in which home birth is safer, even for the mother.

            Realize one other thing: Home birth advocates boast about how many cesarians they prevent by comparing the cesarian rate of women who attempt home birth to the national rate, but this is incredibly dishonest statistically for two reasons.

            First, they toss out all the women who transfer care during pregnancy. Many, perhaps most of them transferred because they developed risk factors, some of which likely required a cesarian. (The previous sentence contains wiggle words because no data is available, MANA didn’t track dropouts, but it is a reasonable assumption that many women who transferred from midwife to OB care needed c-sections in the end.)

            Second, the only women who are “low risk” home births are multiparous women with no history of prior cesarian birth, single head-down fetus, no major medical issues during the pregnancy or generally. The probability of a woman like that winding up with a c-section in the hospital is pretty darned low. Hence, home birth prevents far fewer c-sections than its advocates would claim.

            But by taking even this lowest-risk mother out of the hospital, you remove the possibility of emergency c-section in the unlikely event that it is needed. You prevent her from getting the pitocin and other treatments that minimize blood loss and speed recovery. If she tears, she won’t be able to get skilled repair right away, and she might not get it until it’s too late for full recovery.

            Worst of all, if complications occur, her baby won’t have access to a proper neonatal resuscitation team with lots of equipment and experience. He won’t be examined by newborn nurses and pediatricians multiple times during his first few days of life. And the subtle signs of dangerous problems may be missed until it is too late and the child suffers lasting damage or death.

          • pburg

            “the only women who are “low risk” home births are multiparous women with no history of prior cesarian birth, single head-down fetus, no major medical issues during the pregnancy or generally…But by taking even this lowest-risk mother out of the hospital, you remove the possibility of emergency c-section.” “There is no possible circumstance in which home birth is safer, even for the mother.”

            But the birthplace study actually shows a slight decrease in perinatal mortality and intrapartum related neonatal morbidity for these low risk homebirth multips compared to obstetric units (http://familyinequality.wordpress.com/2011/11/29/study-shows-homebirths/). Hospitals contain their own risks. When risks are low for the mom then comparisons can be made.

            I would agree that it is impossible to predict with absolute confidence real life risks dealing with birth decisions. But certainly there are instances where a mother or baby might have lived if she had chosen to birth at home. One issue with homebirth risk assessment is that we are generally dealing with risks of omission vs risks of intervention. I think most women would choose the intervention risks. As for the friends I mentioned, a 7th, 8th, or 9th cesarean may be more risky than an breech/multiples vaginal delivery. A recent piece in the Atlantic made me think of them and their difficult decision http://www.theatlantic.com/health/archive/2014/03/when-a-placenta-tries-to-kill-a-mother/283751/

            Me: “No woman should be forced to choose between an unattended high risk homebirth or a surgery which she may believe to be even more dangerous.”

            You: “Well, then she believes wrongly. I’m sorry, but that’s just all there is to it.”

            It is the right of the woman to make that call. She shouldn’t be deprived of healthcare because of it. We’ll never know what have been the case my friends delivered in a hospital. They wouldn’t have experienced better outcomes than what their specific homebirths provided. But I would never claim that things couldn’t have gone wrong. Would you claim that if they had multiple cesareans nothing could have gone wrong?

          • Young CC Prof

            Better at home? No, that’s not what the graph shows at all. It shows that they were approximately the same. Also, keep in mind the care a low-risk woman in Britain gets is inferior to US maternity care. (Really, it is. Our outcomes are better, even though our inputs are worse.)

            Your fundamental argument seems to be that your friends with many children would have been less safe overall if they produced all those children in a hospital, but that’s pretty unlikely. Clearly, these women are able to bear easily. They never would have had a c-section due to failure to progress. If they’d had one breech, multiple, or other complication along they way, they could have had a safe hospital vbac the next time.

            And the risk of obstructed labor goes down after the first birth, but the risk of severe MATERNAL complications goes up after about 4 kids.

            Your friends refused medical care that could have made their labors easier to recover from in order to avoid c-sections that probably wouldn’t have happened to them anyway.

            Yes, the woman has the right to make the call. She also has the right not to be lied to. Not to be financially exploited by home birth midwives who promise safety that they simply can’t deliver, or who promulgate outsized fears of interventions.

          • pburg

            “Better at home? No, that’s not what the graph shows at all. It shows that they were approximately the same.”

            I didn’t write better at home. That’s a straw man. I wrote the graph showed homebirth had a “slight decrease” in bad outcome v hospitals for certain women. Which is true. I agree the numbers are “approximately” the same.

            “Your friends refused medical care that could have made their labors easier to recover from”

            Easier than what? They had no issues recovering at home. They had more chance contracting, and needed to recover from, an infection at a hospital. My sister and my neighbor both had infections from their catheters after hospital birth. Making life pretty hellish the first few days postpartum. My other neighbor suffered a spinal headache. I personally know more complications from hospitals than at homebirths. Anecdotal. Yes. That’s why it’s important to keep an eye on the statistics *while keeping in mind* that they are comparing different types of risks and are unable to measure ethicality or real word practicalities.

            “If they’d had one breech, multiple, or other complication along the way, they could have had a safe hospital vbac the next time.”

            Like many women who have twins and breech births, they had subsequent ones. If they had bet on not having those complications again, they would have been wrong. 7 cesareans later they could’ve been in a more risky situation. And “safe vbac”? If birth is inherently dangerous, can’t we say this doubly applies to vbac? It’s tough to try vbac after one cesarean. After two, it’s likely not going to happen. I can’t see how you can be so certain my friends were wrong.

            “home birth midwives who promise safety that they simply can’t deliver, or who promulgate outsized fears of interventions.”

            And the same criticisms can be made of deifying interventions. No medical practitioner should promise safety. You are falsely generalizing homebirth midwives.

            Women deserve medical care during birth because it is a basic human right. It’s coercion to threaten them with the choice of either unattended birth or surgery. In my state, a mom is legally allowed, and has medical access, to full-term abortion. Why shouldn’t a high risk mom have the choice and medical access to deliver her full-term baby at home?

          • Young CC Prof

            Okay, so now you’re telling me your friends had repeated breech or multiple births at home? How many friends, and how many of these risky births?

            “Why shouldn’t a high risk mom have the choice and medical access to deliver her full-term baby at home?”

            Because the experts won’t do it, because they know it can’t be done safely. Asking a doctor to help with something he believes is unsafe or immoral, THAT’s coercion.

          • pburg

            “How many friends, and how many of these risky births?”

            This seems irrelevant. Though I could see how someone may think I’m making this up :) Two women I know and love (they are sisters from a family with 13 children). One had two sets of multiples in a row (out of 7 children.) The other sister had 2 breech and one set of twins (out of 9 children.) So what’s more risky? A seventh c section or breech delivery at home? Depends. right? The different types of births involve different risks to mom and to baby. This is what I loved about the Atlantic article. Risks assessment gets slippery when we put into account the future fertility of the mother — an often overlooked element. This is particularly applicable to Amish, Orthodox Jews, Traditional Catholics, Muslims and various other religious communities with culturally deviant family sizes.

            “Because the experts won’t do it, because they know it can’t be done safely. Asking a doctor to help with something he believes is unsafe or immoral, THAT’s coercion.”

            Another straw man. We were discussing homebirth midwives assisting in a service the provide willing. I never suggested that we ask doctors to do what they believe is immoral.

            Though, on a similar note, some doctors would perform vaginal delivery of a breech presentation if they were trained to. ACOG stated that vaginal breech may be a reasonable choice. A closely monitored trial of labor seems to be what they find permissive. If my friends had found a doctor who was willing and trained, then those births would have been in a hospital. Med schools should train future OBs in breech vaginal delivery. If not, some women might decide, with good cause, that the hospital risk is higher for them than at home. Is that coercive?

          • Young CC Prof

            Doctors will do vaginal twin births under reasonably favorable conditions. (Higher-order multiples born at home is just plain crazy, since it’s VERY likely they’ll need a NICU.)

            Breech home birth… 5 deaths out of 222 births. And almost half of those 222 mothers wound up getting a c-section anyway. Repeat, a 50% chance of emergency transfer and c-section, more than 2% chance of losing the baby. The incidence of brain injury or severe maternal injury was not reported.

            That’s what everyone ignores. Breech births are more dangerous to the mother, too, higher risk of hemorrhage and severe tearing.

            Now, maybe these women should have access to vaginal breech birth. Here’s why they can’t, call it a bad reason if you want to:

            Those doctors would have to train on someone. There are not enough women out there who consider a c-section worse than a dead baby for them to practice ON. Further, if you look at the data from a few decades ago, even doctors who were VERY well trained at saving breech babies lost some of them. In the modern legal environment, this would be unacceptable. It doesn’t matter how many waivers the patient signed if the baby is dead solely because the doctor undertook a risky procedure in flat violation of the standard of care. Worse, if the baby is brain-damaged or otherwise seriously harmed but alive, the parents often have no choice about suing. The health insurer will sue on their behalf with or without their permission.

            I didn’t mean to misrepresent your argument there. See, home birth midwives aren’t health care providers by any reasonable definition of the term. I did think you were suggesting doctors or skilled and experienced CNMs doing home birth, and that’s not possible right now.

          • pburg

            young cc prof,
            2% fetal mortality for vaginal breech homebirth, 50% emergency cesarean. Those numbers would be lower in my friends’ cases because their breeches occurred after successfully birthing a singleton and their babies were in the complete breech position. Now for the other half of the equation: What’s the maternal mortality rate for woman having a seventh cesarean?

            The probability of placenta accreta is 6.7% for a group of women who had six or more cesareans. Only a percentage of these will suffer death. But, hysterectomy and transfusion are likely. Hysterectomy was required in 9% of all woman studied who had 6 or more cesareans. Other risk factors, like a myriad of surgical complications also dramatically increase for each cesarean. I couldn’t find a study that compiles all the risks into a quantified percentage or research which studies 7th 8th or 9th cesareans individually — probably because there are so few of them.

            “There are not enough women out there who consider a c-section worse than a dead baby”

            Playing the dead baby card doesn’t apply here. Under certain conditions and close observation in a hospital, ACOG stated, and reaffirmed, that outcomes for vaginal breech were excellent. The problem is that the doctors stopped being trained before more favorable research emerged:
            “One report noted 298 women in a vaginal breech trial with no perinatal morbidity and mortality (9). Another report noted similar outcomes in 481 women with planned vaginal delivery (10). Although they are not randomized trials, these reports detail the outcomes of specific management protocols and document the potential safety of a vaginal delivery in the properly selected patient.”

            A mother expecting breech may fit the selective qualifications and therefor have good reason to believe a scheduled cesarean would be unnecessary. In my friends situations, the dangers of the unnecessary cesareans would have continued to mount dramatically for all of their many pregnancies. I think it is typical of institutionalized care to cater to the masses forcing the outliers, who have different needs, through a system that will probably do them more harm than good.

            “home birth midwives aren’t health care providers by any reasonable definition of the term. I did think you were suggesting doctors or skilled and experienced CNMs doing home birth, and that’s not possible right now.”

            (1) midwives are referred to as non physician medical practitioners. (2) There are experienced CNMs doing homebith right now. Many CNMs work with OBs and operate out of birth centers as well as home.

          • Young CC Prof

            I’m not sure how having a c-section for breech on your second birth would lead to having 7 or 8 c-sections. A woman who had a relatively easy vaginal birth before the c-section baby, c-section was due to a non-recurring complication like breech, and wants more children in the future is a prime candidate for safe hospital VBAC!

            Yes, under very careful selection criteria, including ultrasound measurements of the fetus to confirm it is neither growth-restricted nor macrosomic, frank or complete breech position, spontaneous labor at term, not a first-time mother, attendant with lots of experience dealing with breech babies, and you can get breech outcomes that aren’t horrible. (Of course, a mere 800 births without a death does NOT add up to proof that it is as safe as planned c-section!)

            However, these criteria mean that many, perhaps most women with breech babies aren’t eligible. And very very few modern women want more than 4 children, which means the powerful incentive to avoid a c-section just isn’t there.

            So you’re talking about a very rare case: The woman who wants a very big family, and winds up with a breech baby relatively early in her reproductive life, but NOT the first child. I don’t think there are enough such women in the whole country to even support one breech delivery program. And what woman with a couple of young kids already wants to travel hundreds of miles to give birth?

            Also, you keep complaining about how obstetricians aren’t trained in breech, and I think you’re missing a key point. Training requires practical experience, which means having cases to observe and practice ON. The vast majority of women would not consent to let a resident practice a MORE dangerous technique on them.

            So, vaginal breech means letting some amateur who learned about it in a book catch the baby. Possibly one who learned from a book that was just plain wrong. Outcome: 5 deaths in 222 births, plus 3 babies whose fate was unknown because the midwife couldn’t be bothered to find out. Infant and maternal morbidity were not reported.

            Now if you’re really bound and determined to avoid a c-section for breech, there is another option: External cephalic version. Works about 60% of the time.

          • pburg

            young cc prof,

            “A woman who had a relatively easy vaginal birth before the c-section baby, c-section was due to a non-recurring complication like breech, and wants more children in the future is a prime candidate for safe hospital VBAC!”

            But her breeches were reoccurring. A mother who has had one breech is more likely to have another. It is reoccurring disposition. Same with the twins. My friend had two sets in a row. It reoccurred.

            “you’re talking about a very rare case”

            Yes. Yet, both sisters fit this profile. They would have had multiple unnecessary sections. My one friend would have had at least two. The other, three. That’s why I can safely assume their subsequent births would have also been cesareans. So what are the risks of a seventh cesarean? Are they comparable to the risks of having an otherwise low risk multip give birth to a breech/twins?

            “Training requires practical experience, which means having cases to observe and practice ON.”

            The excuse that there is no one to practice may justify the problem. What it also does is justify my friend’s decision to have “high risk” homebirths. Its not common for women to want more than 4 babies. But in countries and some religious subcultures desiring many children is the prevailing mind set. There should be obstetric practices to accommodate these women. When there is not, we can’t blame these women for opting out of the system.

          • Young CC Prof

            I hate to say this, but having seven or eight children is just plain not as safe as having two. There is no way to make it as safe. Even if all are uncomplicated vaginal births, the risk of maternal complications goes up, and goes up a lot after #6. Postpartum hemorrhage, for one. Also, uterine rupture is possible in a grand multipara with NO history of uterine surgery at al! I mean, you’ve got how many children already and you’re risking your OWN life to produce yet another one without access to medical care?

            I still just cannot comprehend risking a huge chance of your full-term baby dying or being permanently and severely disabled just to make it more likely that I can produce many more children. I mean, what if you didn’t conceive again?

            I will defend these women’s legal right to make that choice, but I will also do my very best to talk them out of it.

          • Box of Salt

            “Risks assessment gets slippery when we put into account the future fertility of the mother — an often overlooked element.”

            I’m sorry, pburg, on one hand I agree. Risk assessment should be individualized, and may not be straightforward for many mothers. But then there’s this sticking point. Exactly how much weight should you give a child you have not yet and may never conceive? Over the one who’s trying to be born right now?

            “The needs of the many outweigh the needs of the one*” – but don’t those many need to exist **before** you put their needs first?

            *the few? Wrong film, fans. Yes, the one you’re thinking of is the better one.

          • pburg

            Box of salt,
            “But then there’s this sticking point. Exactly how much weight should you give a child you have not yet and may never conceive? Over the one who’s trying to be born right now? ”

            I agree. Existing life should take precedence over future births or probable future dangers for the mother. If the current baby will clearly need obstetrical help, and the means of help doesn’t prove a comparably clear risk, then a reasonable person will choose to give birth the hospital. But factors like dangers to the future lives of children or to the future life of the mother can be put into play when the existing baby faces a relatively low chance of danger.

          • The Computer Ate My Nym

            I’m not sure I’m willing to grant the UK birthplace study. The data for multiparous women looked underpowered to me. I’ll agree that it showed that the risk for appropriately screened and monitored women in the UK is, at most, not very high, but it doesn’t prove no risk. Also, I worry about what would happen if you compared low risk midwife run units versus OB run higher risk units in the UK in the same way as they did in the Netherlands…in other words, are home births in the UK safer or hospital births not as safe?

          • Young CC Prof

            Are home births in the UK safer or hospital births not as safe?

            Both. Home births are safer in the UK primarily because they tell large numbers of women NOT to do it and transfer sooner.

            It’s difficult to make international comparisons with totally different populations, gene pools, preexisting health status and health care systems. However, it appears that compared to the USA, hospital birth is NOT as safe in the UK, or the Netherlands, or Australia.

            I really do believe that one reason multip home birth in the UK looks as good as it does is because their maternity care system overall is not as good as ours.

          • pburg

            young cc prof,
            I happened to run across these few sentences in an abstract. It sums up what I was attempting to explain regarding the hierarchy and common sense:

            “Proponents of evidence-based medicine have made a conceptual error by grouping knowledge derived from clinical experience and physiologic rationale under the heading of “evidence” and then have compounded the error by developing hierarchies of “evidence” that relegate these forms of medical knowledge to the lowest rungs. Empirical evidence, when it exists, is viewed as the “best” evidence on which to make a clinical decision, superseding clinical experience and physiologic rationale. But these latter forms of medical knowledge differ in kind, not degree, from empirical evidence and do not belong on a graded hierarchy.” Mark tonelli

          • Young CC Prof

            I looked up Mark Tonelli. I’m sure he’s a fine and compassionate pulmonologist, but I’m not impressed with his philosophy. Among other things, he wrote an article about why empirical evidence can’t be applied to alternative medicine, and just because something has been proven not to work multiple times in multiple different ways is no reason to stop doing it if you “feel” it should work.

            Physiologic rationale is important. Clinical experience is relevant for diagnosis in particular. But when multiple experiments performed in different ways by different people show that A has no effect on B, the other stuff just doesn’t matter! It’s time to give it up.

          • pburg

            I read the abstract. I wonder if this is what Dr. Amy was referring to when she accused me of promoting radical uniqueness: “[CAM] view illness and healing within the context of a particular individual only.”
            A sincere thank you for bringing up his other works. For all I know he is a quack. I still like what he said about the hierarchy ordering types of “evidence” that differ in kind, not degree ie apples and oranges.

          • fiftyfifty1

            “Eg. doctors told moms to put babies to sleep on their tummies in order to avoid SIDs.”

            No, doctors told women to put babies on their tummies in order to avoid *aspiration*, which a prone position does indeed help avoid. Unfortunately the risk of death from SIDS is higher than the risk of death from aspiration. Once evidence indicated that SIDS was increased in the prone position, and that SIDS was more prevalent than fatal aspiration, the advice changed.

          • pburg

            Thanks for the correction! Though, despite it, my question remains: would you judge a mother for putting a baby to sleep on her back at a time when mothers were informed, at the risk of the baby’s life, to put the baby on her belly? Similar to doctors instructing mothers to put their babies to sleep in the wrong positions, x rays of the mothers pelvis before birth were also instructed as a safety measure before research showed that it did more harm than good.

            The truth in both cases was that the intention was good and that these measures could prevent certain problems. The opposing critical information wasn’t there yet to properly assess the situation. This history is one reason why some women are hesitant to accept medical advice as gospel and birthing interventions that don’t seem pressingly necessary. Can we say that in twenty years we won’t look back in horror at what is routine medical practice today? Conscientious objection is essential, even when the evidence is not there to back up the reasoning.

          • Young CC Prof

            “Can we say that in twenty years we won’t look back in horror at what is routine medical practice today?”

            In many cases, yes. The “science was wrong before” argument is not entirely invalid, but often overused. There are practices which in the past were based on essentially common sense, which were later tossed out on the basis of solid scientific evidence.

            It’s impossible to be completely certain of anything. And there are still many things doctors don’t know, there are medical practices today that are based on “best guess” because no real evidence is available. But there are an awful lot of things doctors DO know.

          • pburg

            I completely agree. Bringing up the mistakes of the past can be/ is overused. It applies when the alternate flaw in thinking is assumed as iron clad logic. It’s best to make suggestions and recommendations based on what the best information we have right now, put into perspective how strongly supported by research, and assess the possible draw backs. AND still allow for the patient to say thanks, but no thanks without the fear of ridicule.

          • fiftyfifty1

            “AND still allow for the patient to say thanks, but no thanks without the fear of ridicule.”

            Barring serious mental illness (e.g. psychosis) or immediate danger to others (e.g. active TB) patients almost always have the right to say “thanks but no thanks”. But that doesn’t mean I can’t form an opinion about their choices or express it.

          • pburg

            fiftyfifty1,

            “that doesn’t mean I can’t form an opinion about their choices or express it.” Yes. But personal judgement and expressing concern is not necessarily ridicule. We cannot tell a woman where she must to give birth. I think Dr. Amy agrees with this. She just also feels like she’s justified in wagging her finger when the mother faces tragedy because of it. It’s akin to anti choice protesters informing women why they believe abortion is murder vs showing post-abortive women pictures of mangled dead baby bodies and calling these women murderers. *Shudder* Feel free to get info out there. Women need to know what risks they face. But leave it at that.

          • fiftyfifty1

            There are different levels of evidence. Sometimes the best we have is expert consensus. Later, we may have an upgrade to observational studies or even randomized controlled studies. I never blame someone for following the best advice we have available at the time, even if it later turns out to be wrong. I also never fault someone for choosing the “non-standard” path when evidence is weak, conflicting, or when the outcome doesn’t really matter. But where I do judge is when evidence is at least moderately strong and when outcomes matter. That is the case with homebirth in the United States: there is clear evidence of harm and the outcome (death and brain damage) is not trivial.

            Here are some examples:

            I do not judge: Choosing epidural or not in labor (outcome is trivial), baby feeding method (research is conflicting), pushing position (outcomes trivial), whether to circ or not (outcomes largely trivial in the developed world), delayed cord clamping (evidence weak and outcomes trivial), CIO vs.not (evidence weak and outcome trivial).

            Things I do judge: Homebirth in the U.S. (evidence at least moderately strong and outcome very important), vaccination (evidence extremely strong and outcomes important), vitamin K for the newborn (ditto), seat belts (ditto), sleep position (evidence at least moderately strong and outcomes very important).

          • pburg

            I have some major and minor quibbles with your judge/ do not judge list. But each of those issues deserve their own topic. So I’ll try to focus on homebirth. Some underlying issues involved with homebirth pertain to the other issues you listed.

            “Things I do judge: Homebirth in the U.S. (evidence at least moderately strong and outcome very important)”

            Evidence

            There are issues that cannot be studied empirically. So evidence or no evidence, when it comes to humane medical treatment we can only judge based on informed conscience. Thankfully, most inhumane treatment is going to have bad outcome, but we can’t always be sure and sometimes these outcomes are difficult to measure.

            Many aspects of what homebirth haters call woo is actually having a sensitive conscience toward what is undue burdens for women. I have witnessed birth in 4 of my local hospitals (FYI, I have NO professional affiliations with pregnancy or birth, just many sisters who wanted me with them). Some were better than others, all involved some type of issue that could be considered burdensome eg. shared recovery rooms, rude nurses, not being allowed to be out of the bed during stage 1 labor, given pitocin without patient’s knowledge/ permission. I could go on. I’m aware there are hospitals with more respectful staff, better accommodations, and looser regulations. I just haven’t experience them first hand. It makes me wonder why there is such a regional discrepancy.

            In terms of evidence that can be studied empirically, there are multiple factors that change the risks dramatically. As I’ve mentioned, being a low risk multip with a care provided who won’t hesitate to transfer when danger presents itself has a very low chance of bad outcome. The birthplace study has shown it can be negligible compared to similar hospital births (these requirements do apply to some women in the US.) It’s a broad brushstroke to judge all homebirths without knowing the circumstances.

            Outcome

            The baby’s life is always the trump card — with good cause. But it can blind us from what is important about life itself. For instance, Letting our kids play without adult supervision. There are more or less risks depending on the ages, competence level, companions, relative safety of the environment etc. But it is always safer for them to be supervised. If something bad happens to them while not being supervised, even if the risk is small, can we blame the mother? Many would. As long as there was a “safer option” it’s the normal human reaction to point fingers. Regardless if it is actually good psychologically, physically, and mentally for the children in the long run to be helicoptered or for their parents to be the helicopter. The problem is that these factors are less quantifiable. That’s why we must look at the fact the absolute risk for poor outcome is small. We allow (or at least we should allow) parents to make their own decisions based on their unique situations.

          • The Bofa on the Sofa

            Can we say that in twenty years we won’t look back in horror at what is routine medical practice today?

            Of course not. The probability that something (more likely somethings) we are doing now will be ultimately shown not to be the best way to do things is very, very high.

            That’s the not the question, though. The question is, “Will THIS SPECIFIC PRACTICE we are doing now be shown not to be the best?” And, in that respect, for pretty much everything, the answer is probably not. Moreover, the chance that the proposed alternative WILL be right is even less.

            Considering that there are probably hundreds of things that you can say “we are doing now” in terms of pregnancy and childbirth, even if 90% of them are never revised, that means there will be dozens of practices that will be changed in the next 20 years. Then again, the chance that anyone one specific practice will change is only 10%. Therefore, it doesn’t make sense to say, “science has been wrong before, and will be wrong again, therefore don’t do this one” is wrong. You ALWAYS play the odds; that’s the strategy of maximum return. And if you get additional information that changes the odds, you revise your bets accordingly.

            But even though the race does not always go to the fastest, nor the battle to the strongest, that’s the way to bet.

          • Amy Tuteur, MD

            I do think we will look back in horror twenty years from now at the idea that homebirth is as safe as hospital birth. People will be asking themselves how anyone could ever have believed such nonsense, just like people are now asking how anyone could have believed that vaccines caused autism.

          • The Computer Ate My Nym

            Can we say that in twenty years we won’t look back in horror at what is routine medical practice today?

            I certainly hope so! I look back at what we were doing 20 years ago and some of it’s pretty unsavory. Treating NHL without antibodies? Horrors! CML without BCR-abl inhibitors? What were we thinking! If we don’t look back in horror 20 years from now, that will mean that medicine has made no progress and that’s far worse than any anecdote about changing recommendations ever could be.

            Yes, medical practice has been wrong before. Yes, there is almost certainly something in current practice that is wrong. Probably lots of things, really. And what happens when something is found to be wrong? The recommendations, “standard dogma”, and practices change. Sure, there is resistance. Scientists are people, they can be stubborn, enamored of their own ideas, and downright corrupt just like anyone else. But eventually the data will win. Because you just can’t fake reality, as Merck discovered when they tried to hide Vioxx’s dangers.

            So, what happens when a practice in “alternative medicine” is proven wrong? Nothing. The data is ignored or dismissed as “flawed” (a meaningless word in the absence of an explanation of what the flaw is), no practice is changed, no new recommendations, no acknowledgement of being wrong. And no improvement in care.

            Conscientious objection is essential, even when the evidence is not there to back up the reasoning.

            I disagree. Objection for objection’s sake is likely to do more harm than good. OTOH, if you have sound reasons, theoretical or practical, to be concerned, certainly bring them up! Get the evidence to determine whether your concerns are warranted or not and then suggest changes based on the data. But don’t just say you won’t (vaccinate, have a baby in the hospital, etc) because you’re objecting. Give a reason and evidence for your proposed course of action.

          • pburg

            “Get the evidence to determine whether your concerns are warranted or not and then suggest changes based on the data.” In terms of conscientious objection, there is often no evidence/data to go on. For instance, let’s say we don’t look back in horror at certain current obstetric practices but, as Dr. Amy speculates, we look back in horror at the fact homebirth was practiced at all. This is not unlikely. It is also not unlikely (in such a brave new world) that all embryos are weeded out for genetic abnormalities. How awful is it that we allow children to be handicapped and face short, suffering lives when we can just select the ones who are healthy and strong? For the sake of our children’s well being, embryonic genetic screening becomes mandatory. On what data or evidence can we object? How cruel do we seem if we are willing to risk the lives of our babies?

          • Young CC Prof

            I’m honestly not entirely sure what you’re trying to say here. “In terms of conscientious objection, there is often no evidence/data to go on.”

            In a way, you’re right. Moral and ethical decisions are not based entirely on data. For example, people don’t usually decide whether abortion is morally wrong on the basis of statistics. Statistics can tell us what other people have to say on the question, in the form of opinion polls. They can tell us how many abortions are performed each year, and how many are performed for medical reasons as opposed to just unwanted pregnancy. They possibly can tell us the short and long term health consequences for the woman, and maybe even for society as a whole. But none of that tells us how much consideration we should give to the rights of the fetus. It doesn’t answer the ultimate moral question.

            Or, as your example. Science can tell us whether embryo screening is possible, and whether it’s financially feasible for all or most babies to be created that way. (The answers are “yes” and “not yet.”) It can tell us what effect this would have on the miscarriage rate, and on the potential fertility of older couples. It can determine the benefit to society of having far fewer children born with serious health problems. But no, it doesn’t tell us whether we SHOULD do it, or whether it would make us more ableist and less tolerant in the end.

            You make an interesting point. I fail to see what it has to do with home birth, however. Where is the moral incentive NOT to deliver your child under appropriate medical care?

          • pburg

            “Moral and ethical decisions are not based entirely on data…I fail to see what it has to do with home birth, however.” Eating is a basic human need. Not being able to eat during labor is a big deal for some women. Depriving women of food during labor is a type of abuse.

            Sleep is a basic human need. The day or two after delivery is one of exhaustion for moms. The few moments when not nursing or dealing with visitors, it’s essential to give the body much needed rest. But the constant temp, blood pressure checks and introductions by the shift change nurses interrupt any hope of a proper recovery. Depriving women of sleep is type of abuse.

            Not being allowed out of the bed during stage one labor is an enforced regulation in many hospitals. There is evidence that this increases the length of labor. Being deprived of movement during labor is a type of abuse.

            Some hospitals are better about these regulations than others and things have improved immensely over the years. But not enough.
            Eg.
            When husbands were not allowed in the delivery rooms, should women have just put up with it? At the time it was the norm. Now it’s seen as somewhat ridiculous. What changed this regulation? RCTs? Meta-studies? We don’t need “evidence” to dictate basic humane treatment of women and children. Being around loved ones is part of the psychological environmental factors which led to so much backlash earlier in this thread. ‘Where’s the evidence!!’ was the response. If it’s not measurable than who cares if it traumatizes women. Civilization regresses when EBM becomes the gold standard and we lose sight of the dignity of the person.

            Was the woman’s desire to be around their spouse not a good enough reason to deliver at home? Even if she was low risk? Ethical treatment of the birthing and recovering mother is not something to scoff at. It’s not about a luxurious experience at home. It’s about avoiding undue burdens in the hospital.

            Lack of Consent:

            Some personal experiences come to mind. I was determined not to feel like a lab rat during my second birth, I developed a modest birth plan. No IV (the hep-lock I was ok with). I spoke with the doc and he said that was fine. When I got to the hospital the nurses were preparing the IV and I informed them of my conversation with doctor. The response verbatim: “I don’t care what your doctor said.” In went the IV.

            My youngest sister also had a simple request that she was assured was reasonable before the birth– delayed cord clamping. After her baby was born and the OB reached for the clamp, her husband informed the OB of their wish. The OB switched into defensive mode, snapped saying there was “no evidence”, and on went the clamp.

            Long after my eldest sister’s labor, we were reaccounting the event. I mentioned how the nurses were upping the levels of pitocin every once and a while. My sister was dumbfounded. She was never asked or even told that she was given pitocin!

            Birth is an intimate and vulnerable experience. When women say they preferred their homebirth experience because “I was in control” it seems selfish and not worth being farther away from an operating room. But, being “in control” is what separates rape from consensual sex, slavery from freedom, and medical abuse from freedom of care.

          • Young CC Prof

            You know, I thought we were having a reasonable discussion, but it seems like every time I counter your points, you turn 90 degrees.

            I asked why there was a moral imperative to birth at home, you say that not being allowed to eat or sleep is a form of torture, therefore being woken for vitals and not being allowed to eat during the 8-24 hour period of labor is torture, therefore refusing to go to the hospital for labor is being a conscientious objector.

            Because having your blood pressure taken is so much worse than risking your own life or your child’s life.

          • pburg

            Well what are your feelings on birth center births? Even ones attached to a hospital allow the woman to go home and sleep afterwards. Are they risking the lives of mothers and children? How about checking vitals when mother is awake? There should be a reasonable window of time intervals to allow for rest.

            You don’t believe that burdensome regulations and lack of consent are hindrances to ethical care. Fine. But I answered your question without a 90 degree turn. The absolute risk of homebirth is low – for certain women it is essentially the same risk as at the hospital. So why blame women for choosing the one that doesn’t involve what they believe to be unethical conditions?

          • Young CC Prof

            OK, so you are claiming that women are treated unethically in the hospital, and the treatment is so cruel that some women find fleeing from the hospital is the only reasonable choice. Do I have this right?

            File a complaint with the state medical board!

          • pburg

            I don’t think fleeing from the hospital is the only reasonable choice. Many women love thier hospital experience inspite of these problems. That doesnt mean hospitals shouldn’t change to accommodate for the needs of the mother. And, yes, women should have the option to decline hospital care. For these unmeasurable reasons, and for other reasons that can be measured, home can be a reasonable option.

            It’s easy to be flippant regarding regulations which may or may not be harmful to the woman based on the circumstance. But certainly the lack of consent should universally be considered unacceptable to health care professionals and state medical boards. But, in reality, not so much.

          • Stacy21629

            “The absolute risk of homebirth is low – for certain women it is essentially the same risk as at the hospital.”

            Except it’s not. Read the recent MANA and CDC studies. It is not possible to know before labor which women and babies are at increased risk. Choosing an uneducated care provider far from emergency care to avoid being woken up in the middle of the night is a ridiculous trade-off.

            These things you’re complaining about are *inconveniences*. There’s nothing “ethical” or “unethical” about it. Certainly not “abuse”. Holy hyperbole Batman.

          • pburg

            I discussed the safety statistics earlier on this thread and not all homebirth midwives are uneducated.  Many work with OBs. Your statement (and others like it on this site) is what’s glarringly hyperbolic.  There are levels of abuse. Some are inconveniences or even non issues. Being deprived of food never bothered me personally. But I have short labors.  Some women have very long labors and desire nourishment during what is essentially a marathon of pain management.  Same with sleep interruptions.  It may not be a big deal to some women. Women with cronic fatigue syndrom would disagree.  This also applies to not having the husband in the room. I’m sure there were women were thrilled that their husbands didn’t witness their birth. Does this mean it wasn’t cruel to the moms who wanted the support and to their husbands who wanted to be there?  Conveyor-belt care hurts women.

    • Jessica S.

      What safer place to have your baby delivered than a facility fully equipped and staffed to deal with any scenario? “Home” is not a safe place. It might be more comfortable, but that doesn’t equal safe. And using “primal brain” as an explanation doesn’t excuse the risk. We’re able to reason, so we’re not subject to it.

    • PJ

      Well, I think transport during labour sounds hideous. In fact, it’s one of the biggest things that puts me off homebirth. In those situations where homebirth safety approaches the safety of hospital birth transfer rates are around 40%–not really good odds when the appeal of homebirth is supposed to be the nice ambiance.

      I call baloney on your primal brain theory. I personally could not have cared less what my surroundings were when i gave birth, or who was there. I didn’t expect that to happen, either.

  • Trulyunbelievable2020

    Another OT: When you google “Christy Collins Midwife” it now could not be clearer that she was just involved in a preventable death. Great work, Amy! That simple fact may very well save a life.

  • Sullivan ThePoop

    This is OT and from the NY times article about autism that Dr. Amy posted on facebook. It says that elective C-section increases the risk of autism by 0.5 and then goes on to say that most elective C-sections are for nonmedical reasons, but they said my SIL C-section was elective and it was for medical reasons. I think it is more likely that babies born prematurely are often delivered by C-section. What do you guys think?

    • Ash

      Can a healthcare professional clarify what classifies an elective c-section? Is a scheduled c-section for breech elective?

      • Karen in SC

        Elective is the medical term for non-emergent. It does NOT mean “just because”. There is usually a definitive medical reason for proceeding to c-section.

        • Sullivan ThePoop

          My SIL’s C-section was for twins where baby A was 30% smaller than baby B who was transverse breech. I am not sure in what world trying to vaginal birth them would have been a good idea.

          • Dr Kitty

            The official recorded indications for my CS was
            1) Maternal Spina Bifida
            2) Maternal request

            Which reflects the fact that my OB thought that we had a 90% chance of obstructed labour from likely CPD because of my wonky spine and pelvis, and I decided that given those odds I preferred to skip the obstructed labour part and opt for a planned pre-labour CS.

            An elective CS is like an elective gallbladder surgery or an elective hip replacement.
            It is scheduled for a convenient time, but it isn’t done without a reason.

        • The Bofa on the Sofa

          Elective is the medical term for non-emergent.

          I suspect that this is the source of the confusion.

          A c-section that prevents a problem is medically indicated.

          As I’ve always pointed out, if you want to get technical, EVERY c-section is “elective” since they only happen when someone chooses to do them. They don’t happen spontaneously.

          However, that is not what it is meant by an “elective c-section.”

      • Mr.G

        Elective=Scheduled and NOT “unindicated”
        You can do a scheduled cesarean with a medical indication or without, in which case it’s usually “maternal choice”.

    • Elizabeth A

      (Warning: I am speaking as a layperson here.)

      “Elective” sometimes has a very different meaning in hospital (and insurance) parlance then laypeople thing it does. My c-section, for example, shows in the books as “elective,” which may have been true in the sense that it was (barely) scheduled, and could potentially have been delayed until an unknown later moment when a crisis occurred that put someone’s life in imminent danger (as opposed to not-imminent, but clearly very near, danger). But because the attending OB was able to “schedule” my section for 45 minutes after I arrived at the hospital hemorrhaging from placenta previa, instead of doing a lightning speed evaluation and calling a crash section, and because I suppose I could have argued for a delay to see if the bleeding stopped… well, it’s on the books as elective.

      Premature babies are more likely to delivered by c-section, because the circumstances for which we deliver babies prematurely are far wider ranging then unstoppable pre-term labor. And I suspect premature babies are somewhat more prone to autism and autism-spectrum disorders, because they miss out on in-utero brain development, and then suffer from the breathing and feeding difficulties that often follow on prematurity. That said: the outcomes for many premature infants are excellent. The care and technology improves all the time. Many premature infants will be absolutely fine, and many more will have good quality of life despite prematurity-related disabilities, so I don’t see this as a reason to delay c-section in cases where it’s needed, or as an argument against providing premature infants with the very best care available.

    • AllieFoyle

      I think that reporters often wrongly conflate “elective” with “not medically indicated”. This makes it seem as though doctors are doing unnecessary c-sections and increasing the rate of autism as a result, when it is just as likely that the factors that increase the rate of having a c-section also increase the likelihood of autism.

      • Sullivan ThePoop

        unfortunately this was not a reported. He is a neuroscientists.

    • Mariana Baca

      I thought MRCS was actually really rare?

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

        Real MRCS is maybe 1-2 percent – comparable to the rate of homebirth. Finding a provider/hospital/insurance that is accommodating can be a real challenge.

        • Dr Kitty

          MRCS, of course, still includes tokophobia, sexual abuse survivors and various psychological indications.

          • The Bofa on the Sofa

            So what you are saying, then, is that “c-sections for convenience” (e.g. too posh to push) are very, very rare?

      • SuperGDZ

        I wonder. I suspect a lot of women who choose MRCS attribute the CS to a “big baby” or some such in order to avoid the whole “too posh to push” discussion.

        • DaisyGrrl

          If I ever have a baby, I’m going to push hard for an MRCS (not easily obtained where I live). If I get it, I’ll tell friends and family the truth, but acquaintances and anyone being nosy? Active. Herpes. Outbreak. If that doesn’t shut them up, I don’t know what will.

          • The Bofa on the Sofa

            Herpes simplex 10?

          • DaisyGrrl

            Okay, that’s a win!

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

      I call bunk – but until they do an actual study on actual MRCS and the outcomes, it would be really hard to know.

    • Anne

      Most elective Caesarean sections are for repeat Caesarean section, offered because the risk of trial of scar (the medical term for VBAC, and more accurate prior to the birth, IMO) is greater than that of repeat Caesarean.
      Others are for twins, breech, praevia, IUGR.
      Medical indications, all.
      As is desire to avoid vaginal birth (either primary or following a traumatic prior birth).
      They all require counselling regarding pros/cons- a process called informed consent common to any surgical procedure (or medical treatment, for that matter).
      For preference, I would use “planned” rather than “elective”, but meh, it is common medical terminology.

  • moto_librarian

    This tragedy encapsulates everything that is wrong with American homebirth midwifery:
    1) A CNM (who definitely has the education and training to know better) fails to screen out a patient who is not low-risk even at the beginning of her pregnancy (45 year-old primip). Fails to transfer care when the stakes get even higher (patient is postdates).
    2) Rather than blaming the incompetence of the midwife, mother blames the medical establishment. She should actually be wondering why her CNM didn’t apply for and receive hospital privileges, since she had the appropriate credentials to do so. Mother also ignores the fact that CNMs routinely work in concert with OBs in hospital settings.
    3) Midwife will almost certainly escape accountability for her role in this tragedy,nor will their be financial redress for the family.
    4) Due to her age, mother is unlikely to have the opportunity to have another child.

    • Guestll

      Heineman wasn’t a primip, but it didn’t matter here.

      • moto_librarian

        I just reread her latest article and realized that, Guestll. Editing my post to reflect that.

    • Ellen Mary

      She was 45?!?!?

      I admit I thought they were harsh with me @ 36. Because they offered induction @ 39 weeks & suggested induction @ 40 weeks. (But would not give me a NST @ 39 weeks). However, though I was unsure about induction solely based on dates & AMA, having read the literature on PubMed, I absolutely would have insisted on the NST if they were not offered starting @ 40 weeks. Actually the article I looked at suggested starting them really early, maybe even 36/37 to help an AMA woman to achieve the same StillBirth risk as a younger woman.

      Post dates @ 45 without NST is definitely loco. :(

      • Angela

        Can you post the link to that article, please? The MFM doctor that consults with my CNM suggested beginning BPP’s at 36 weeks and I didn’t really understand why so early.

      • Guestll

        Why is offering you an induction at 39 weeks in order to mitigate issues around AMA pregnancy “harsh” ?

        It’s not a personal reflection on your age. We really need as a culture to move away from the current notion of age as a social construct as it relates to fertility and pregnancy. It benefits no one.

        • AmyP

          Plus, none of these medical decisions are some sort of judgment on us as mothers. This is not a test.

          • Guestll

            The perception is that it’s a judgment against them, as women — you’re old! — and all of the negative perceptions of ageing women. Not as a judgment of them as mothers.

  • Amy Tuteur, MD
    • Trulyunbelievable2020

      Haven’t read it yet. I just hope that if there’s nothing egregious save for one or two piddling little errors you’ll just ignore it, Amy. I agreed with you 100% the last time you engaged with these folks and I wrote posts and tweets on your behalf, but when all was said I done I wasn’t so happy to see the blog focus so much on what ultimately seemed to be a rather pointless squabble in the end.

      Of course you’re the person writing this material and you’re free to do what you want. Just my two cents. Take ‘em or leave ‘em.

      • Sullivan ThePoop

        I read that article. I did like the way that they showed how much better the UK birth study was than the MANA study but I did not like how they said the MANA study showed bad outcomes to be rare.

        • fiftyfifty1

          Yeah, this really annoyed me:

          ” Although the data did show that poor outcomes are rare, because of the lack of control group it’s impossible to say if they are less rare than in hospital, though the suggestion is that they are”

          Why must people persist in insisting that we need a “control group” instead of the CDC data in order to tell if bad outcomes are more common at home? Look, there are 3 lime-green VW bugs on my block of 12 houses. I do NOT have to hit the streets with a clipboard sampling a bunch of other neighborhoods to determine whether my neighborhood has a statistically significant over-representation if instead I can go to national manufacturing statistics. When a reliable, comprehensive nationwide manufacturing database exists that records data on virtually every car says that lime-green bugs make up fewer than 1 out of every 1000 cars, then I can use THAT as my comparison group.

          So one final time everybody: there IS a comparison group. It is the CDC Wonder database which contains the outcomes of nearly ALL the hospital births during the same time period. And it proves that the MANA outcomes suck.

          • Young CC Prof

            They also could have compared the Birthplace study directly with the MANA study, since the number of home births was almost identical. MANA: 22 intrapartum deaths. Birthplace: 6 intrapartum deaths.

  • Mariana Baca

    Given I’ve never been pregnant, I don’t know the answer to this question, but to books like “What to Expect when you are expecting” cover things like common birth complications, dangers of post-dates, etc? I feel there should be an entrance-level pregnancy book that gives mothers simple yet scientific knowledge of birth complications as part of the standard “learning about the changes in my body” reading pregnant women do. And recommend all new mothers read it.

    • Karen in SC

      I think it does, at least basically. I remember reading about HELLP syndrome there after my SIL had it. This was 20 years ago before google research, so that book was the “bible” of pregnant women.

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

      There is no lack of literature available. Real mamas choose not to read them since they are so obviously written by Big Medicine who so badly wants to wrest your glorious birth from you and turn you into a sacrificial sheeple.

      • Mariana Baca

        Ok, Do you have 1 or 2 titles to recommend to people? I know there is no lack of literature, but I was thinking more of “what commonly read book” covers these things, that people are so ignorant that they are swayed by the NCB crowd. Most people that have never been pregnant don’t know post-dates are dangerous, or that PPH is common, or that there are things that might be unexpectedly wrong that can’t be easily resolved. If the recommended literature and birth classes are full of woo, is it surprising that is what mothers absorb?

        • moto_librarian

          I think “What to Expect” is a good title. There’s also a “Your Pregnancy Week By Week” that discusses testing, complications, etc.

          • Mariana Baca

            thanks!

          • Dinolindor

            I personally really disliked “Your Pregnancy Week By Week” and eventually stopped reading it altogether because of a specific medical element that I felt it had completely wrong. It said don’t worry about testing out your thyroid levels until the late second or third trimester – even if you have a pre-existing thyroid issue. That’s just plain wrong, and it’s actually crucial to make sure hypothyroidism is being medicated correctly in the *first* trimester. As my endocrinologist put it, you “tell your husband, then call me, then call your OB.” I can only hope that I had an outdated edition and it’s since been fixed. However, I do like “What to Expect” aside from all of their dreadful word play. As someone mentioned on another post, it’s easy to skim and get the important information and skip the things that you know won’t apply to you.

          • Sullivan ThePoop

            I developed hyperthyroidism during my 8th month with my first.

          • AmyP

            WTE is very good as a reference.

        • Guestll

          Mayo Clinic Guide to a Healthy Pregnancy

          • Mariana Baca

            Oh, that one looks really good, actually. thanks!

        • Dr Kitty

          I think we should crowd source a new book from the posters here.

          “The Evidence Based Guide to Pregnancy for the Risk Averse”

        • Anj Fabian

          I’m going to have to vote “No.” on WTE. It’s very friendly. It’s very reassuring. It’s extremely careful not to present anything in an alarming way.

          Rereading it well after I was pregnant, I realized that it downplays and minimizes various problems. It’s great if you are prone to anxiety. If you want a more honest, more informative and more detailed source – look elsewhere.

          • Wren

            I found it depended a lot on which version you read. The one I read back in high school when I was babysitting regularly for a family expecting numbers three and then four was friendly and downplayed problems. The one I read when I was pregnant 9 years ago was terrifying, with potential risks listed all over the place. “Eat X or do Y and your baby could die!” I’ve heard the version after that one really toned down the risk stuff.

          • SuperGDZ

            I took my WTE along to the hospital for the birth of my daughter, in case of something happening that I hadn’t prepared for. But as much as I tried I couldn’t find the bit that explained about your baby dying.

          • Dr Kitty

            I’m very sorry for your loss.

          • Jessica S.

            I’m so sorry your daughter died. I imagine they wouldn’t want women to expect that, but it doesn’t make it less of a reality. I hope you’re doing well.

        • Laura

          Don’t a lot of the mainstream pregnancy books say, “Talk to your provider”?

    • Comrade X

      Yup, my ex-sister-in-law was HORRIFIED by how honest mainstream pregnancy & childbirth books were about potential complications and dangers. It’s SCAREMONGERING, don’t you know. Informed consent, minformed zonschment.

      • AmyP

        I find that section of my old copy of What to Expect really scary and I think I’d only consult it for reference. My problem with it is that even in the worst case scenario, you’ll only wind up with at most two or three of the bad situations, so it doesn’t make sense to prep for all of them and be knowledgeable about all of them. The most helpful thing to know is when to call for medical advice–bleeding, fever, amniotic fluid leaks, whatever.

        The advice in WTE to watch for lack of movement is also not super helpful. That’s pretty much a ticket to Crazytown if one has to monitor one’s unborn baby that closely. There were certainly very long stretches where I didn’t feel much at all, even with totally healthy pregnancies.

    • AllieFoyle

      I guess I’m in the minority here, but I had a hard time finding information about the medical side of pregnancy and birth. I felt like most of the books available at the library and bookstores were NCB/midwifery oriented, and the more mainstream options (basically What to Expect) had very minimal information.

  • Amy Tuteur, MD

    By writing a book and aggressively promoting her views about responsibility for homebirth deaths, Heineman has started a valuable public discussion.

    She wants you to know whom she blames for her son’s death. I think it is critically important to publicly question her claims so that women will consider that 1. babies can and do die at homebirth and 2. who is responsible when that happens.

    • Trixie

      She’s like Ruth Iorio (although Iorio’s life was, thankfully, saved by the hospital). Using the disastrous homebirth experience to promote herself and the NCB philosophy.

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

    I think a more apt comparison would be free syringe programs for IV drug users. If someone contracts a disease because of a lack of clean needles it is partially their fault for choosing to use. Its also partially society’s fault for not doing anything to protect people who are in that situation. If there are no safeguards in place for people, and no advocacy for it, then essentially we are collectively saying that the results are acceptable.

    Pretending that people who are tasked with helping are *never* to blame in any way is unrealistic. There hasn’t been much effort for harm reduction outside of discouraging homebirth (which obviously does nothing to reduce harm for people who aren’t discouraged). Hell, you could blame the public for not giving enough of a shit to fight CPMs when they push legislation. I sure as hell do.

    • Amy Tuteur, MD

      The problem with that analogy is that drug users are in the grip of addiction and that their judgment is impaired by drug use. Those factors do not apply to homebirth.

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

        No but a lot of homebirthers are in the grip of what has been described a cult (even here).

      • Comrade X

        OK, what about people who (sober and sane) decide to take part in dangerous “extreme sports”? They are probably more culpable than your average indoctrinated homebirth mum, maybe less responsible than an addicted drug user…but the ambulance crews are still waiting at the bottom of the cliff in case anything happens.

        • Amy Tuteur, MD

          Because they pay them to wait.

          • Comrade X

            Not in my country. But I take your point.

          • Dr Kitty

            Actually, most of the ambulances and crews at events ARE privately paid in the UK by the organisers, they aren’t NHS crews on standby.

            They look identical to the casual observer.

            http://www.eventmedic.co.uk

        • Stephanie

          Extreme sport junkie here: Becayse its only my life that I risked when doing my sports, and I know if anything happened to me it would have been my own fault. Most extreme sport individuals feel the same. In addition, since I’ve had kids, I have not participated and choose not to participate until they are grown. Because right now I wouldn’t only be risking myself. And yes, we pay for the ambulances to wait.

      • Alenushka

        Addiction is a serious illness . There is of then a co morbidity of mentally illness. So, yes, harm reduction approach is appropriate. People who desire on HB are of sound mind and body.

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

        I disagree. A cult mindset is very, very similar to addiction, and is just as hard to escape. Although I definitely agree hb moms bear some responsibility, that brainwashing goes deep.

        An OT example – my former cult leader has a new group of followers. Over the last week, he has been claiming we met when he was 17 (he was 19). His inner circle have defended this accusation, despite the fact that the cult activities made a big internet drama that has been documented in many places. It’s an easily disproved lie on his part, yet his followers have gone so far to claim I have altered the data recorded by outside sources 10 years ago in order to hide the “truth.”

        Once you’re in deep, you can’t judge. The brainwashing thinks for you – much like the addiction thinks for an addict.

        • AllieFoyle

          You don’t even have to be in a cult. You can simply be unlucky enough to get the wrong information from the wrong people at the wrong time.

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

            I’d argue that’s how you get into a cult to begin with but I think we’re starting to split hairs at that point ;)

        • Laura

          Where is your hope then for getting out of the cult and making some sense of the mess it caused for you? And I certainly don’t mean any insult to you personally, as I can see that you are very intelligent.

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

            The only way I’ve seen people really get out of cults is when something they can’t internally justify, ignore or explain away causes a crack in the armor they’ve built to protect them from truth/reality. It’s very difficult to say what that will be – I personally had mountains of factual evidence telling me my cult leader was lying as often as he was breathing. I could ignore or justify it (because I had different ways of knowing!) for years. It was an epic disaster followed by a small, but easily provable lie that cracked me. I was blessed to have a family (esp my mother) who supported me and got me into therapy.

            Again, not unlike addiction; I hit bottom, had a “moment of clarity” and had to rebuild myself and my life without the thing I’d used to shield me from reality.

            tl;dr: Facts and truth are the only escape. The truth will out – literally.

          • Laura

            Glad you had a mama who stuck by you! I am happy you have gotten out of that cult.

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

            Thanks! This month officially is when I’ve been out longer than I was in. I cannot even express my gratitude to my mom and family.

      • Trixie

        There are also factors such as intelligence, basic science literacy, critical thinking ability, etc. that can come into play. An Amish mother with an 8th grade education who doesn’t understand what Group B Strep is, who faces tremendous social pressure to homebirth and save money by using the cheaper midwife, bears less responsibility when disaster happens if her midwife leads her astray. Heineman is educated, a college professor and a published author, who works at a university where they also have an actual hospital. She could access the information if she wanted to.

    • RSM

      It is the heroin addicts fault entirely. Taking away responsibility for their use, and related actions, is the very worst thing you can do for them. No addict is powerless, and telling them this makes them believe they can do nothing for themselves- which is NOT true!

      Addicts are NOT helpless. EVERY time a drug addict goes to use, they have an opportunity to do something differently. They must be empowered by personal responsibility, not turned into helpless creatures by denying their agency.

      So who is to blame? The person that picked up the syringe in the first place.
      It takes effort to be a junkie. Heroin isn’t something you just pick up, like a cigarette, it is deliberate, and requires repeated bad choices.

      The biggest difference between HB and addiction is the perception of safety, and societal approval of the dangerous action.

      There is not a single addict, or person, in this country that thinks injecting drugs is anything but hazardous. There are no groups out there telling people that heroin use/needles are acceptable and safe. This is not an accepted behavior, and kids are told the facts about this particular drug from the time they are in grade school. HB is the opposite of this, and until recently, it really was possible to think HB was as safe, or safer. The beliefs that lead to HB (NCB) are approved, and even pushed, by professionals.

      By denying addicts needle exchanges, or even just the ability to buy clean ones OTC (most places DO allow this), society DOES fail. It fails the addict, but most of all, it fails the community by allowing the easy spread of preventable disease. Still, addicts make choices every time they use, even if impaired.

      Society FAILS HB moms by not regulating them the same way we regulate all other HCP’s. Letting them do what they want, when they want, and pay them too, makes HB more dangerous than it needs to be. The NCB community that spreads the lies FAILS moms, and the legitimate professionals that either promote, or are silent and complicit, with the HB MWs also FAIL HB Moms.

      Still, moms DO make the choice to HB, and with every appointment they choose this type of care. They prize this ability, and brag about it anytime things go well (and often even when they don’t!)

      • attitude devant

        Absolutely with you there. We have a member of our family who is often suicidal. It does NOT help to portray her as powerless. She is the ONLY person who can help herself, by going to therapy, taking her meds, ect.

  • Trulyunbelievable2020

    Slightly OT: Just came across a gem from MDC. Every once in a while (by which I mean at least two to three times a week) you get someone on these types of forums who is really just a certifiable moron. Elizabeth Heineman clearly made a very stupid decision, but I think we can all agree that she’s probably a fairly intelligent person in general. Folks like these are a totally different specimen. Please note the brilliant use of quotations in this post:

    “For you other natural/unassisted moms. I am planning on having ahomebirth (with midwife) however, I am totally against testing for GBS. With my last pregnancy I was GBS “unknown” and so didn’t have to get antibiotics. However, we ended up having to go to hospital since my daughter appeared “jaundiced” and since I was GBS unknown they made a horrendous deal about this and pumped her (unnecessarily) with antibiotics for a week! I was furious. Since she was perfectly healthy and did not need their “intervention”.

    I want to avoid all the “politics” of this situation this time around but still wish to not have antibiotics for my birth. As I believe they destroy the good bacteria of both mom and baby.

    Has anyone “swabbed themselves” for GBS and just didn’t actually swab anything but pretended to do so? Would this work for producing a negative GBS swab and avoiding all the medical “interventions”? I plan to still take heavy doses of PROBIOTICS, garlic, kefir, etc. To make sure I am GBS free at birth. Any suggestions or others who have done this?What would a lab test for in a swab GBS culture?

    Thank You”

    Seriously, you moron– why did you go to the hospital in the first place when your baby “appeared ‘jaundiced?’” After all, you know so much more than them. And you’ve been taking PROBIOTICS!!!

    • Comrade X

      Reading that just raised my blood pressure. Physically.

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

        Hm. You need more kale.

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

      Neonatal jaundice is not a sign of GBS infection necessarily. It could have been ABO incompatibility, which no amount of garlic, kale, or kfir could have helped. This story sounds as if quite a bit was omitted. But you are right — the mother is what I call an ignorant expert.

      • Trulyunbelievable2020

        “which no amount of garlic, kale, or kfir could have helped”

        Oh, c’mon… now you’re being silly. No amount of kale? Is there any medical problem that can’t be solved by a certain amount of kale?

    • Bombshellrisa

      She has earned the idiot stick and twit basket medals of honor. If she knows so much about GBS, then she should know that her kefir and garlic aren’t going to do a thing. She obviously has never seen a baby girl who died in utero because her mom had GBS or a baby die shortly after birth whose mother wasn’t treated. When I went into labor one day before I was supposed to have my appointment that included the swab for GBS, my status was unknown too and easily remedied with a bag of antibiotics. Maybe they were an unnecessary intervention-but what if they weren’t?

      • moto_librarian

        My first swab got lost, and I repeated it at my 38 week appointment. When my water broke at 38 + 3, I was planning to go unmedicated, but called the on-call midwife to be sure that my test was negative because I knew I would need to go to the hospital for antibiotics if it wasn’t. She looked up the results via computer and cleared me to labor at home.

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

      Hope that someone told her that sending in an unused GBS swab would not give a “negative” result, but trigger a red light that the swab must be repeated. Easier to do a swab and then refuse antibiotics, no one can be coerced into receiving treatment if they are willing to sign a release ‘against medical advice”.

      • Trulyunbelievable2020

        Yes, I did. I have now created my 87th account on MDC. I’m really, really trying to successfully fake advocacy in order to hopefully give them at least a little bit of reasonable advice. I’m trying as hard as I can to work at least one egregious grammatical error into each post in order to fit in. (Just to be clear, I’m no expert myself: I’m just a person with two working brain cells.)

        I’ve just figured out that trying to prove to these people that they’re stupid simply doesn’t seem to work. Better to try to minimize the risks that they’re taking. Although I suppose that I could be wrong on this.

        • T.

          “I’m trying as hard as I can to work at least one egregious grammatical error into each post in order to fit in.”
          You win the internet today.

        • Trixie

          Great work you’re doing over there. Now I’m going to try to figure out your new name.

    • Carolina

      Do some people get to do their own swabs? My OB did mine. Other than collecting urine, I’ve never been responsible for providing a swab, blood, etc. It’s done for you. Odd.

      • Guestll

        We do our own GBS swabs here, in the bathroom during an appointment.

      • Trixie

        I did my own. It’s not rocket surgery.

        • Carolina

          Not saying it is. Just was odd to me.

    • Dr Kitty

      “Jaundice” can be a sign of “sepsis” which can cause “death”.
      “Jaundice” can cause “kernicterus”, which can cause “brain damage” if left untreated.

      I had a beautiful yellow baby for the first week, but I wasn’t worried because we were keeping an eye on her bili levels, they were well below the treatment curve and she was very well.

      If you have a jaundiced baby that *might* have GBS sepsis the only sensible and safe choice is to treat them as if they *have* GBS sepsis until you can prove otherwise.

      Because if they have GBS sepsis and you wait the 48hrs for test results, there is an excellent chance they will die.

      • AmyP

        I admire your use of quotation marks.

      • Young CC Prof

        I still haven’t forgiven the hospital for releasing my son without testing his bili again.

        37-week 5 pound baby, so elevated risk for, you know, any sort of newborn issue. Cord blood bili, just a hair over normal. 48-hour bili, 9.5. 72 hour bili? Eh, he’s fine, why should we bother testing again, just take him home, let the pediatrician test in a day or two. And what did I know? I knew lots of babies got jaundiced and it usually wasn’t a big deal, so I didn’t ask the right questions.

        94-hour bili? 21. By the time we got him to treatment, he was too sleepy to eat. Oh, and separately he was down 14% from his birth weight with sodium levels in a rather alarming zone. I still shake when I think about it.

        Releasing him, without a word to us implying that his condition was anything but thriving, was gross freaking negligence. Their maternity/prenatal care is great, but I am NEVER having another baby in THAT hospital. I’ll go to the hospital that saved him, even though it’s further away and my wonderful OB doesn’t practice there.

        • LadyLuck777

          Yea, I got a phone call from my pedi office saying that his direct bili was 21. I lost it. My husband insisted that I heard wrong. We rushed to the ER (I’m thinking surgery) who was ready for him and got a phone call in the ER saying “Oops! It was indirect after all.” Either way, I was grateful that interventions were available, but I was so relieved that we only needed fluids and bili lights for three days in the NICU.

  • Comrade X

    As a Brit, I am absolutely appalled that medical professionals seemingly have no duty of harm reduction or harm mitigation in the United States. In the UK, if some crazy fuck insists that she’s going to give birth to her breech twins at home with high blood pressure and a maternal age of 40, real NHS midwives and doctors have a POSITIVE DUTY to go to her home and provide her with the very best care they can, while strongly encouraging her at every point to transfer to a place with better facilities and more staff. Absolutely no way is it those midwives’ and doctors’ FAULT or RESPONSIBILITY if something tragic happens to mother or baby(ies) at home in that situation. But the idea that they have ZERO duty whatsoever to actually try to make her as safe as possible is genuinely shocking to me. I know y’all are culturally very into personal responsibility and self-reliance and stuff, and there are many things that I truly admire and adore about your country, but wow, that’s fucked up.

    • Alenushka

      We do not have resources for that. We have ON shortage as is. NHS does not have it either. You keep sending two MW to houses while your maternity units are understaffed and poor women get increasingly woo based care instead of epidural and OBs. Hospitals can concentrate resources and special lists and lives. OB in the living room is a waste of a doctor. If someone wants to take ridiculous risks that is on them. Why should I as a taxpayer and insurance system participant enable that?

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

        lol someone hasn’t looked at the defense budget.

        • Karen in SC

          An interesting point, but one not easily acted upon. It would require diverting defense monies to medical schools so more talented individuals choose that profession. As it is, it takes smarts, dedication, and a huge debt to enter the medical profession.

          I wish our legislators felt that way.

        • staceyjw

          I am all for more cash for the medical system, and am a critic of the ridiculous military spending we do need, while a millions of people are homeless, but HB is NOT something we need to pay for.

          I do not know how the UK is, but I am sure that their military budget is not like ours.

          HB is a luxury in industrialized nations. It is unnecessary, and a drain on resources now and later. It does nothing to improve care. In the USA, Medicaid does not pay for more than basic care, so HB is a ridiculous thing to ask for.

          If more money goes to maternity, I would rather see it go to ensuring 24/7 OB and anesthesia coverage at all hospitals, as well as 24/7 epidurals. Since the majority of women WANT epidurals, that is who should be catered to. Not the ones that want a resource intensive, harmful practice that harms babies!

          • AmyP

            Exactly–it’s more resource-intensive than hospital birth, while yielding worse results. And then you might need to transfer anyway…

      • Comrade X

        I think this must be a basic cultural disconnect between our two nations. Whatever it was Oscar Wilde said about two peoples divided by a common language seems to fit here.

        • Alenushka

          Keep making assumptions. My native language is Russian and I grew up in Soviet Union. Next time someone want to do brain surgery at home, should we have OR suit in the their living room? No number of MW and OB in anyone’s living room will make it as safe as hospital birth. I completely understand OBs who do not want to even consider home-birth. OB love helping people . They love saving women and babies. That is where it is at. No normal OB wants to watch someone bleed out or suffocated in their comfy living room My doctor sometime advises me against certain thing I want to do. Why? Because it is her duty. Her duty is not making me feel comfy, loved and like everything is going my way in this world. Her duty is to prvode science evidence based treatment.

          • Comrade X

            Alenushka – I sincerely apologize for making assumptions about people’s nationalities.

            I agree with you that you cannot do brain surgery at home, that home will never be as safe as a hospital, and that doctors should not ever be forced into providing inappropriate treatment to their patients.

            I do think there may be a case to be made, though, that in an emergency, a doctor has a duty to provide the best treatment they can under the circumstances. That is all I was saying.

          • Alenushka

            Apology accepted. Here is the catch. Homebirth is not an emergency. It is event well planned in advance despite all the warning that is not a good idea. Risk has to be assumed. When I go swimming in the pool, I assume that I can drown. I do not demand ICU crew on site. I bike to work without a neurologist in tow. I assume the risk and that is not helathcare providers fault that I do the things I do.

          • SuperGDZ

            The point is that usually these women will not have seen a doctor. It isn’t the responsibility of doctors to track down random women who aren’t their patients and invade their homes.

          • Dr Kitty

            If a woman in the UK is advised against a HB and still insists, she’ll get midwives, but a Dr won’t attend her Homebirth.
            Where did you get that idea?

            Patients in the UK cannot demand a course of treatment their doctor believes to be medically unsafe and no consultant obstetrician on call would ever leave a busy labour ward to attend a HB they knew was unsafe. The needs of the many women on labour ward outweigh the needs of the one woman who is actively choosing a high risk birth against medical advice.

            You insist on NHS HB even if you are high risk you get NHS HB. Two midwives. No Dr.

            Same as everyone else, and every midwife and Dr you see will make every effort to get you to transfer to hospital before, during and after labour.

          • Joyous76

            There aren’t enough midwives in my area of the UK to do homebirths anyway. So I don’t think she would have even gotten that.

          • Trulyunbelievable2020

            “Клеветникам Аленушки!”

          • AmyP

            Chto klevetnikam Alenukshki?

            (Sorry, not one of the cool kids–someday I’ll type in actual Cyrillic.)

      • AllieFoyle

        But that is their system in the UK. Midwifery care and home birth is integrated into maternity care as a whole. Her point is that UK home birth midwives would never have planned a home birth for a woman with risk factors like this because they operate under a standard of care, while midwives in the US seem to be free to do whatever they feel like for whatever reason strikes them with little to no consequences or accountability.

    • Carolina

      People are allowed to refuse medical care. That’s basic autonomy. However, you do not have the right to demand medical care on your specific terms. Any laboring woman will get health care IN A HOSPITAL in the US. The professionals do not have to cater to crazies. What makes you think someone who refuses to give birth in a hospital will allow medical professionals in her house?

    • Joyous76

      As an American living in the UK who had a baby four months ago. I never saw a doctor during my pregnancy and I only saw one midwife twice and all the other times it was whoever was covering for the person I saw the previous time. If I had decided to homebirth on my own, I just wouldn’t have bothered calling anyone after going into labour and since none of the midwives I saw seemed to remember anything about me I am not sure they would have noticed. I was supposed to have an appointment every week after 38 weeks, but there weren’t any available in my area. Good thing I went into labour at 39+1.

      • Christina Maxwell

        Do you mind me asking roughly where in the UK you are? I’m in the East of Scotland and maternity services are very sub par. There seems to be no lack of funds, they keep building shiny new birth centres (miles from the hospital) and doing up the rooms at the hospital. However, you will not get to see an actual OB during your pregnancy unless there is something going really wrong, epidurals are as rare as hen’s teeth and homebirth is heavily encouraged.

        • Joyous76

          Cambridgeshire. Isn’t it depressing? I used to live in Glasgow. There are a ton of women having babies here and many of us older. My dental hygienist remembered more about my pregnancy than the midwives and I usually had to travel to another centre to get an appointment. Good thing I drive. Our new birth centre is in the hospital though. I got an epidural, but only because I had ICP and my babies heartbeat speeded up and they wanted her out with forceps quickly.

  • Jessica S.

    I’m a big fan of “fighting” substandard options by creating and promoting the better alternatives. The bottom line frustration for me is the degree to which hospitals and the “medical establishment” is maligned. Trying to change the mindset of home birth advocates is exhausting to me. (This isn’t to say it’s universally pointless. I’m also a big fan of individuals pursuing the solutions they’re motivated by, rather that dictating “this is the one true way!”) I’m sure there are improvements that can be made in hospitals and in practices, but I suspect the larger problem is that the reality of what a hospital birth is like is not the dominant narrative.

    This may not make sense to anyone, or it may seem as if I’m splitting hairs or whatever saying is appropriate here. :) But when faced with the problem of what to do about the safety of home birth, what message is appropriate, what’s “off limits” or should anything be considered as such, etc., I find myself at the same point: I don’t feel like women who are likely to choose home birth are giving hospital delivery a reasonable and reality-based consideration. I want to understand exactly what they think is going to happen in the hospital, and counter the false concerns. Let home birth become irrelevant because hospital delivery on its face is a more attractive alternative.

    Ok, rambling over. :)

    • Amy Tuteur, MD

      99% of women choose hospital birth whether they think the hospital is attractive or not. I don’t think the “attractiveness” of hospitals has anything to do with the decision to choose homebirth. The decision is all about REJECTING conventional alternatives, not the unattractiveness of conventional alternatives.

      Homebirth is about not being one of the sheeple. So if everyone is going to the hospital, homebirth advocates aren’t going regardless of the attractiveness or unattractiveness of the hospital.

      Homebirth advocacy is a philosophy, not a search for more attractive hospitals.

      • Comrade X

        I think that’s true for some people who choose homebirth, but probably not all. Otherwise the homebirth “midwives” wouldn’t spend so much time and energy demonizing hospitals, doctors, nurses and real midwives when grooming their potential clients.

        • AllieFoyle

          Agreed. Some people probably are attracted by the opportunity to do something unconventional, but I remember when I was pregnant (before I ever read here) feeling guilty that I didn’t want to do home birth because I perceived it as a healthier, better option somehow.

        • Amy Tuteur, MD

          There isn’t a person on this planet who doesn’t know that hospitals are the safest place to be in an emergency. That’s why homebirth advocates go there in an emergency. The primary argument of homebirth midwives is not that hospitals don’t save babies, but that if you “trust birth,” there will be no need for emergency care.

          Everything else, including the demonization of hospitals is based on the fundamental premise that you won’t need lifesaving care and therefore you are exposing yourself to the “risks” of the hospital without any benefits.

          In order to claim that homebirth is safe, you must believe that you have the ability to control whether or not complications occur, and you have the ability to get to the hospital, where people actually know what they are doing, if a complication does occur.

          Elizabeth Heineman is professor of history and gender studies. If she is a remotely competent historian, particularly one who concentrates on gender, she KNOWS that childbirth is a killer of babies and mothers. She deliberately chose to ignore what she knew, and, instead, CHOSE to pretend that she would have no complications or that she could get to the hospital in time if she did.

          Did she believe that her baby would die when she chose homebirth? No more than the woman who chooses not to buckle her child into a car seat believes her child is going to die in a car accident the next time they take a drive. That doesn’t mean that both Heineman and the mother who doesn’t use a car seat didn’t know that it was POSSIBLE that her child would die as a result of her decision.

          Heineman gambled, just like the mother who doesn’t buckle the car seat gambles, but no one can claim they didn’t know the danger.

          • Comrade X

            “There isn’t a person on this planet who doesn’t know that hospitals are the safest place to be in an emergency. That’s why homebirth advocates go there in an emergency.”

            100% correct. However, if there’s one mantra that homebirth “midwives” and other assorted quacky advocates repeat again and again and again and again and hang onto as if it were the word of the Almighty, it is that “Birth is not a medical emergency”. How many times have we heard that? “Pregnancy is not an illness.” “Birth is a normal event in a healthy young woman’s life.” “Hospitals are for sick people.”

            They accuse obstetricians, neonatologists, paediatricians, nurses and real midwives of “pathologizing” birth. Of making something normal and beautiful into something suspect and scary like a sickness.

            There are all kinds of problems with that point of view, in my opinion. But it exists, and this rhetoric is clearly having some kind of persuasive effect on some otherwise decent and reasonable women.

          • Amy Tuteur, MD

            But Heineman is a gender historian. If anyone knew that childbirth is inherently dangerous, it is her.

          • Comrade X

            Indeed. And for all I know, she has no excuse whatsoever for putting herself and her child in terrible danger. I’m just saying that many decent and otherwise reasonable people are taken in by some of this bullshit, and unless we know for sure that a victim of this line of thinking is really a complicit perpetrator, we should stick to beating the people who are actively and knowingly shoving the bullshit at unsuspecting marks. Of course, the fact that she is writing a bullshit-perpetuating book on the subject arguably puts her in the perp category rather than the victim category. And I’m all for calling her out on it. Let’s just not forget that many women are victims of this dreadful crap too, as well as many babies.

          • AllieFoyle

            I think she’s in both categories. Her book seems like an effort to reconcile conflicting emotions and beliefs surrounding a horrible experience. I’m not a fan of her assigning the blame for her midwife’s incompetence to the medical system, but she also seems to acknowledge that her midwife did the wrong thing in not recognizing and acting on the risks. And that agonizing description of her baby’s death–hardly a selling point for home birth or midwifery.

            (also, isn’t the NCB talking point on childbirth deaths in the past that they were caused by poor sanitation and inadequate nutrition? That might be what she believed)

          • staceyjw

            Seriously? Someone that knows the history of women STILL chose HB? I winder if she took classes from Missy Cheyney……. Or some gender essentialist feminists that espouse HB as the way to use “other ways of knowing” and stay away from the penocracy.

      • Alenushka

        My hospital 18 yeas ago was very nice. Private room. Great nurses. Epidural. Tub if I wanted etc. Above all, safety

      • expat

        I agree that the attractiveness of hospitals wouldn’t be important if the competition wasn’t offering what amounts to fancy hotel rooms, indoctrination clubs, and yoga. I think many women choose ooh to make friends. They sure are going for midwives who act like their friend for a fee.

        • Elizabeth A

          Expat, please keep in mind that plenty of US hospitals are trying to compete by offering, basically, fancy hotel rooms, indoctrination clubs (aka support groups) and yoga. The hospital my daughter was born in brought me my choice of cake most afternoons. The hospital room was private, and a damn site prettier then the one I wound up in after my mastectomy. And just down the hall in a sunny atrium, there were lactation support, new mom’s support, and boredom-fighting groups for ladies on hospital bedrest.

          NCB advocates appear to have responded to these improvements by moving the goalposts. Now, they oppose bathing newborns, and putting hats on them. Because if someone who isn’t the mother puts a hat on a newborn, the mother and baby will be unable to bond. I wish I was joking.

      • staceyjw

        SO TRUE.
        Hospitals, and their MW, freestanding BC, have EVERY SINGLE THING NCBers want. They still don’y go there, and still complain.

      • alannah

        This. I had a horrible experience in the ‘baby friendly’ hospital. Does that mean that I will have a home birth next time? Of course not! I’ll just go back to that hospital and suck it up for my baby’s sake.
        Unrelated thought: hiring a home birth midwife to get away from the lactivist zealotry at the hospital is just going to make it worse. ..

      • Jessica S.

        I did a poor job articulating what I was thinking at the time. I personally don’t think hospitals need to do anything more, although in my post I felt compelled to throw a bone to those who might have been to a horrible hospital. The problem I see with those who reject hospitals is a fundamental misunderstanding – or flat out refusal to believe – of why certain procedures are done and how decisions are made.

        I know I’ve done a shitty job explaining myself when I agree with the responses that disagree. :)

    • staceyjw

      I am personally tired of hospitals catering to the NCB crowd, at the expense of the mainstream majority. We need more 24/7 OBs, more anesthesiologists, more ORs, and more access to quality care for a woman’s lifespan. Women WANT pain relief, they want hospitals, we want nurseries and we use formula! But what are we doing? Making hospitals NCB centers and “baby friendly” places that are not what most moms want.

      Adding serves is fine, but too often, I see entire departments go over to the NCB side, even though those moms are the the minority. HBers are the most ENTITLED bunch I have every seen. And demanding.

      • Jessica S.

        I don’t think I did a good job articulating what I was trying to say, it’s not my strong suit to begin with but pregnancy and anemia have made it 10 times worse! :D

        What I was *thinking*, but didn’t write out b/c I figured someone would say “well, my hospital was totally backwards and awful”, was that there is plenty enough “natural” childbirth resources in a hospital. Dr. Amy, a few weeks back, wrote in a comment about how she practiced and it was very much like what women say they want with “natural” birth. It was beautiful! So, I wasn’t at all trying to suggest hospitals should do more catering to NCB philosophies. I’m saying I wish it was more accepted that that is reality.

  • Trulyunbelievable2020

    “I believe that after decades of successful practice and no bad outcomes, Deirdre made the wrong judgment call in not referring me to a doctor once I was a week postdate. ”

    Does anyone know the last name of this Deirdre person who tragically wasn’t able to get a “reminder” about a very basic aspect of safe practice? I’d like to actually confirm that she actually has been practicing for decades without any bad outcomes. It seems rather unlikely.

    • ArmyChick

      I looked it up and could not find anything. The mother lives in Iowa and the one provider by that name is a Physical Therapist. Unless she gave birth in NY where she used to live….?

      • Trulyunbelievable2020

        Perhaps it’s a pseudonym.

        • ArmyChick

          Yeah it could be. God forbid they are named and exposed for their incompetence.

          • Trulyunbelievable2020

            And then two years from now another 45 year-old mother loses her baby at a homebirth and explains that her provider, “Midwife Incognito,” has an amazing, untarnished record. Pathetic.

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

            NO 45 year old woman, especially if a primip, is low risk, and is NOT a candidate for a home birth. Even in hospital, a midwife would bring in an OB consult from the get-go, even though she might, after consultation, manage the labor and delivery as long as it proceeded normally.

        • Houston Mom

          Her bio says she has been at U of Iowa since 1999. http://clas.uiowa.edu/history/people/elizabeth-heineman
          I also googled midwife/Deirdre/Iowa and had to wonder about name changing.
          One of her colleagues at the university, Monica Basile is a CPM and works with a CNM Kathy Devine in Iowa City. Motherandchildmidwifery.com

    • DaisyGrrl

      I doubt the midwife would claim this incident as a bad outcome. When “babies aren’t meant to live” the midwife is not responsible for the bad outcome. Hence she could have attended multiple deaths and still be a “safe” practitioner.

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

      If, during those “decades”, you have the equivalent of perhaps a couple of months’ hospital experience, you aren’t in any position to declare that your “no bad outcomes” are anything more than luck. ANYONE who works as a midwife in a mid-sized L&D unit, even one which tends to be “low risk”, will see vastly more than ANY exclusively “homebirth” midwife will, as long as 98+% of all births in the US are hospital births. So Deirdre’s claim carries no weight with me; indeed, the opposite: she has a false sense of security.

      I believe that Heineman MUST know, somewhere deep, just how culpable she is — and is trying her damnedest to project her guilt on everyone she can BECAUSE it is so impossible to accept.

      Homebirth midwives want to justify themselves by claiming that doctors and hospitals won’t associate themselves with their own pseudo-profession — in other words, blame the doctors and hospitals for what is their own problem, that they are inadequate and incompetent and unprofessional, so they can’t get the education and experience they need [ roll eyes at this point] to be better and safer. My husband is a taxi driver; having seen what he is capable of just trying to hang a picture, I’d hardly let him build an additional room on our house, even though he claims he knows what he’s doing and all those building codes are just junk to protect the monopoly unionized construction workers have on renovation jobs. Same thing here. Homebirth midwives rank about as high, in suitability for work in hospitals, as cleaners, and I don’t know a doctor or institution who’d let the cleaning staff deliver babies.

    • Anj Fabian

      It takes place in Iowa City, IA. “Deidre” is a pseudonym.

      After Thor died, Deidre went on to lose another baby after the family refused interventions when the client went postdates. The next baby she delivered was a severe SD requiring resuscitation.

      “Deidre” was sanctioned by ……. don’t recall exactly what organization, but between the timing and the location, it should be possible to pinpoint who she is.

      • DaisyGrrl

        With those details, I would suspect Kathleen McCormick Devine. The Iowa Board of Nursing has two disciplinary actions against her – the 2008 one specifically mentions managing post-dates. This midwife also practiced as a lay midwife for many years before she got her CNM.

        At least, that’s what some time with google leads me to suspect. She appears to have gone by the name Kathy Deol at the time in question. I tried running a few other CNM names through the board of nursing but no disciplinary actions that would match what is known about the midwife.

        • Trixie

          It looks like she didn’t get her CNM until 2007? But was a DEM for 13 years before that?
          Now here’s something interesting. The CPM who works for Devine/Deor has a PhD in Women’s Studies from the University of Iowa, which means that she almost certainly interacted with Heineman during her academic career. http://www.motherandchildmidwifery.com/about-us.html

          • Anj Fabian

            It’s a small world – both the academic one and the NCB one.

          • The Bofa on the Sofa

            Yeah, the plot thickens.

            Recall the comment yesterday about how she got her CNM so she could take insurance money. How noble of her.

          • Anj Fabian

            That was my assumption. If “Deidre” wishes to dispute my claim, she can.

          • Houston Mom

            https://www.iowacourts.state.ia.us/ESAWebApp/TrialSimpFrame

            Type in Kathy Deol; someone by that name seems to have had a lot of legal problems. I didn’t pay the cort $25 access fee, so I have no inkling what she has been sued for. Also haven’t checked name variants yet.

          • The Bofa on the Sofa

            I mean, what OB wouldn’t want to be involved with her?

            Damn politics!

          • Houston Mom

            Her husband was associated with her previous practice. I wonder if he was the family practice doctor.

            http://www.manta.com/c/mm76hch/harbans-s-deol-do-phd-pc

        • Anj Fabian

          I checked the book. The Iowa Board of Nursing issued the sanctions. 6 month suspension followed by 24 months of supervised practice.

          • DaisyGrrl

            That matches. If you go to the Iowa Board of Nursing site and enter case # 2008-0510 you’ll see that she had her license suspended for 6 months followed by 24 months of supervised practice in 2010. Here’s the link to the website: https://eservices.iowa.gov/PublicPortal/Iowa/IBON/public/discipline_documents.jsp

          • Anj Fabian

            The only remaining question is if any lawsuits were filed against her in connection with her midwifery practice. There should be one – the second postdates stillbirth had a lawsuit filed as a wrongful death, but it was thrown out.

        • Houston Mom

          Midwife in question received her education in midwifery here. The degree is earned online.

          http://www.philau.edu/midwifery/

          Seems a nursing background is not required:

          http://www.philau.edu/midwifery/Degree_Options/index.html

          http://futuremidwives.org/?p=199 (Philadelphia U mw program from student perspective)

          • Durango

            That first link…I’m horrified that someone can become a CNM like that. Not a huge surprise, then, that a graduate of the program isn’t very competent.

          • Anj Fabian

            Would she have been able to work in a hospital with that education?

        • fiftyfifty1

          What’s with these damn homebirth midwives and their damn shifting names?!!

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

    Harm reduction. There’s a case to be made that women – or at the very least their babies deserve harm reduction. We know homebirth is not as safe as hospital birth – but we also know under certain circumstances, it is not an unreasonable choice. For a woman who has had one prior normal pregancy but fewer than four prior pregancies. For a woman without a history of cesarean, shoulder dystocia, diabetes, etc. For a woman who is using a qualified care provider (with REAL training). For a woman who is living in a place where midwifery is integrated into the hospital setting. For a woman who has been provided with informed consent. Women and their babies deserve homebirth that is highly regulated – homebirth that requires adequate training, informed consent, integration into the health system, and medical malpractice insurance. People make bad choices – and ultimately they must live with those consequences, but why should those consequences be any worse than they need to be? People smoke all their lives and wind up with lung cancer – we don’t then deny them access to treatment for that cancer because they smoked.

    • AllieFoyle

      And, as a society, we don’t allow cigarette companies to make misleading statements about the safety of their products. We spend a great deal of money on ad campaigns ensuring that people recognize the grave risks that come along with smoking. Why don’t we do the same for pregnant women? Why not make sure that anyone who advertises herself as a care provider is adequately educated and trained, practices within safe parameters, and is held responsible for negligence?

      • Amy Tuteur, MD

        Why? Because homebirth MOTHERS won’t allow it. Look what happens any time a state tries to set reasonable eligibility criteria for homebirth: homebirth advocates descend on the legislature en masse demanding the “freedom” to give birth at home REGARDLESS of risk factors.

        Homebirth advocacy in the US rests almost entirely on distrust of obstetricians. You can argue whether that distrust is warranted or not, but I don’t think you can argue about the irony of blaming the people you didn’t trust for not making your decision to ignore them safer.

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

          That’s not fully true – the advocates won’t allow it, but the mothers, particularly those who have been harmed by home birth, are another matter entirely.

          • Amy Tuteur, MD

            At the moment, most of them are too devastated by their loss, and too cowed by the opprobrium of their crunchy community to effectively oppose anything. You can count the loss mothers conducting effective opposition on the fingers of one hand. They are utterly overwhelmed by homebirth advocates.

          • Comrade X

            Then let’s underwhelm them. Let’s give them the tools, the facts, the statistics, the critical thinking skills, the analysis, to break away from the charlatan vampires who are relying on their support and their silence.

          • AllieFoyle

            Honestly, this blog has been a huge first step in countering some of the information monopoly that midwifery advocates have been trying to maintain. It also provides a structure which didn’t really exist before for mothers who have been hurt by midwifery to organize and communicate with the public. A few years ago I commonly heard people claim that home birth was as safe as hospital birth, and sometimes safer. I think publicizing cases in which home birth resulted in serious injury or death, along with recent studies and statistics showing higher mortality rates, has already changed the dialogue.

          • Laura

            And they lose their community of “support” and friendships. They are shunned. That can be beyond tolerable if they don’t have any other support networks.

        • guest
  • Amy M

    Yes, and for the people who will insist on homebirth because 1)women’s autonomy and 2) they think hospitals need to improve then the onus is on them/homebirth midwives to make homebirth safer. The ball is in their court—if those midwives were willing to get CNM degrees and set up a system like what Canada or some European countries have where homebirth is integrated, it would be safer than it is now and they wouldn’t have the politics leg to stand on.

    Then, if women STILL wanted to homebirth, at least proper risk-out criteria would be in place, proper backup, accurately trained attendants and real informed consent. Obviously this is not REALLY what these people want, else they’d be working harder to get it. So in general, I place the blame on the NCB culture that sucks women in and convinces them that are being cared for by adequate attendants, and that they ARE doing something safe. For the ones doing the conning, or the ones who know better and lie to themselves to buy the con, well, that’s a terrible thing.

  • ArmyChick

    They will never take responsibility for the outcome. They say women have the right to choose where and how to give birth but when something goes wrong it is NOT their fault. It’s the establishment’s.

  • Mel

    Thought exercise:

    How many women would choose to home birth if the midwife made it clear that there was no obstetric back-up possible?
    This is my imaginary conversation:
    MW: This birth will be me and only me covering all possible outcomes.
    Mom: But if something goes wrong the hospital is only 9 minutes away….
    MW: That’s true, but by being at home, you’ve chosen to avoid some potential interventions. Because of that, by the time we make it to the hospital, any medical problems are likely to more severe and harder to treat.
    Mom: What do you mean?
    MW: I can’t do a crash CS. If your baby can’t get enough oxygen at home, there’s honestly very little I can do to increase their O2 levels outside of the hospital. Plus, if the doctors lose time trying to stabilize you, then…
    Mom: Wait? Why would they need to stabilize me?
    MW: Let’s say you have a partial abruption and start bleeding out. It’ll take us about…well, let’s say 30 minutes to get to the hospital. By then, you’ve lost enough blood that they can’t give you anesthesia without endangering your life, so they need to give you blood products. Typing blood takes awhile; plus, they have to get consent. An OR might be open…maybe not. Let’s say it takes 30 minutes to stabilize you enough to do the CS.
    Mom: So I’m 60 minutes away from help?
    MW: Assuming there’s no ice storm, yep. Then, you know, a CS isn’t instantaneous. It does take a few minutes to open you up and get the baby out.
    Mom: So my baby may not be getting oxygen for like 65 minutes.
    MW: Give or take.
    Mom: Anything else I should know?
    MW: Well, there are a few maternal risks – I mean, if you get an AFE in the hospital, the baby’s survival rate is over 75% and maternal survival rates are as high as 75%….
    Mom: What if it happens if I get an AFE at home?
    MW: You both die. Sorry. It’s really rare, though.
    Mom: You’ve given me a lot to think about…..

    • Jessica S.

      Mel, this is excellent. This is the kind of frank disclosure MWs should give. Women who still choose home birth in the face of that truth, it can’t be controlled.

      Of course, that’s a perfect world. Telling a mother “if something goes south, the possible of disability or death is much greater than if you were in the hospital.” defies the foundational myth of why home birth is a safe option. It’s an option, but it’s not safe.

    • moto_librarian

      This is what informed consent looks like. Obviously, not an easy conversation, but if you are truly an ethical provider, you have it. Now how many homebirth midwives actually do this? Not very many, I’ll bet.

  • Deena Chamlee

    I am without debate Amy. The sadness is felt. I can only pray that we, midwifery, will in unison have the courage to change. Medicine is not my concern. Midwifery is, and that is the absolute truth.

    • Laura

      I do hope and pray that you can be an instrument of change in your midwifery circle of influence, Deena. But it is precisely the medical aspects of birth that need to be reckoned with in midwifery circles – evidence based care. So, medicine needs to be your concern so that you can explain why medical interventions and cautions and risk-out criteria are SO important. I have no doubt you understand and will improve midwifery care where you are.

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

      Well, I tend to think of midwifery as a branch of medicine, in the same way that nursing is. We all share a common goal, built on a common scientific ground, although we work toward it in different ways.