The cruel choice at the heart of UK homebirth promotion: you can only get best care if you forgo pain relief

Pregnant woman detail backache

Imagine for a moment that the UK National Health Service, in an effort to save money and diminish overcrowding, offered the following service:

Patients who break a long bone, like an arm or leg bone, will be given a choice. They can receive the highest quality personalized care by orthopedic nurses in the comfort of their own home, complete with X-ray, re-alignment of bones that are out of place, and casting, but only if they forgo pain relief. Or, they could opt to wait many hours in the local emergency room for an overworked orthopedic surgeon, who also offers X-ray, re-alignment of bones, and casting, PLUS adequate pain relief.

The NHS is pleased to offer this service because it anticipates significant cost savings from limiting the use of hospital resources, paying nurses instead of doctors to provide care, and zero expenditure on either pain medications or anesthesiologist who might be needed to administer them.

That sounds to me like a choice that is both barbaric and unethical. NHS would be forcing orthopedic patients to choose between high quality care without pain relief and low quality care with pain relief.

Similarly, the latest effort to promote homebirth in the UK has the same barbaric and unethical choice at its heart. Women are forced to choose between high quality, personalized care in the comfort of their own home as long as they accept the agonizing pain of unmedicated childbirth or low quality, rushed care in exchange for access to adequate pain relief.

The orthopedic nurses who staff the new program assure us at NHS that there is really no need for pain relief in the wake of a broken arm or leg. People have been breaking long bones since the beginning of time and enduring it without pain relief. If people had needed pain relief in order to survive broken bones, the human species would no longer exist. The orthopedic nurses point to additional benefits: decreased sedation, the ability to get up and move immediately instead of waiting for anesthetics to wear off, faster healing (according to them) and fewer complications (according to them). Plus, we are designed to heal our broken long bones without any pain relief at all. It worked well for our ancestors; it can work just as well for us.

Sound familiar? It should since these are precisely the claims advanced by midwives in their efforts to promote homebirth.

But that begs the fundamental question:

Why should anyone have to choose between high quality care and pain relief?

There is really no reason why anyone should have to choose between the two, for orthopedic care or for childbirth care. So why is the choice being forced on women in the UK? The forced choice reflects the philosophical beliefs of UK midwives. They believe (without any scientific evidence) that unmedicated birth is better than birth with pain relief. They view an unmedicated birth as a success and a medicated birth as a failure. They prefer to care for women who decline pain relief and they use a variety of methods to force them to do without pain relief including delay, chivvying them into believing that they are accomplishing something by withstanding the pain, or simply refusing to provide effective pain relief altogether.

The promotion of homebirth in the UK reflects the unholy alliance of midwives who wish to increase their autonomy and bureaucrats who wish to save money. It uses an unethical, and, frankly, barbaric, bargain to promote homebirth. You can get seemingly better, more personalized care ONLY if you agree to endure childbirth in agony.

Both midwives and bureaucrats should be ashamed of themselves. This is deliberate infliction of a pernicious philosophy that treats women’s severe pain as irrelevant. Every woman deserves BOTH the highest quality childbirth care AND easy access to the most effective forms of pain relief.

Promotion of homebirth reflects political expediency and not the needs and desires of the majority of childbearing women. It’s politics, not healthcare.

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  • Mattie

    Sorry, but ‘unmedicated’ does not mean no epidural it means no pain relief. Women at homebirths have access to ALL the pain relief excluding epidural, they can have gas and air, pethidine, use water for pain relief and are free to move about and get into whatever position they wish, and if they still find they are not coping they can be transferred in for an epidural (which they are more likely to get as the hospital can alert the anaesthetist of their arrival). Homebirths aren’t all bad, or at least the issue you’re stating in this article is not a real issue

  • AgentOrange5

    I’m one who thinks things are often labeled sexism (when there are actually other explanations), but I have to agree that this idea of wanting women to forego pain relief is sexism. I can’t think of any other reason for it. Sure pain relief isn’t 100% safe (nothing is), but the risks are pretty minimal, and as mentioned nowhere else are patients actually encouraged not to get pain relief. I gave birth to 4 children, 2 with epidurals, 2 with no pain relief. I would have gladly gotten epidurals for the 2 without, but their was no time as they were very fast labors (1 was only 45 minutes! Eek!) I feel exactly the same towards all my children, I had no “birth trauma” (if anything, the 45 minute birth without pain relief shook me up the most), there was no “cascade of interventions”, I only had breastfeeding difficulties with 1 and that was related to a short tongue not any non-existent grogginess. I don’t believe I’m some “anomaly”, I’ve know many women who’ve had epidurals (or at least IV pain medicine during labor) and none of them have had a problem. I can understand being skittish about getting a shot in the back, I was until I experienced the pain of labor, then I decided I was OK with a shot in the back. But this made-up stuff about the horrors of pain relief & this active encouragement of women to grin and bear it needs to stop.

    • jennie c

      actually a rather common side effect of epidurals (i think 5-10%) is a debilitating headache, sometimes so bad that the mother is rehospitalized. as well as being associated with operative vaginal delivery and perineal trauma. if i have another baby (unlikely given my age but who knows ;), i’ll try to forgo the epidural.

      • moto_librarian

        Um, no, it’s more like 1 in 100 (1%) for spinal headaches, and most of them can be relieved via a procedure called a blood patch. Recent studies suggest that operative vaginal delivery and perineal trauma are not affected by epidurals to the extent previously thought.

  • http://radicalfeministforlife.tumblr.com/ Wharves of Sorrow

    Shame on the UK!
    The Netherlands is also quite fond of woo! Natural childbirth ideals prey on a particular Dutch cultural ideal of normalcy. http://stuffdutchpeoplelike.com/2013/02/12/natural-drug-free-birth/

    • Alannah

      I think the author of that blog post is getting it dead wrong: Dutch women aren’t “into” excruciating pain any more than women elsewhere in the world. They don’t get epidurals simply because access is severely restricted. Even if they birth in hospital, often there is no anesthesia coverage for labor epidurals at all, or none after hours.
      Dutch midwives’ training is all about ‘pain is a part of birth and women should just tough it out’ so on labor wards have a culture of accepting and even glorifying pain. Midwives go to great lengths to keep their patients drug-free whether they want it or not.
      The ethics of this situation are of course highly debatable and there is a movement in the Netherlands demanding the right to pain relief in labor. It’s pretty similar to the battle for the right to hospital birth when the evidence became available that Dutch homebirth midwives outcomes were not good. Those much-praised 30% or more homebirth rates in the Netherlands only existed because the government had a strong financial incentive in place to encourage homebirth. After that was removed rates have been dropping steadily. Homebirth is now only for those women who genuinely desire it and it turns out that there aren’t as many as the midwives would like to believe.

      • http://radicalfeministforlife.tumblr.com/ Wharves of Sorrow

        Thank you for your insightful reply. I am interested in Dutch culture as someone of Dutch descent in the New World but I have to rely on English sources so it’s harder to know what’s really going on. It is really disturbing to hear how hard it is to access pain relief in The Netherlands and I hope the activists there succeed in making pain relief available to all those who need it. It is scary that this kind of thing happens in the “developed” world. I hope no other country with state funded medical care does anything as dangerous as what the UK is doing right now. Some areas in policymaking would really do better technocratically.

  • Sadie

    I had a home birth and had extremely well controlled pain. At no point was I ever in excruciating pain. Giving birth in an environment where I felt relaxed and comfortable meant that anxiety and stress was not adding to the pain. It is rubbish to suggest it is a choice between hospital or agony.

    • fiftyfifty1

      You had what sounds to be a very straightforward birth. When just a little relaxation can bring a pain level down to “extremely well controlled” we know that the underlying labor has been very easy indeed.

      That is lovely, and I’m so glad that was your experience, but the majority of women are destined for a very different experience. Severe pain is especially likely with first births and malpositioned babies among other factors.

      But why should only those, like you, who win the birthing lottery get an easy birth AND personalized care? Women who experience excruciating pain during birth deserve BOTH personalized care AND relief of their pain just like you! They shouldn’t have to give one up to have the other.

      • Sadie

        If you reread my post you will see that at no time did I suggest women shouldn’t have choice on where to give birth. Nor did I say that just a little relaxation was the only method of pain control that got me through my 1st time labour I used a TENS machine throughout and gas and air was on standby although wasn’t required. This article started with the claim that to have a home birth is to forgo any pain relief whatsoever which is just absolutely not true. If women are to truly have informed choice about where to give birth they deserve more balanced information than is contained here.

        • fiftyfifty1

          My goodness you did win the birthing lottery! When just some relaxation and a distraction device (TENS unit) are enough to bring you pain level down to “extremely well controlled” you have had an easy labor indeed. And on a first time labor to boot, what happy luck!

          But what if you hadn’t been so lucky? Why should the women whom Fate has handed a difficult labor have to make the choice of facing hours of agonizing pain at home vs. facing a notoriously understaffed birthing ward in the hospital (where they may yet be denied pain relief depending on the level of crowding and/or the prejudices of the midwives)? Surely you don’t find such an arrangement to be just?

          Unless, of course, you believe your luck was not actually luck at all but rather the reward for being somehow more *deserving* than women who suffer agonizing pain?

          • Sadie

            Dear me, please try to read my posts before replying. Show me where I have suggested being more deserving or lucky than any one else? I think what I advocated was informed choice for all women, I don’t want anyone forced into any scenario they are not 100% happy with. But informed choice requires access to unbiased factual information. I am trying to suggest that there is an alternative to the agonising hell you insist is normal for childbirth. However, having now looked at some of the other content on this site I realise this is not the place to come for balanced info.

          • LibrarianSarah

            So to you “unbiased factual information” is that any woman who homebirth has “extremely well-controlled pain” because that happen to you once? That sounds logical.

          • Sadie

            No, of course not., that would be ludicrous. This article states as fact that to have a home birth is to accept “the agonising pain of unmedicated childbirth”. This is misleading for 2 reasons. 1, there are forms of pain relief available at home that whilst not suitable for everyone are enough for many to make labour tolerable. 2. Unmedicated childbirth is not necessarily agonising, yes of course it can be but it isn’t for everyone so you can’t state it as fact. I have no issue with anyone’s views as long as you stick to facts not assumptions, generalisations and scaremongering.

          • LibrarianSarah

            1. Do you have any evidence that the “pain management” available at a homebirth is effective? Or that anything about the homebirth experience reduces pain? 2. So if Dr. Amy said that “If a woman between the age of 14 and 35 continuously has sex without any form of birth control she will eventually get pregnant” would you react the same way? Because I could have all the unprotected sex in the world and I will never get pregnant. But for most women that sentence is absolutely true. I am an outlier just as you are an outlier in not finding childbirth painful. And I am pretty sure that you are the greater outlier in this case.

          • Sadie

            Pain management for women in labour: an overview of systematic reviews, Jones et al 2012. Shows evidence that some of the methods available at home are effective and acknowledges that control, confidence and relaxation may modify the pain experience.
            Can’t see any relevance to your 2nd point I’m afraid. And I never said I wasn’t in pain, I said it was well managed in a variety of ways. Really struggling to understand why that is such a contentious statement.

          • Stacy21629

            Because you said:
            “It is rubbish to suggest it is a choice between hospital or agony.”

            Since the vast majority of women have some kind of pain relief, most would disagree with that statement (perhaps not in NCB echo chambers…).

            I had a homebirth, labored in water, walked, squatted, had great support people…and was in absolute agony. Twice. Puking my guts out.

            I’ll have an epidural this time. TYVM.

          • fiftyfifty1

            “I am trying to suggest that there is an alternative to the agonising hell you insist is normal for childbirth.”

            Of course there are exceptions to the rule! Fate sends a small percentage of women a nice easy time as it did with you. But for the majority of women, Fate sends severe pain. When that is the case, the “alternative to the agonizing hell” can only be had from an anesthesiologist. Relaxation and distraction only work for mild to moderate pain, while the majority of women are fated to suffer severe to agonizing pain. A woman should not be forced to make a choice between letting Fate hand her what it may vs. adequate staffing.

            Unless you believe you know some way to influence Fate? If so, do tell!

  • Sue

    Ironically, those people waiting in EDs to have their broken bone realigned under anesthesia no longer have to wait hours for pain relief, because EDs have prioritised analgesia. It’s considered a key performance indicator of good ED care.

    • Karen in SC

      That’s excellent news. I remember being so upset at how long we waited when my son’s arm was broken. He was laying on the floor crying and crying. The nurse had to wait on a call to get the dosage right. It was very difficult for both of us!

  • Beth S

    OT: But kinda in the same vein, anyone else see the controversy over Mila Kunis saying she wants to do unmedicated because she wants to do it right? Not that I think what she said was wrong, it was off hand and she mentioned she wanted the doctors machines and everything else around. I just find it sad that in some corners of the world you can’t say something is right for you which is what I took the statement as without being called a bully.

    • Stacy21629

      Yes, I saw it. Dr. Jen Gunter blogged about it:
      http://drjengunter.wordpress.com/2014/05/12/celebrity-birth-plans-and-being-mom-enough-for-a-natural-delivery/

      Unfortunately, many women DO mean “right” as in “anything else is wrong/lazy/cop-out”. Whether Mila believes that, I don’t know.

      • Beth S

        I agree with you, but I think she also said something about this being her choice and it was what was right for her, I’m on hour 28 of being awake so I don’t remember.
        I know what you mean about many women believing “right” is what they believe and nothing else. I had a crunchy friend tell me that I should have risked death rather than get a C-section, I told her she could kiss my grits…well that’s the polite version.

    • Sue

      No doctors or machines….so she won’t have her cellphone or laptop?

      • Beth S

        No she said she wanted those around her.

        • Sue

          OK – doctors and machines are good so long as the doctors don’t act on what the machines say?

          • Beth S

            I think it was more trying to avoid them if at all possible which I do understand.

    • OldTimeRN

      I’ll never understand why the use of pain meds for excruciating pain is considered wrong?

      Or going without is considered right?

      No one is going to give you a medal when it’s over. An epidural doesn’t hurt or effect your baby.

      And why the hell do people listen to celebrities about anything?

    • Trixie

      Meh, at least she seems to be going to a hospital.

  • Young CC Prof

    Has anybody read the whole report? It’s actually a 127-page document! I’m only up to page 41, but so far the thing that bothers me the most is:

    “Do not perform cardiotocography on admission for low – risk women in suspected or established labour in any birth setting unless the initial assessment indicates there is a risk factor for, or actual, fetal acidosis”

    This was repeated several times in different places. No fetal heart monitors unless there’s another sign of a problem. If there is a sign of a problem, do a 20-minute strip and then go back to intermittent auscultation if normal, plus exhortation to make no decision based on strip alone.

    No CEFM, no admission strip. Really?

    On the plus side, they say, “Do not offer or advise aromatherapy, yoga or acupressure for pain relief… If a woman wants to use any of these techniques, respect her wishes.” In other words, stop promoting quackery.

    • Stacy21629

      “No CEFM, no admission strip. Really?”
      Forget that. That constant whosh-whosh-whosh was the most wonderfully comforting sound. I absolutely want the belt again.

      I had intermittent monitoring at home. 45 minutes between doppler HR checks. Normal (150 I think) then decels (80s-110s). Was my baby’s HR in the 80s for 2 min prior to the doppler check? Or 40min? If I’d had CEFM I would know and, more importantly, my CNM would have known. Instead, her care might have been delayed because of intermittent monitoring. Thankfully she was A-OK but the gap in knowledge of her HR upsets me.

      • Young CC Prof

        Under slightly different conditions, a guideline like that might have killed my son. He was growth-restricted, borderline oligo, failing placenta, but none of that was readily apparent except on ultrasound. My fundal heights were normal.

        Luckily he was breech, so I never went into true labor, but if he’d managed to turn, and if I hadn’t had a third-trimester ultrasound…

      • Louise

        Ok firstly, finding an intervention comforting is not a reason for offering it as standard. Some women might find having a pap smear every month comforting, but it would still lead to tonnes of false positives and unnecessary treatment with all that that entails. Same with CEFM where there are no risk factors to indicate it.

        That said, 45 MINUTES between IA with a doppler???? Is this standard for American CNMs? IA should be every 15 minutes in 1st stage and 5 minutes in second stage. 45 minutes terrifies me. Almost not worth bothering at all.

        • Stacy21629

          I’m not saying CEFM should be required or possibly even offered to every mother…but I liked it. I paid cash for my delivery and I was quite content to pay the $240 for that service.
          I don’t know what the standard is. This was with a home birth CNM but I experienced pretty much the same frequency of monitoring with my previous home birth CNM (different) as well.
          Nurses really go in every room every 15 minutes in the hospital and listen?

          • Beth S

            I loved it, when DH and I got bored we started doing the Geico Boots and Pants song to the baby’s heartbeat.

          • areawomanpdx

            Yes, the standard for CNMs is every 15-30 minutes during the first stage and every 5 minutes during the second. Additionally, the standard requires one-to-one nursing care in active labor.

          • Louise

            In the UK, contrary to what Amy states, every woman usually has a midwife with her the whole time she is in active labour. I worked on 2 very busy CLUs (OB-LED units in American) and rarely saw this deviated from. Yes, the midwife may be caring for more than one woman if one being induced and one is post-natal, for example, but I have never seen a woman in active labour not have one-on-one care. There are scare stories in the press, and I am sure it does happen in what can often be an overstretched system, but it is the exception rather than the norm and in six years of midwifery I never saw it happen, nor have I ever heard of it happening first hand. The IA guidelines are drawn up with the full expectation of one-on-one midwifery care, and even if a midwife did have more than one patient to care for, she would be in major hot water and risking disciplinary action if she didn’t manage IA every fifteen minutes, or indeed if she left a patient alone for fifteen minutes.

            We don’t have nurses on UK maternity units. All of what would be nursing tasks in the US are performed by midwives.

          • Sarah

            A lot of this is incorrect A midwife would not be caring for one woman who is being induced and one who is postnatal, they would be on entirely different wards. And women in active labour are certainly left, I know of it happening. As your experience is in the past tense Louise, ie you don’t work in the NHS now, perhaps you are unaware of the current pressures.

          • Beth S

            Okay I’m only an American and I know this sounds a little snippy, but is it just me or does it seem a little well hypocritical that when Duchess Catherine gave birth she got a hospital and the best docs money can buy, but for the average British citizen they’re encouraging things like home birth?

          • Louise

            Well, in my unit (where I worked until 4 years ago) we had induction rooms on the delivery suite, and I certainly cared for women being induced as well as women in recovery, ie first few hours post-natal, before being transferred to the ward, simultaneously. Every hospital has slightly different arrangements.

            As for women in active labour being left, I hear that sort of thing is far more common in London than elsewhere in the country I never worked in London, and maybe things have deteriorated even since I left the UK.

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

        The whole point of EFM is NOT to simply get a FHR within the 120-160 range: it is to see how the FHR behaves during and after contractions as well as to see beat-to-beat variability between contractions. A doppler simply cannot really give the same kind of information EFM does.

        It constantly amazes me that some women think that EFM is merely a means to behave sadistically towards laboring women, by “tying them down” and putting tight, sometimes uncomfortable belts on them.

        And I don’t understand why a brief admission strip should be frowned upon. It not only relays information about the FHR, it also gives an idea of the quality of the contractions –I’ve had women whose facial and vocal expressions were totally at variance with the contractions they were having, especially in certain cultures. [Chinese women tend to be more stoic, even with strong contractions while Puerto Rican women bring down the roof screaming even with a totally flaccid abdomen]

        • Beth S

          And here I thought it was to give Mom and Daddy something to keep the beat to whilst laying there bored (Just kidding although DH and I did the Geico Boots and Pants song to my babies heart beat whilst waiting.)

        • Stacy21629

          “The whole point of EFM is NOT to simply get a FHR within the 120-160
          range: it is to see how the FHR behaves during and after contractions as
          well as to see beat-to-beat variability between contractions. A
          doppler simply cannot really give the same kind of information EFM does”

          I understand and agree, completely. I didn’t say it in my first response but that was/is my other fear in thinking over the birth – not only did we not know her heartrate was low but we did not/could not know the character of those decels. Vital information we were missing.

          Again, I was so wonderfully thrilled to get to the hospital and have that belt on my abdomen.

        • Medwife

          And sometimes the toco is not on quite right or the patient s obese and the fact that the patient is Puerto Rican makes it less likely for staff to question the information the screen is telling them.

          I try to watch those cultural stereotypes.

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

            Well, of course one must not be misled by cultural stereotypes too much. Yet there often is an element of cultural conditioning that affects patients’ reactions in labor. We learned that, even when smiling, if a Chinese woman had tears in her eyes during contractions, she was usually quite advanced in labor. Nigerian women, for some reason, snap their fingers during contractions, and I have LOTS of stories about Puerto Rican and Santo Domingan ladies, who have a strong belief that if their labor is easy, the child will be a weakling, so they act as if they are being torn apart, to ensure that “el grande baron” will be a tough kid.

            There are Jewish jokes too, which have an element of truth in them. When a woman stops using expletives and begins calling for her mother during contractions, she’s probably nearly fully dilated.

            Keeping one’s sense of proportion and objectivity is everything, in the end.

    • Louise

      Up until 6 years ago I was a midwife on a large obstetric consultant-led unit but we didn’t do admission srips or any CEFM at all without clinical indication. Well, one or two of the older midwives still insisted on doing them with their patients but it was very much frowned upon by everyone else including the doctors. It is not evidence-based practice.

      • Karen in SC

        Really? Could you explain?

    • yugaya

      No admission strip baseline, no problems later if the baby dies or is injured because there is no undeniable proof that the problems occurred after the midwifery care began, or that the midwives ignored/failed to notice them.

  • Ginab

    American obstetricians and lay people should really keep their opinions about other countries birth and medical practices to themselves. Especially when they do not know the culture, didn’t train there, and aren’t qualified to practice there. Unless you are a British citizen or have had or are about to have a baby in a British hospital, your opinion about what British midwives are doing or not doing is completely irrelevant – and uninformed. As a dual citizen who gave birth twice in American hospitals, under the care of highly qualified obstetricians, with epidurals – and suffered horrible complications due to the incompetence of one of the doctors – I am qualified to say that I wish I could have been at home or at a birth center in Britain under the care of well trained, competent, caring midwives. We all know that medical care in the US is dictated by medical insurance companies and that success and competence is measured in cost and outcomes (numbers) rather than patient satisfaction and well being. This is not the case in the UK where they are a lot more concerned with the choices and well being of an individual. I know I prefer to be treated as a human with feelings rather than a cow in a dairy farm. Americans need to take a long hard look at their own inefficient expensive unfair and demoralizing medical system rather than criticizing a system they know nothing about.

    • Stacy21629

      “We all know”
      No, we don’t. Care to back that up? MY medical care has been dictated by me and discussions with my care providers. I don’t ever recall an insurance agent being present for any of my ob/gyn exams.

      “This is not the case in the UK where they are a lot more concerned with the … well being of an individual.”
      Not the babies, since increasing numbers of babies are dying preventable deaths at the hands of midwives in the UK.

      Publicly available information is open for discussion. I’m sure you’ve NEVER had any sort of opinion about politics, world affairs, current events in ANY country other than the US or UK. Ukraine? Eh, no opinion. Iraq? Iran? Afghanistan? China? Nope, nope, nope, nope. I don’t talk about nuthin’ from nowhere I’m not from.

      Sure.

      • Ginab

        No but I wouldn’t dream of arguing a political point about China with a person who actually lives in China because I would look like an idiot
        And are you saying that medical care is not dictated by insurance companies??? Lol…and what insurance do you have? Surely not Medicare
        But whatever you do don’t go to Britain because babies are dying by the thousands….no millions…in that backwards country. Very few even make it to age 5!

        • Young CC Prof

          Medicaid, not Medicare. A large percentage of pregnant women get care under Medicaid, which is for the poor, but Medicare is for the elderly and severely disabled, a group that produces few children.

          And if you see a specific error we are making, please correct us, rather than just scoffing.

          • Ginab

            The only error I see is a rather rigid and fanatical viewpoint which is not ever going to become open to discussion or accepting of other views. I hope you find what you are looking for.

          • Amazed

            Until your viewpoint shows that you’re capable of reading with comprehension (I am referring to the comment about comparing perinatal outcomes that you were incapable of understanding), it isn’t likely to convince anyone.

          • Jessica S.

            Translation: I don’t have an answer, so I shall flounce. It’s funny, b/c everyone engaging with you is trying to have a discussion, and have pointed out errors in your argument – instead of correcting or explaining, you pout. Who’s not open?

        • Stacy21629

          Your ignorance of statistics is showing. The absolute number of babies dying is irrelevant.

          • Ginab

            Actually each and every baby that dies is deeply relevant – and it’s statistics and arguing about meaningless things with someone I’ve never met and never will meet that is irrelevant. I hope your choices of how to make a difference work out for you.

          • Stacy21629

            YOU came here and picked an argument.

            You didn’t have to post. You could have read and stomped off. But YOU wanted to argue, so you commented.

            And of course I don’t mean the babies are completely irrelevant. Just like I’m sure you don’t think they’re “meaningless” either if they’re in statistics.

            If I’m offered:
            Room 1 – 1000 women, 1 will have a dead baby
            Room 2 – 1000 women, 5 will have a dead baby

            My *statistical* risk of a dead baby in Room 2 is still very low, but I’d still rather be in Room 1 and I guarantee you that most if not all of the women in Room 2 would also rather be in Room 1. You just want to point to Room 1 and say “But, but, ONE baby still died!”

          • Stacy21629

            And they have made a difference. Once I was ignorant of the follies of NCB claims and the grave dangers I took having my child born at home far from medical intervention if he needed it.

            I got a positive test Sunday. I’m 5w 5d today. This baby will be born in a hospital.

            Reading this blog is what made the difference for me.

          • Jessica S.

            (Congrats, Stacy!!)

          • Mishimoo

            Congrats! Wishing you a very boring pregnancy and a comfortable + safe delivery.

          • AmyP

            Yes! May your biggest dilemma be figuring out what new stroller you want to buy!

          • Stacy21629

            Thanks all. :)

          • Beth S

            Congrats hun, wishing you a safe and boring pregnancy and delivery and just to be nosey you doing it in the hospital or at home this time? No judgment just nosiness.

          • Amazed

            Congratulations!

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

            B’sha’ah tovah! [that means, "in a good hour" as in you should deliver and everything be good]

          • Stacy21629

            Is that Hebrew? You’re in Israel, right?

            What’s funny/ironic is that I actually had Shabbat dinner with one of my classmates last week (she is Jewish, I am not) and she asked if/when we were planning to have another…and I shrugged it off. Didn’t even realize I was late at that point, haha!

          • araikwao

            Congratulations, may it be smooth sailing for you both

          • yugaya

            Not relevant enough for MANA to publish how many babies died at the hands of its members for years and years. Not relevant enough for MANA to publicly warn mothers planning to homebirth that breech is NOT a variation of normal according to its own stats, because a simple variation of normal does not kill nine times more breech babies at home than in the hospital. Not relevant enough for Midwifery Today founder Jan Tritten to say a word about the part that she and Midwifery Today played in the death of Gavin Michael.

        • theNormalDistribution

          Yeah… I can see how only accepting arguments from people you consider an authority on the topic at hand could be a useful heuristic for you if you are completely clueless about everything ever and lack your own critical thinking skills…

          But I’m at a loss as to how living in China makes one an authority on Chinese politics.

        • Stacy21629

          Not even if you had a degree in Chinese political studies and had taught Chinese political studies at an Ivy League institution and had lectured to other professors of Chinese political studies?

          You might not have lived in China, but your education, training and teaching experience would more than qualify you to comment on Chinese politics, without ever living there.

        • Jenny_from_da_Bloc

          I had a traumatic injury and have had over 20 operations so I know quite a bit about insurance and how the sustem works. My care was never dictated by insurance companies, it was decided by my parents and doctors. Insurance does not dictate a patients care. Sometimes a procedure requires pre- authorization which is usually pretty simple to obtain. Even my reconstructive and plastic surgery was covered so I wouldn’t spend the rest of my life looking like Quasimodo. Now Medicare is a completely different system and I have never seen a Medicare patient denied treatment due to their coverage, ever

        • Beth S

          I’ve had both, Medicaid and private insurance, the doctors dictated my care every single time.

        • Tabitha Ziegler Yaffe

          I am currently receiving prenatal care in Germany after having six births, in a variety of situations (private insurance, HMO, Tricare, military hospitals, private hospitals etc.), and I can say without a doubt that my care in the US was far superior than what I’m receiving here. Anti-nausea meds are almost never prescribed for patients with severe nausea or hyperemesis, even when the patient is hospitalized for dehydration. Tricare patients are considered private pay here, so the local OB practices tend to milk us for extra $$$ by giving ultrasounds at every appointment, and NSTs starting at 20 weeks, even with low risk patients. Hospital midwife delivery standards are full of woo, with epidurals frowned upon, and homeopathic weirdness expected. Post-partum care is minimal at best, and pain management pretty much non-existent. I’ve been advised to purchase my own post-partum care supplies in advance of giving birth, and request pain meds from my Army physician (which I am then to take to the hospital, hidden in my personal items as they will otherwise be confiscated). My satisfaction with care is not a consideration because this is a national health system. There is one mediocre standard of care, and absolutely zero incentive for care providers to do anything more because most patients don’t have the option of seeking care elsewhere. I’m considering driving to the Army hospital in Landstuhl when I’m in labor simply to be able to receive decent, reliable care.

      • SNM 1

        Medical care is dictated, to some degree, by insurance companies. In my state (where I currently am finishing up school), Medicaid will no longer cover elective inductions prior to 39 weeks. Doctors and CNMs will have to show medical necessity to have this covered. Additionally, in OB care, insurance dictates which tests it will cover, the number of ultrasounds you can have, etc. We do not dictate our care choices… Our options are often limited to what an insurance company has decided is best, unless we are “lucky enough” (insert sarcasm here) to have something outside of normal to show different care is needed… Just recently I had a patient who needed a treatment that is evidence based and supported by literature and we were having to fight with her insurance to get it covered…

        • Stacy21629

          REIMBURSEMENT for medical care is dictated by insurance. I realize that medical care is expensive, but no insurance company is going to prevent a doctor still doing a test or procedure. They just aren’t going to pay for it. I know that’s kind of splitting hairs, it just seems like folks make out like there’s an insurance agent in a doctor’s office or hospital physically preventing them from performing a test or procedure. Unfortunately, in this country, it means that those with the means will pay for it themselves and those without may go without.

          • Medwife

            Sure. They won’t reimburse for it. So the patient gets stuck with the bill (definitely will happen if it’s a hospital) or the clinic eats the expense. Enough bills get eaten by the clinic or hospital and it folds. Those without are definitely going without, no maybe about it. Inability to pay increasingly means not getting treated. I order nonstress tests that are absolutely indicated and my “insured” patients aren’t showing up because the deductible for the NST is hundreds of dollars.

            ARGH. <>

    • Young CC Prof

      Despite a significantly higher premature birth rate and a system that excludes a large percentage of pregnant women from proper care (and that exclusion is inexcusable, I make no bones about it) perinatal outcomes are better in the USA.

      • Ginab

        But this is really my point….you can’t just exclude the huge amount of poor women who receive substandard or no care and then say “oh if it wasn’t for them our perinatal outcomes are better than any other country” That is just manipulating the statistics. As I said before, I am a US citizen and have been for 30 years. Numbers are always manipulated and interpreted to suit the needs of the person with the agenda. I have no agenda – I’m just saying better to deal with the log in your own eye rather than screaming about the splinter in someone else’s. Fix the high prematurity rate and substandard care for huge numbers of poor women before complaining about midwives or home births in another country.

        • Young CC Prof

          Nope. COUNTING the excluded poor, perinatal outcomes are better in the USA. (Maternal outcomes are not, and lack of access is the primary reason for that.) But the perinatal death rate is lower in the USA than in Britain, and the stillbirth rate is substantially lower.

        • Stacy21629

          Did you not read what she wrote:
          “DESPITE x, y, z…perinatal outcomes are better in the USA”

        • Jessica S.

          Reread what she said.

        • Jenny_from_da_Bloc

          I work in the US healthcare system and the poor women on Medicaid and w/o insurance are treated by the same doctors and in the same manner as women like myself with “Cadillac” healthcare plans. I have never, not even once seen or heard of a pregnant woman who did not receive proper care due to money or lack of insurance. If they are not receiving proper care its because they did not seek care or treatment.

          • AmyP

            “While previous research has estimated about 40 percent of the nearly 4 million annual births in the United States were paid for by Medicaid, the latest study by researchers at George Washington University and the March of Dimes looked at individual state data and estimated that in 2010 about 45 percent of births were covered by Medicaid.”

            http://capsules.kaiserhealthnews.org/index.php/2013/09/nearly-half-of-births-in-the-u-s-are-covered-by-medicaid-study-finds/

            In poorer states, nearly 70% of births are paid for Medicaid.

          • Bombshellrisa

            And in WA state, that means homebirth will be an option because most of the CPMs accept Medicaid. There is also an incentive (it’s small) to keep C-section numbers down for OBs

          • Bombshellrisa

            I agree with one small point to add: they get the same care once they have the paperwork done and are covered by Medicare. And for a lot if women, they have to wait to see if they qualify and a lot don’t get covered until they are into their 2nd trimester. I have seen doctors and nurse practitioners who don’t understand the process and be quite rude to these patients who come in for their first visit at 20+ weeks.

          • Young CC Prof

            Definitely, I know people who had a hard time getting the Medicaid and didn’t start prenatal care in a timely fashion. Delayed start means no dating scan, no MSAFP, no triple screen, blood work shows up pretty darned late…

          • OldTimeRN

            I don’t know how Medicaid works in other states but in NYS every pregnant qualifies for Medicaid, regardless of income. Also Medicaid goes back 90 days to cover bills. So there is no need to delay care. Many clinics have social workers who can help with paperwork for insurance.

            In our hospital Medicaid patients are treated exactly the same way as patients with patients with private insurance. As a nurse I don’t even know or care what type of insurance they have. It makes no difference in the care I give.

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

            Do you even know what financial arrangements your patients have? Back in the antediluvian days of my American L&D career, we had [1] patients with private doctors [who presumably had either insurance or the means to pay privately], and [2] patients who came via our outpatient clinics who paid on a sliding scale determined by the social services department of the hospital. [Beth Israel was not only a teaching hospital, we were partially funded by a major Jewish charity]. We never knew who paid what, but we knew for a fact that some of the private patients were receiving charity as some of the doctors worked pro bono or nearly so for certain haredi communities while some of the “charity” clinic patients were paying considerable fees. It made no difference to the care in L&D; it was irrelevant.

            Everything I read nowadays points to a huge variation between states in the kind of benefits offered, btw.

          • anne

            I believe medicaid pays for about half of births in the U.S. In a lot of states you are qualified if you are pregnant. One of the lushest maternity hospitals in the area where I went to college (steak and champagne dinner for parents after birth, birthing suites over a decade ago, etc) has a huge percentage of medicaid patients and they are treated exactly the same.

          • Jenny_from_da_Bloc

            Most of my friends had their children with Medicaid and all it took was a simple proof of pregnancy from planned parenthood or going to the Medicaid office and doing the paperwork to get in the program. Most had this done by 8 weeks and it was quite simple, even for Ukrainians with limited English. Its a state run program supplemented by the federal government and would defeat the programs purpose to take 20 weeks to get approved. I have never heard or seen it take longer than 2 weeks.

          • Young CC Prof

            I think it depends on the state. Also, there are people who are in weird situations, like a woman whose husband JUST lost his job, which meant that they had no money but didn’t technically qualify yet.

          • Bombshellrisa

            And not just weird situations, try being self employed and applying for Medicaid in WA state. I went through that, I sent the same paperwork four times (tax returns and quarterlies to prove income). And because I had lost my job and my husband had lost his two major accounts only recently, the only paper work we had made everything look good on paper.
            I wonder what exactly it’s like now with the ACA, but I applied when I took a pregnancy test and didn’t get approved officially until 21 weeks.

          • Jenny_from_da_Bloc

            Yes, I’m sure extenuating circumstances exist in certain situations. I just don’t agree with Ginab saying that woman on Medicaid receive substandard care because it just is not true. I know a woman who received a MRCS on Medicaid in Florida without any problems. I’m sure guidelines vary by state but what we can’targue is the program was creates to help pregnant woman. In Ohio they receive gift cards for going to all their prenatal appointment! People bash American healthcare all the time but you don’t see Medicaid denying children with cerebral.palsy surgery to walk and then giving woman like Josie Cunningham a $5k boob job on the NHS. It’s ludicrous what she is saying

          • Young CC Prof

            Absolutely, Medicaid probably literally saves thousands of women and children every year. New York City analyzed all maternal deaths over a 5-year period and found that pregnant women with no insurance at all were 7 times more likely to die than women with private insurance and 5 times more likely than women with Medicaid. Given than the Medicaid women may have been higher-risk to begin with, clearly Medicaid is winning.

            However, maternal health would probably work even better if all women had access to basic care starting BEFORE conception.

          • Jenny_from_da_Bloc

            Yes, true.

          • Free from the Woo

            Exactly! I had Medicaid for all three of my births two of which were in freestanding birth centers and could have been homebirths had I so desired. Also for pregnancy medicaid the income limits are much higher than for regular medicaid.

          • Beth S

            I think with the ACA and don’t quote me on this one, but I think they took the income limits off of Medicaid.

          • Young CC Prof

            Sort of. Pre-ACA, in many states, adults simply were not eligible for medicaid unless they were pregnant or had cancer or something. In other states, it was only for the truly destitute, again unless pregnant or children.

            Now, (in most states) all of the poor are eligible, and middle-income folks who don’t have insurance through their jobs are eligible for subsidies to buy insurance privately. Except some states, out of pure spite, refused to expand Medicaid, so a lot of people are left out. And then there are these other weird gaps.

            ACA is a messy patchwork solution. It’s better than we had before, but it doesn’t cover everyone, and it doesn’t address the huge amounts of money our system wastes arguing over who will pay for what.

          • Beth S

            That makes sense, I mean my state expanded Medicaid and has one of the best websites for signing up (Kentucky) so a lot of us are now able to be insured. Then again I don’t know much about the changes as I was covered before it kicked in, but I know my DH and DSS now are covered, and I won’t lose my insurance after the kiddo is born.

        • Beth S

          When my ODD was born I was on Medicaid, when this one was born I had one of those Cadillac insurance plans. You know what it was the same experience when it came to quality of care either way. Never was I told I couldn’t have something I wanted because of the cost, not even once. I had a C-section this time with drugs, guess what it was better, but I could have had one the last time had my body not failed me.

        • Sarah

          Eh, no. As a British citizen who has given birth in an NHS hospital, I am delighted this is being raised here. Why exactly should the situation in the US be Amy’s only concern?

      • pj

        Perinatal outcomes in the US are probably as good as they are precisely because the medicaid threshold is lower for maternity care–ie medical care in this instance approaches a public healthcare model.

        I think it’s kind of odd for Ginab to claim that US medical care is concerned only with cost and outcomes rather than patient satisfaction. I’ve experienced both public healthcare and the US system and the most tangible difference to me is that there is a lot more emphasis placed on the customer service side in the US. I get patient satisfaction surveys sent to me regularly here; never experienced THAT anywhere else! This seems to me to be a quite natural outcome of a capitalist model of healthcare.

        To be honest, the US system works really well if you are fortunate enough to be able to afford it. But I would still always advocate for public healthcare.

        • AmyP

          That’s true–I am FLOODED with patient satisfaction surveys in the US. That started a few years ago.

          • Young CC Prof

            But would you believe, the one time I was really dissatisfied, there wasn’t a checkbox to cover it?

            However, I did file a complaint, luckily no permanent harm was done. Still, those surveys are pretty dumb. Patient satisfaction is NOT linked to better care. Here’s a better survey:

            Were you in pain, and if so, was your pain addressed quickly and effectively?
            Were you and/or your loved ones kept informed about the process of treatment?
            Any particular praise or complaint?

    • AmyP

      There are a number of UK posters (including at least one GP) posting here. We also have good coverage for Canada and Australia.

  • Amy Tuteur, MD
  • Stacy21629

    Question regarding epidurals – as I understand, they don’t prolong stage 1 labor (and stage 2 minimally, 15min). Why is it that the standard view seems to be to make or encourage women to wait as long as possible before getting an epidural?
    I know they’re not “risk free” but in EVERY other area of medicine and surgery PRE-emptive analgesia is key. Prevents windup, provides better, longer analgesia.
    We’d never make the guy getting an appendectomy wait until his pain was a 10 or he couldn’t handle it. We’d never repair a fracture without pain medication on board already.
    My second labor went fast – 5cm to baby in arms in 2.5hours. I don’t care HOW dilated I am when I show up with this one – if I’m regularly contracting or my water is broken I want my epidural now.

    • Guest1

      I guess it depends where you go. In the past 3 hospitals I’ve worked at, nobody has been made to wait once they’re admitted in labor-not by OB’s and not by anesthesia. Many people choose to get epidurals @ 1 cm and that’s ok. It sounds like you would definitely be a candidate for a sooner-rather-than-later epidural!

      • Haelmoon

        I guess it depends if you are actually in labour. If a primip comes in with painful contraction, but is only one centimetre, I wouldn’t necessarily offer her an epidural yet. I would offer her something for the discomfort, but it is not clear that she is in labour yet. By strict definition, you are not in labour until there is cervical change and at least four centimetres dilated. This play in part to the timing of epidurals – I don’t want a lady to suffer, but I don’t want her to have an epidural if she is not in labour. If it is an induction, she can have the epidural as soon as she wants, the goal is to get her in labour.

        • guest1

          Which is why I said “once they’re admitted in labor.” In other words, they would obviously not get an epidural if OB wasn’t sure they were in labor. Labor is defined by cervical change, not by a “four centimeter” minimum.

    • C T

      Oh, it’s a bit longer than that, especially for nulliparous women. Per a paper published in 2014, the median length of 2nd labor numbers are:
      Nulliparous, no epidural = 45 minutes.
      Nulliparous, epidural = 120 minutes.
      Multiparous, no epidural = 14 minutes.
      Multiparous, epidural = 38 minutes. The study’s main author is Yvonne Cheng, it was published in Obstetrics & Gynecology, and the title is “Second Stage of Labor and Epidural Use: A Larger Effect Than Previously
      Suggested.”

      • Stacy21629

        I guess that’s why they wrote “previously suggested”.

        Thanks for that. Wish I could see the full text as the abstract just talks about 95th percentile. As I said, I went from 5cm to baby in arms in 2.5hrs with only 2 pushing contractions. I’m not too worried about potential prolongation of stage 2 in *my* personal case.

        • C T

          I had to ask my brother in med school for those stats since he had access through his university. I, too, wish I had the full text.

    • Jessica S.

      That’s a good question. I don’t think I was told I had to wait until a certain point. After my water broke (I had been in the hospital for a day and a half already, started with cervical ripener), they just said to let them know when it was too much. I hadn’t had any contractions, at least not noticeable, until my water broke and wasn’t hardly dilated, maybe a 1 or 2 at most? I never had any intention to go med-free, but I figured I’d might as well know what the contractions felt like, and know “why” I was getting the epi, just out of pure curiosity. In the 10 mins it took (very quick!) to get the anesthesiologist in there, I was like “now I understand what the epidural is for!!”

  • pettelly

    Again, this isn’t about midwives! I don’t get the obsession with blaming decisions on home births in the UK on them!! You really don’t understand how things work in the UK and you’re incorrectly projecting your prejudices and experience in the US.

    Most midwives, who work on high-risk OB led units as well as in birth centres or attending home births (or a mixture of all types of care), want to provide the best possible care – and it’s just as frustrating for them that they’re understaffed. Part of the issue with pain relief, for example, is that women DO have to wait for an anaesthetist for whom pain relief in labour is the lowest priority – compounded by the shortage of anaesthetists!

    However, it’s true that one of the considerations of some women in the UK (including friends of mine) when choosing a home birth is the quality of care you get compared with hospital. That’s not right. But the answer isn’t denying the choice of home birth but bringing up the standard of the care provided in hospitals to that of home birth.

    • Young CC Prof

      The large majority of individual midwives are definitely doing their best. The UK midwives’ organization has issued statements aimed at reducing the number of women who get pain relief, however.

      Also, I believe that if resources were not wasted on supporting home birth, it would be easier to provide quality hospital care. (Home birth requires 2 midwives all day, plus dealing with emergency transfers)

      • AmyP

        Yes! In a hospital situation, each laboring woman is not tying up two midwives in her room, all day long. That would be ridiculous.

      • pettelly

        I think that women’s choice to home birth should be supported on the NHS if that is what she wants and an individual woman shouldn’t have to worry about tying up NHS resources. The NICE study seemed to suggest, however, that home births and births in midwife led units are actually cheaper due to the lower level of interventions. The key isn’t to restrict choice but to adequately fund maternity services.

        • Amy Tuteur, MD

          But 98% of women aren’t interested in homebirth. Why should the government promote something that women don’t want?

          • Stacy21629

            Exactly!

          • pettelly

            According to the report, there is a lot of unmet demand for home births – I think they were estimating that it could reach 8 or 9%. And the report isn’t juts about home births but midwife led units in hospitals. The rationale is that home births (for certain groups) and midwife led units (for low risk women) are just as safe as ob led units but that interventions are lower and that reported patient satisfaction is higher. You may not agree with this (that’s probably an understatement) but the rationale behind it is to provide better care and choice. That’s not a bad thing (provided the right funding is put in place to implement properly). .

          • AmyP

            petelly said:

            “According to the report, there is a lot of unmet demand for home births – I think they were estimating that it could reach 8 or 9%.”

            I guess then we’ll have enough numbers to compare hospital vs. homebirth mortality in the UK.

          • http://gamesgirlsgods.blogspot.com/ Feminerd

            Oh, so the UK wants to do the Netherlands model.

            Except that the Netherlands model kills babies too. There is a higher rate of complications and neonatal deaths among low risk women seen by MWs than among high risk women seen by OBs in the Netherlands …

      • Louise

        Home birth does not require 2 midwives all day. You typically have one midwife for the first stage of labour and she only calls the second in when the patient is entering second stage.

    • Gene

      But why is a labouring woman’s pain a lower priority than, say, a conscious sedation for a fracture reduction (done by me in the ED, but some places are the territory of anesthesia)?

      • theadequatemother

        when you have a shortage of anesthesiologists that implies a busy emergency OR. If you simply have a string of appendectomies to deal with you can do the epidurals between cases. But when you have two anesthesiologists on and they are both in emergency long cases (which happens a lot) then the epidurals have to wait.

        There would be a strong incentive/ expectation from administration for ER sedation to be provided in a reasonable time frame because otherwise those patients would choke up the OR and impede flow. Whereas a laboring woman having to wait for her epidural is already in a birthing suite room and not giving the epidural quickly is not going to impede flow and efficiency. Although maybe it would be interesting to model the efficiency effect of early epidurals given that Cynthia Wong found labour was 90 min shorter if the epi was given at first request rather than waiting until after 4 cm.

    • OldTimeRN

      What is the standard of care and who decides what research is evidence based that we should be following?

      BTW what is the standard of care at home?

      • pettelly

        Guidelines regarding quality of care are released by NICE or by advisory bodies such as the RCM or the RCOG.

        NICE releases the ways in which it assesses evidence so you can look it up.

        • OldTimeRN

          “say a home birth MAY be just as safe for low-risk pregnancies.” So they don’t know for certain?

          “A home birth carried a higher risk for first-time mothers the risk of harm was still small – less than one in every 100 deliveries.” I’d hate to be that ONE baby or mother with complications.

          “provided transport arrangements are in place for hospital transfer in the event of an emergency” Those minutes tick away very slowly. In a hospital we can stat section a mom and have her baby out in under 2 minutes. Would a HB Mom even be in car in 2 minutes while her baby’s life slipped away?

          “or should there be a request for pain relief.” Well that’s good

          “About 15 women in every 100 have an unplanned caesarean, although this varies around the country. Ten in every 100 births are planned caesareans.” OMG the horror, an alive baby.

          “Approximately 40 in every 100 deliveries are “normal” births – women who spontaneously go into labour and do not require any real intervention other than support and pain relief.” And the other 45? Or the 10% of babies birthed who need medical intervention? Or the 1% who need serious medical intervention ? Are they waiting to see if they are “the one”?

          • pettelly

            Presumably, the number of preventable perinatal deaths which occur at home births in the UK versus hospital births are so small that they are statistically insignificant, if they exist at all. Midwives who attend home births are sent from the hospital. If a woman needs an emergency c-section asap, they’d call an ambulance and speak to the drs at the hospital – the woman would be taken straight to the OR where everything would already be ready for her. Of course that takes more time than if she were at the hospital but clearly those kind of cases are so rare that the benefits of properly attended and integrated home births outweigh the risks (according to NICE, not me).

          • pettelly

            And not knowing for certain whether home bitths or hospital births are safer makes total sense to me, as I replied to a previous poster. Fortunately, preventable perinatal deaths among low risk women are very rare both in hospital and at home, it’d be very hard to sufficiently power a study (in the UK) to really say with any degree of confidence which is safer. Both are very safe when carried out properly (fully integrated care with hospital, good emergency transport, properly trained midwives etc) and both are valid choices

    • The Computer Ate My Nym

      How does having more home births help with the midwife shortage? Two midwives are needed per home birth, whereas one midwife plus ancillary staff plus on call OB can cover several women in the hospital. It doesn’t seem like in any way a helpful plan if the problem is a midwife shortage.

      • pettelly

        It won’t. NICE is independent from govt. They release their findings based on the best available evidence, taking into account cost. It’s not binding and if there aren’t enough midwives to implement the recommendations, they won’t happen. As I said above, the RCM has already pointed this out.

        • Stacy21629

          “taking into account cost”
          Let’s see, Option #1 – cheaper birth, higher chance of dead baby. Option #2 – more expensive birth, near guarantee of live baby.
          Hmmm….this is a hard one.
          Whether I’m paying or the government is paying, my child’s life doesn’t have a price point on it.

          • Busbus

            If the injury rate for babies at homebirth is higher (and most statistics suggest it is), then the cost saving argument is also foolish. One single baby with HIE will wipe out the possible savings made on literally thousands of homebirths if you take the care into account that this baby will need throughout his/her lifetime (and that’s not even mentioning the lost earnings of the mother or father of the baby who will likely care for him or her and the unimaginable heart break and loss of a normal life for the child.)

            ETA: I hate these economic calculations when it comes to awful outcomes like this, but if we are talking cost, then that’s what we need to think of.

          • Young CC Prof

            That’s what I think. There is no POSSIBLE way that home birth is really cheaper in the end.

          • Stacy21629

            Even in simple cases. My last attempted home birth cost $3500 to the midwife and we got an initial bill of almost $9K from the hospital transfer. That was for 17 minutes of intrapartum care, unmedicated vaginal delivery, no repairs, no medications, discharge 6 hours later. We sure saved money on that one…

            Oh yea, and we still had to pay $400 to the CPM assistant that got lost on her way to our house, barely arrived before we transferred, came to the hospital and sat and did nothing.

            Cheaper my foot.

          • pettelly

            That’s the US system for you which is known for being incredibly inefficient.

          • MLE

            You forgot, $350/hr to hold the space

          • pj

            Most people coming to the US from overseas will at some point find themselves shocked by the cost of even the most basic healthcare there. Costs in the US are in no way predictive of costs anywhere else.

          • pettelly

            There isn’t any evidence that UK home births are less safe than hospital births. it makes sense that you can’t make that call. Statistically you’re not going to get much power. Thankfully, preventable perinatal deaths among low risk women (and the report also says multiparous as well – that hospital births are safer for first births) are very rare, whether at home or at the hospital. The home birth situation in the UK isn’t the same as the US, much better regulated and integrated with hospital care.

          • pettelly

            You have a very American attitude. Unlike the US, no pregnant woman in the UK has to make the choice of where she gives birth based on cost. It’s immaterial for the individual woman the cost of home birth, birth in midwife led unit or birth in obstetric led unit. It’s her choice regardless of how much it costs.

            Unlike in the US, no woman has to consider whether she can afford her copay before asking for an epidural, for example.

            I’m not saying the system is great in the UK but the system here in the US is pretty shitty although in different ways (I’ve experienced both).

            NICE, as a body, considers cost overall. But for a baby’s life, you’d be looking at millions to save a life such as happens with NICU care for very premature babies.

            And, you’re pretty naive to think that economists don’t put a price on your child’s life btw…

          • AmyP

            For most US women, homebirth is the expensive option in terms of money out of pocket.

            The only people who would choose homebirth because of expense would be those who were too well-off for Medicaid and without private insurance. In practice, it’s easier to arrange payments with a hospital than to come up with $3k in cash upfront for a homebirth midwife. I’ve seen the recommendation on a personal finance show to shop the birth in advance to your area hospitals–apparently you can arrange for a discount that way. Also, hospitals often forgive debt. In fact, given the prevalence of hospital debt forgiveness, $3k for a homebirth would almost certainly be greater than the cost the hospital would take in payment for a real hospital birth, with all the bells and whistles and machines that go ping.
            Going with homebirth for financial reasons is very uncommon in the US, although I confess that last year, I heard a comfortably middle class caller to a personal finance radio show explain that she’d had a homebirth to save $12k to speed up their debt repayment program. Urk.

            Homebirth for purely financial reasons is very uncommon among poor US women.

    • Mariana Baca

      You are right, the solution is not to eliminate homebirths. But the solution is not to promote *more* homebirths when the issue is lack of anesthetists. It solves the monetary/administrative problem but not the medical one. The real solution is to spend more money on anesthetists and less on midwives.

      • pettelly

        That’s very simplistic as you don’t know where the shortages are. Midwives fulfill a crucial role in the NHS maternity services. They do a lot of jobs similar to L&D nurses in the US plus deliver babies in straight forward deliveries (unlike the strange US system, both doctors (senior and junior) and midwives are employed by the hospital (or NHS trust). The lack of funding means that there are not enough midwives or doctors either to really provide the best quality care. In fact, the Royal College of Midwives has pointed out that the NICE recommendations on home births cannot be implemented with current staffing levels. Hopefully, this will push the govt/NHS to better fund maternity services which will benefit all women.

        • Mariana Baca

          My reply was based on your comment. You stated that there was a shortage of anesthetists. I proposed that if that is the case, the solution is not more home births.

          If the problem is a shortage of midwifes, the solution is still not more homebirths, since homebirth takes more midwifes.

          More homebirths can solve certain problems by reducing access and using lower cost providers. But those solve the problems on the govt’s end, not on the patient’s end.

          • pettelly

            Promoting home births won’t solve the staffing problems. Hopefully it’ll highlight the fact that there are such shortages! The guidelines were developed to improve outcomes based on best available evidence, regardless of the fact that implementation will take more resources.

        • Mariana Baca

          Also, CNMs in the US are employed by hospitals just like doctors and perform the duties you describe. The problem with the NICE recommendations is that they seem to be prioritizing cost to the govt over quality of care.

          • pettelly

            I’ve seen a couple of hospitals where CNMs are directly employed by the hospital. I find the system here very weird where doctors pop in to the room and suddenly you get a bill because they’re not actually employed by the hospital (although I understand it’s changing a bit). It’s also, extremely wasteful to have an ob attend every birth and every check-up and zero evidence that it leads to improved outcome.s

        • toni

          What is strange about the US set up? The only real difference (as far as I – the patient – is concerned) is that the doctor delivers the baby not the nurse. The nurse acts like the midwife throughout labour; chatting with you, checking the strips, rubbing your back, with the doctor popping in every so often. Once first stage is over the doctor comes in to catch the baby. I much much much prefer that system because the doctor is right there in case of a complication unlike in the UK where the midwives do everything with varying degrees of doctor oversight and then if things get scary they have to call and wait for an obstetrician.

    • pj

      So many people missing your point(s), Petelly! ;)

    • Stacy21629

      petelly are you really claiming that no single midwife was consulting in the crafting of these recommendations?
      These recommendations are anti-mother and anti-baby and I guarantee you many midwives contributed their opinions in creating them.

      • pettelly

        I don’t think the guidelines are anti mother or anti baby. They’re evidence based. Of course midwives were involved, as were obstetricians, nurses,, gps, laypeople etc. And actually they’re draft recommendation prior to a full stakeholder input. But I don’t understand why Amy has singled out midwives out of ALL the groups inputting into these guidelines in her blog. Pretty disingenuous as part of her diatribe against midwifery in general, despite fundamental differences between the unregulated system in the US and what happens in the UK.

  • Lori

    Okay, this made me think of my own little dilemma. Personal story time y’all! ;o) Okay, so I would love to hear anyone’s thoughts on this. I’m due with my second in July, my first was an unintentionally unmedicated childbirth. (As in, I got to the hospital at 4 cms, felt the pain wasn’t bad, slept between ctx in the tub for 2 hrs then got out and was 9 cms. Asked for an epidural at 6, midwife immediately started the bolus and nurses told me anesthesia was notified but the place was unusually busy, then, 4 hours later, had the baby sans pain relief. Now its my second time around and my midwife is telling me I will probably have this baby much faster (though admits it will hurt just as bad), seeing as my first labor was “fast” for a first baby. This makes me think there’s an even slimmer chance of me getting an epidural.

    So I’m in Ontario and I’ve got 3 options, homebirth which is something I’ve never been personally interested in, midwife led birthing center across the street from the hospital which offers pretty much no pain relief aside from N2O, and the hospital, which, in theory, offers epidurals and more, but due to an old ventilation system they can’t qualify to offer N2O.

    So would you go to the hospital, crossing your fingers that you either DO get the pain relief you want or at least have an easier time delivering, or the birthing center, thinking at very least you can make your brain feel fuzzy for the ordeal?

    • Pilo

      I’d go to the hospital and request an epidural as soon as it’s established that I’m actually in active labor.

    • theadequatemother

      Ask for the epidural as soon as possible. Or give up on the idea altogether or switch to a bigger teaching hospital.

      And what the hell…4 hours? FOUR HOURS and they couldn’t find someone to do your epidural? Was it the middle of the night? Was the only anesthesiologist available in a really long case? Is this a teaching hospital? Did they “forget” to remind the Ane to come after an hour? Did the Ane assume that since you were 9 cm at the request you had delivered in that hour? I realize these aren’t questions you have answers to…

      If you want an epidural guaranteed in Canada you pretty much had to go to a teaching hospital. In smaller places if the Ane is tied up in the OR or home after 11 pm you are SOL. Most anesthesiologists won’t come in from home “just” for an epidural. Some will come in if there are three or so epidurals lined up but that’s not a given and if LDR is used to no epis at night they won’t push for you. If they are stuck in the OR most will never call in their second unless a stat case comes in.

      If you are at a teaching center then they can send the resident (epidurals as so simple that after they’ve done 20 or so they are competent) or leave the resident in the OR and do the epidurals.

      • AmyP

        Maybe an induction to guarantee access to an epidural?

        • theadequatemother

          my induction resulted in no epidural. I thought it would increase my chances but…no. I can’t recommend that unless you have a hx of precipitous labour and can convince them to place the epi before they do the AROM.

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

            Too bad they wouldn’t place the epi before the AROM – that was a shame…

          • Haelmoon

            I have done that before – especially if the mom has polyhydramnios as a problem – they often start labour quickly, and there is that small chance of cord prolapse. Last one I had, we did have a cord prolapse, but a nice quick C-section with mom awake because the epidural was already in. There were other issue that lead us to take the chance of cord prolapse.

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

        The message we send to women when the healthcare system fails to meet their needs: you don’t matter.

      • Jacob Wrestled (Danielle G.)

        My reaction is similar: 4 Hours is LONG time!

        To be fair, I have only delivered once. And I delivered at a large, well known hospital. I believe Labor and Delivery has anesthesiologists on staff around the clock. So, perhaps my expectations have been set too high by my experience in this environment.

        But here is why my expectations are so high: Upon being admitted, a nice resident came by and explained my pain relief options to me. Later, when I decided to request an epidural, the nurse relayed my request and he was back in 10 or 15 minutes. They not only made sure I knew I could get pain relief, but they were fast once I made the request. I was startled at how well organized it was.

        If my experience is not typical, then this is really too bad. It should be. Perhaps I should thank my lucky stars and stay with my current provider!

        • Jessica S.

          That was my experience, at a university hospital as well!

      • Something From Nothing

        That’s not entirely true. I’ve worked in three community hospitals as an ob and we always have had 24 epidural service and our anesthesia certainly do come in at night, even for Multips who might progress quickly. There is sometimes a wait if the main OR is busy, but that doesn’t happen often as they communicate with labor and delivery before they start a long case. Our anaesthetists , for the most part, believe pain relief in labour is an essential service to be offered 24/7.

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

          ….my personal experience seems to correspond more closely with what TAM says, but things might have changed since I last ventured to the local hospital to have a baby.

          • theadequatemother

            Things did change significantly in bc between when you had your first and your second Mrs W. The govt started compensating anesthesiologists fairly for placing an monitoring labour epidurals.

            Other provinces have different pay scales so that might lead to some of the discrepancies in our experiences.

      • Haelmoon

        I recently booked a multip for induction, just so she could have an epidural. First labour arrived at 9 cm, delivered in under two hours, had a PPH and needed manual exploration of the uterus. Second pregnancy did the exact same thing – both times at 40+ weeks. Saw her at 38 weeks, cervix was 4 cm dilated. Booked her for an induction at 39 weeks. Broke her water, then she got an epidural (we made sure anaesethia would be available), delivered with 3 hours of ARM. She loved it. Mild PPH, needed uterine massage, loved her epidural even more than. It is possible to make it work for women if there is enough flexibility in the system (other times our induction list is so long she would never have made it to the top of the priority)

        • Jessica S.

          That’s a great story!

      • Lori

        Yeah, I’m not really sure what went down. There are 2 hospitals in town (neither is a teaching hospital unfortunately) and I work at the smaller one and WE have a 24 hr anesthesiology service so I’m certain the other hospital does as well. Also, virtually everyone I know who’ve had babies here got requested epidurals with the exception of one friend who arrived to the ER crowning and the baby was delivered within 10 minutes so, ya know, understandable.

        I also have never felt that my midwives were holding out on me either. I mean, I can’t prove it either way but my primary midwife went and asked for one as soon as I requested it then returned and started the IV bolus. Then her or the back up went out almost hourly to ask what was up. She said it was unusual for it to take so long and after I asked her if I should have asked sooner and she said 4 hours SHOULD have been enough time to get one in normal circumstances.

    • C T

      I’d always choose the hospital because it’s better equipped to handle rare, unpredictable cases, such as my nephew who was having trouble breathing right after birth and had to be helicoptered to a higher level hospital ASAP. It turned out to be a severe congenital diaphragmatic hernia. Totally unsuspected prior to birth.

    • Medwife

      Am I understanding correctly that you were 9cm, asked for an epidural, and gave birth 4 hours later? So the time frame was roughly, one more hour to reach 10cm, then you pushed for 3 hours? I wouldn’t call that “fast”. You had a fast first stage, but actually a prolonged second (pushing) stage. For a first timer without epidural, I call for ob consult at the two hour mark. Maybe anesthesia was notified but you were pushing by the time the were available and the midwives figured you were about to deliver so called them off? I think that’s bullshit by the way, I have gotten my patients epidurals ling after they started pushing- for one thing, if it’s taking a long time, they might need a vacuum or c/s, and they’re going to need anesthesia for that.

      If your goal is an epidural, I echo TAM that you should ask before you’re really uncomfortable. Don’t wait. You are basically guaranteed to get very uncomfortable, even if for only a short time!

      • Lori

        I think I pushed for about 2 hours (but my husband remembers it being 1), at the next cervical check, I’d say an hour or so later, I was told I was almost complete, but with a cervical lip, that took maybe another hour or so to go away. Its hard to remember specifically the timing of everything but I know I looked at the clock when I asked and it was 6am, and she was born 5 minutes to 10 so I’m sure about the 4 hour wait for the epidural. That’s why I’m feeling so paranoid that I will get shafted again. =P

    • Jessica S.

      I’d ask for the epidural right away. Can you place an order in advance? (Kidding. :))

      • Lori

        Haha, I’m actually a nurse and we use thoracic epidurals for post-op thoracotomy patients all the time. I’ve joked I should just toss the supplies into my overnight bag just in case.

    • CognitiveDissonaceHurts

      Did you notice the amount of stairs involved in the birthing centre across the street from the hospital? If you had to be transported for emergency reasons, that doesn’t look like it would be an easy thing to accomplish.

      Have you requested a meeting with the chief of obstetrics to discuss the pain management (or lack of) during this last birth?

  • Zornorph

    This is the sort of thing that happens when government is allowed to control people’s heath care choices. Even in the US, Vermont is trying to go to a single-payer system. This sort of thing is the natural result of ‘free’ health care for all.

    • theadequatemother

      No it isn’t. The NHS is a govt organization where the doctors are employees complete with pensions. So when the admin wants to make a sweeping reform they can. Sweeping reforms hit the NHS on a regular basis.

      In Canada where we have a single payer system, for historical reasons, physicians never became employees. We are independent contractors and we have considerable power to shape (and block) changes.

      • drmoss

        That’s changing fast, as provincial governments have realised they can save much money and better control what docs do and when they do it by making them, effectively, employees. Any Canadian doc on an AFP is working as an employee, but gets no pension. Plus they have to do exactly what their admin lets them do and no more. Sadly, many younger docs fall for that. I work in a four doc community. The three youngsters are paid a salary, get six weeks paid vacation, two weeks study leave and have set hours. I’m sticking with fee for service, last had a week off in 2006, but I can thumb my nose at the administrators. We used to have a decent system, but now we have more administrators than beds in each hospital and all the dollars are keeping them employed and not going to patient care.

        • GuestS

          I think they’re more controlled by local government rather than centralised, it’s done by separate primary care trusts and all offer slightly different things according to their local population. There are also various specialist hospitals spread around the country. It’s not simply a case of David Cameron down.

        • Haelmoon

          In BC we have AFP but also sessional payments. These are like a cross of FFS and AFP. I am contracted for a specific number of hours and patient care. However, I can work beyond the scope of my sessional practice (MFM) and bill FFS whenever I provide general (OB) care (like when I am on call). Its a nice mix, but I am not limited at all how I practice. I think the specialist AFP/sessionals are different that for family physicians.

    • Paloma

      It has nothing to do with the government. Is the US you have the idea that if the system is completely public (or paid for by the government) it means they have a say over the choices you make, and it is VERY mistaken. In Spain the system is completely paid for by taxes and the government and I have never heard of one case even similar to this.
      What leads to a situation like this is not staffing the hospital to it’s needs. That depends on the person in charge of the schedule, and has nothing to do with funding. If you have an obstetric unit you SHOULD have an anesthesiologist assigned to it INSIDE the hospital (what if you had an emergency and needed a crash C-section?). In Spain there is always someone in charge of epidurals AND another person in the emergency OR. If a woman doesn’t get an epidural it is either because they didn’t want it or because they arrived at the hospital too far into the labour (this happened to my mom). But never because there wasn’t someone available to do one. If you try to understaff a unit, then you have this problem. But this depends on whoever is in charge of organizing and if they know how to do it well, the government hardly has anything to do with it.

    • T.

      I live in Italy. I’ll take NHS over not going bankrupt if I get cancer, thanks.

      Today I had to put down my doggie. I am in rough water, and I had to agonize with “what if what he has is curable but I DON’T HAVE THE MONEY TO CURE IT?”. “Luckily” his cancer was not operable.
      I can’t THINK of having the same thoughts with a loved one. I just CAN’T.

      So no, thank you. I am an atheist or I would be blessing my NHS, with all the faults and flaws it has.

      There are several things that I think shouldn’t be in Extreme Welfare. But public education and public health are not among them.

      PS: All caps are intentional. They are intended to be a scream, because in my mind, I was indeed screaming.

      • araikwao

        Sorry about your dog :(

      • Stacy21629

        “Today I had to put down my doggie. I am in rough water, and I had to agonize with “what if what he has is curable but I DON’T HAVE THE MONEY TO CURE IT?”.”
        This is my job, every single day. The dangerous intersection between emotions and finances.
        My sympathies on the loss of your dog.

        • Jessica S.

          I have always admired how vets do a great job counseling owners on these matters. I’m sure it’s not an easy job.

          • Stacy21629

            The money stuff is the hardest thing. Especially when I know I can fix the animal. Unfortunately, neither I nor the clinic can pay our bills if owners don’t pay…so except in life-threatening instances, no money, no treatment.

        • T.

          I understand you, completely. And we paid everything. I was just… Well. You can image.

          Thank you.

      • Mishimoo

        I’m so sorry about your dog.

        • T.

          Thank you ^^

      • Spamamander

        I’m so sorry about your loss. I had to have one put to sleep because of injuries and sadly I had the same conundrum… I had already spent $700 patching up my other dog. How much treatment would ultimately be did end up being a consideration, though the vet assured me given the circumstances she would have opted to put him to sleep as well, the muscles of his neck had been badly torn by another dog and the chances of him recovering and being able to lift his head were very small.

        I actually in a way made a decision like this about myself. Two years ago an emergency CT scan of my abdomen after my horse kicked me showed what might be a mass. I didn’t have insurance and I already ended up in arrears because of the ER bill. Only recently did I get a repeat scan to ensure there wasn’t anything wrong… what could have happened to my health in those two years?

        • T.

          Yeah… it is a horrid decision to make. I am glad it is not mine. And sorry it was yours.

          Thank you^^

      • Jessica S.

        So sorry about your sweet pup. We had to put our kitty down two weeks after our son was born (nearly 4 years ago). I like to think she held out until she knew I’d have a sufficient distraction, b/c without him to take care of, it would have been 100 times worse.

        • T.

          Thank you :)

    • pj

      You realise that you can still get private healthcare in a public healthcare system? Here in the US, I pay more in taxes towards healthcare than I would in a country with public healthcare and I get NOTHING for it. I’d prefer to at least get the choice of free healthcare.

    • pettelly

      What sort of thing? An independent body releasing guidelines? Increasing choice for women? Why is that any worse than an insurance company deciding what they will cover and what they won’t? Or a doctor just dropping a patient whose opinions he or she doesn’t agree with? No one is stopping any woman from paying to give birth in a private hospital or private wing or even with an independent midwife at home.

      Give me the NHS over the fractured, unequal and inefficient US system any day.

    • pj

      Incidentally, this can be reversed to make the kind of reaction people used to public healthcare have about the American system: “wow, you let PRIVATE COMPANIES, whose ultimate aim is to make a profit, determine the kind of care you can and can’t receive?!”

      • Paloma

        In my country (Spain), there is an enormous respect for the public healthcare system precisely because they feel that they want their doctors to choose the course of treatment without worrying about the profit they (or the company) are making but rather what is objectively better (best outcome with the least adverse effects and risks). Also, not everyone is able to pay for certain treatments and their medications, a public system allows everyone to have access to a better health and to be equal, no matter what their economical resources may be.

        • AmyP

          So, how common are epidurals in Spain for vaginal birth?

          • Paloma

            Almost everyone gets them. Even the people I personally know and weren’t sure, did just in case there was some complication they could speed things up. I’ve actually seen patients worried because they thought they wouldn’t be able to get one, and never heard anyone question a mother because they got one.

          • Spamamander

            Can I emigrate?

          • Paloma

            As wonderful as healthcare is right now in Spain, the >25% unemployement rate, corrupt politicians robbing all kinds of money and trying to take down our public, universal healthcare system and privatize it, etc. I wouldn’t recommend it. I actually tried to emigrate a few months ago and eventually stayed in Spain, but I may do it in the future once I finish residency.

      • Spamamander

        I live in the US and it horrifies me. Insurance companies wanting to pay the least they can to make a profit- oh sure, that’s going to really give incentives for best treatment!

    • Louise

      Yawn…The government does not ‘control’ people’s healthcare choices in the UK (or any other public system of which I am aware) to nearly the same extent that HMOs control people’s choices in the US. There is no suggestion that women should be forced to have home births, nor, contrary to Amy’s spin, that they would receive a substandard quality of care in hospital. I currently live in a country where there is no free healthcare and that terrifies me. I was never terrified in the UK under the care of the NHS.

  • Free from the Woo

    Totally OT but I just saw this posted in NGM’s Facebook and was curious as to Dr Amy’s and y’all’s opinion.

    http://rhrealitycheck.org/article/2014/05/13/lawsuit-staten-island-hospital-forced-patient-c-section-will/

    • Karen in SC

      Can’t give my opinion until I’ve read both sides. Might be a legitimate claim or might not. BUT because this woman was in the hospital under a licensed OB, she has the ability to sue for damages. And the hospital will hold meetings etc and policy changes may occur.

      Compare that to a women unsatisfied with a homebirth. No legal recourse and complaints to NARM do absolutely nothing. Even when death or severe disability occurs.

    • Zornorph

      Really can’t say too much without more info, but dollars to doughnuts this woman was one of those who was obsessed with having a ‘healing’ VBAC. As unchristian as it is, I really want to slap people who place the value of their ‘experience’ over the health of their child that way.

    • The Computer Ate My Nym

      Hard to say for sure, but if they really imposed a c-section on a competent patient who was refusing they went outside the usual ethical norms. I might think that her decision was a bad one (again, hard to say, but I suspect that it was), but that doesn’t mean she didn’t have the right to make it, if she was competent.

    • Medwife

      I’m initially repulsed by the details I know through the article, but realize I don’t have close to all the details. My bet is that if her bladder hadn’t been perforated no attorney would have touched her case though- not enough payoff involved if “all” that happened was a total violation of consent.

      • Stacy21629

        If she had nasty adhesions, though, doesn’t that make a bladder perforation more likely? I know when I’m in a dog’s belly and there’s adhesions all over the place it really makes the entire procedure that much more difficult.
        Who knows, maybe this OB just read where another OB delayed a C-section, the mother had a vaginal birth and the baby had cerebral palsy (and sued and won) and just thought – “forget it, I’m getting this baby out alive and well”?
        Because you know if this women’s uterus ruptured during TOLAC and the baby died she would have argued she wasn’t pushed enough on the risks and should have been given a C-section.
        Why isn’t a healthy baby good enough for these people?

        • OldTimeRN

          I recently had surgery which I thought was going to be performed one way. Unfortunately because of adhesions it had to be performed another way. Should I sue? Hell no I’m just happy I picked a doc who knew what was best for her patient and who didn’t force the procedure and potentially cause damage.

        • Medwife

          Should they have gone through the informed consent process in which they listed bladder damage as one of the potential harms, and a healthy baby as a potential (extremely likely) benefits, and then she consented and they knicked her bladder, sure, very unlikely to get sued. But that wasn’t the case. She refused the procedure, had it forced on her, and was harmed. They gambled and lost. Consent matters.

          • Stacy21629

            Oh, I agree 100% – consent matters.

            I just think they would have “lost” no matter what they did. At least they “lost” and mother and baby are alive and healthy.

  • ngozi

    I think we should stop feeding the trolls and let them starve to death…

    • C T

      Oh, but their slobbering crudity and lack of clear logic is so informative for those who might think the trolls are normal, sane women……

      • Bombshellrisa

        We could use some of this: Troll B Gone

        • ngozi

          I think we should pitch in and buy Dr. Amy a case of this for her birthday.

  • cera

    I would just like to know Dr. Tuteur how many unmedicated births have you witnessed? how many home births? you are full of shit, this article is full of shit and so is just about every piece of anything you’ve written. you want to scare women into the hospital like the rest of the medical world so you can have control of another person’s body and what she does with it. The human body is a wonderful thing, you should allow it and observe how wonderful it really is during labor.

    • yugaya

      I think Disqus is acting up again, the above comment showed up under Nym’s username in my feed. :)

    • Rachele Willoughby

      Yes, Dr. Amy, just how many natural births *have* you witnessed (other than your own four, of course)? I know it’s hard to count but go ahead and round to the nearest hundred or thousand as necessary. ;)

      • yugaya

        Also, how many preventable deaths occured in the hospital during your career because you chose to ignore risk factors or clear signs of distress and let the woman’s bodies do what they were made to do? I mean, you are not really a natural child birth friendly attendant without a couple of babies killed.

        • MLE

          So sad but true. Also don’t forget the lack of remorse.

    • C T

      Oh, brother. It’s actually REALLY easy to have an unmedicated birth in the hospital. I’ve had four in three different countries under the care of four different OBs. If women ask for an epidural, that’s their choice; why would you want to take away pain relief from women who really want it just because you don’t happen to want it?

    • ngozi

      I’m glad the hospital staff chose to save my child’s life rather than observe how wonderful my body was during the labor/delivery of my last child. My body was probably wonderful in some ways, but that placenta sure wasn’t!! (ooops, feeding a troll!!)

      • Trixie

        Not enough kale.

        • ngozi

          Maybe I should have stuffed my vagina with garlic. I don’t know how I missed that one; I even GROW garlic!!

          • Trixie

            Oh, that’s perfect! Vaginas love to eat local!

          • Bombshellrisa

            A locavore yoni!

          • Jessica S.

            Oh my god, I’m DYING at that comment!!!

          • MLE

            Save a step and plant the garlic in your vagina

    • Trixie

      Actually, a good number of the regulars here have had unmedicated births — I’d venture an even higher % than the general population.

      • ngozi

        I have had two. The first time I had an unmedicated birth was because the hospital staff didn’t believe I was in labor and it was too late for it. I had done a lot of laboring at home that time. The second time I had a unmedicated birth was because I wasn’t experiencing pain that needed medicating. I never had an epidural until my C-section (I think that may have been a spinal).
        I have had a nurse to be rude to me because I didn’t want an epidural, but I have never had anyone in the hospital to force pain medication of any kind on me.

      • AmyP

        My first birth was probably about 50% unmedicated and the second was 90% unmedicated (fast four hour labor, late epidural). I’m not a fan.

        You don’t need to go the whole way to realize, hey, this is only going to get worse.

      • theadequatemother

        I’m an anesthetist that had an unmedicated birth. But not by choice. In the health care system where I work I have seen quite a bit of delaying tactics when women ask for pain relief in labour. That happens regularly because of the lingering effects of Dr Michael Smith. I’ve actually never had to cajole anyone into accepting an epidural. I had one experience in 10 yrs where I walked into a room to find a woman sitting up “ready for the needle” but when we discussed it she decided not to go ahead. So I left.

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

          I believe you mean Dr. Klein…

          • Aki Hinata

            I have had five unmedicated births. I happen to be lucky. Women who want pain meds should get them post haste!

      • Jen

        I’ve given birth twice – my first an induction which was a breeze (as far as labours go anyway!) with a shot of pethidine to help me through. I’m still singing its praises two and a half years later. I did ask for an epidural but my baby was born 30 minutes later, no time for the anaesthetist to come in on a Sunday evening. However my lovely Ob gave me a local just before he crowned.

        Second was spontaneous, four hours from ‘oooh, I think that might have been a contraction’ to ‘holy crap I just had a baby and it’s not even lunchtime yet’. No drugs, no time, although I did have a few regrets about that just before I pushed him out, it was all good. Peth was (sadly) not an option this time as my first birth had actually been quite quick and I didn’t want to risk any effects on my baby, I don’t like the gas and there just wouldn’t have been time for an epidural.

        My husband is a nurse and works with anaesthetists, many of them offered to come in and do my epidural whenever I wanted it, so it was nice to have the offers!

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

      The hospital where I trained and worked for 8years, in NYC, was a pioneer in unmedicated birth and a great supporter of it. During that time I also was a Lamaze instructor. Later, in the UK, I did homebirths as part of my midwifery course, and, since moving to Israel, have also worked in hospitals where a large percentage of patients did not want analgesia, at least initially. I have, without a doubt, vastly more experience with birth, in all its forms than you have.

      If a woman wants to suffer for no good reason, that’s her choice. If she wants pain relief, as long as her baby’s safety is not compromised, that’s her choice, too. But she has a right to have all options available, along with all the technological advances to make her birth as safe as possible for her and the baby. Making the experience “pleasant” for the mother is secondary.

      BTW, I find your language unnecessarily vulgar, crude, and offensive. You are also unnecessarily paranoid.

    • The Computer Ate My Nym

      Right you are! I so wish my CNM had simply observed me and my baby “wonderfully” dying of obstructed labor instead of calling that nasty old (male even!) OB for a c-section! And I was so much more in control of my body when I was in 10/10 pain and able to do nothing but scream than when I had an epidural, had 0/10 pain, and could move freely, chat with my partner, and take a nap.

      • An Actual Attorney

        My uterus “wonderfully” grew a fibroid that blocked my cervix completely. I do wish my OB had “wonderfully” watched my body “wonderfully” explode my uterus and my baby’s body “wonderfully” die. You are so right.

        Now all I have to show for it is an actual wonderful 4 year old refusing to go to bed.

        • MLE

          It sounds like the basis for an amazing action movie (minus the dying).

    • Paloma

      I’m guessing since Dr. Tuteur was a practicing OB in a major hospital, she has probably witnessed thousands of births, probably much more than you ever have, since you use such logical and rational arguments to discuss. Oh wait… YOU DON’T.
      I am a medical professional too and I am incredibly offended by your statement that everything we want to do is control anyone’s body. When we go into medicine, nursery, etc. we do so because we want to heal and help people, by actually saving their lives instead of imposing a certain belief and model of how they have to do anything. The human body is a wonderful thing, but the people that they actually are (or in the case of a child, will become) is far better than a body part, and helping them to live and bring a child into the world safely is far better than observing them while they are in pain and struggling, or even dying.

    • Jenny_from_da_Bloc

      Until something goes wrong like shoulder dystocia or a hemorrhage, than it’s not so wonderful. obvious you know nothing about DR. Amy because she has had unmedicated births herself. So maybe get your shit straight before it starts pouring out of your mouth and making you look like an asshole.

    • OBPI Mama

      Like my midwife sat and observed all the red flags of an impending shoulder dystocia during my homebirth? My body is so wonderful it decided to try to kill my baby by keeping him in me (shoulder dystocia).

      I think the human body is amazing. I think the labor process is fascinating. It’s wonderful and it’s miraculous and it’s dangerous and it’s unpredictable. Keeping in mind all 4 of those things does not take away from anyone of those descriptions. But what I love more than a wonderful body is a wonderful, healthy, LIVING body… especially the 9lb ones!

    • Bombshellrisa

      When people ask this question (you are far from the first person who has), I wonder what it is about seeing a “natural birth” that is supposed to teach someone something? CPM call themselves “experts in normal birth”, which is a misleading way to imply that by choosing them as caregivers, you will be promised a “normal birth”. Seeing uncomplicated vaginal births does not prepare someone to be able to diagnose and treat anything. Fwiw, I was a homebirth midwifery apprentice and doula, didn’t have the benefit of pain medication during either of my labors and I have seen plenty of home and birth center births.

      • yugaya

        -”what it is about seeing a “natural birth” that is supposed to teach someone something”

        There was that birth photographer somewhere stating that the fact that she ‘attended’ hundreds of births made her more qualified to discuss neonatal resuscitation than a person with a medical degree.

    • Pilo

      This is like asking a meteorologist/weatherman about how many sunny uneventful days they have seen. Who cares? We have meteorologists so that we can have trained and wise guidance when things are not going well (predictable or not). No one cares about how accurate the meteorologist is when the weather is sunny and calm. On those days, a taxi driver can give you a forcast with the same accuracy as a meteorologist–just like a taxi driver can deliver a baby during an uneventful delivery. But that doesn’t mean that all women who are likely to have smooth deliveries should be delivered by taxi drivers.

    • araikwao

      Would witnessing a wonderful homebirth somehow negate the disproportionately high number of deaths?

    • Jessica S.

      “The human body is a wonderful thing, you should allow it and observe how wonderful it really is during labor.”

      What about when in doing so, the baby and/or mother dies? Is that wonderful, too? B/c unless you’re a complete idiot (question asked, answered) you have to know that in almost every case, in a hospital, if a baby is healthy at the start of labor, all disasters are preventable at that point. This is not true in “trust body” la la land. Professionals know how far they can “trust” the human body: about as far as they could throw it.

  • Wild Snorlax

    You literally could not be more full of shit if you tried. An unreferenced, anecdotal piece of writing hugely biased by your own need to cling to a hospital. Women and baby die in hospitals – let’s see your stats on that, kiddo.

    • Jessica

      You must be new here.

    • The Computer Ate My Nym

      Numerous posts on this blog discuss the statistics. The numbers vary with the study, but the bottom line is home birth results in more deaths, more low Apgar scores, and more complications than hospital birth. Heck, even the MANA data shows more deaths in the home birth group.

      Also, you’re metaphorically abusing the word “literally”.

      • araikwao

        Yup, until I see faeculent vomiting and overflow diarrhoea, I don’t believe the snorlax for a second. (Wait, was that too gross? Sorry. Kind of.)

        • An Actual Attorney

          “faeculent vomiting” — i am working that into every conversation I have the rest of this week!

          • araikwao

            Let me know how it goes :P

    • ngozi

      “Women and baby” do die in hospitals, but usually those are higher risks situations. In those situations, the woman would have been risked out of midwife/homebirth care (by a responsible midwife).
      Why don’t YOU give us the stats on babies and women dying in hospitals?

    • Amy Tuteur, MD
    • Paloma

      Your alias is very appropriate, since apparently you have researched the pokémon you named yourself after better than the statistics Dr. Amy has posted time and time again in this blog.

    • Jenny_from_da_Bloc

      Yeah, but statistically more babies die during home birth.

      • Jenny_from_da_Bloc

        And the stats are all over this website Snorlax

    • Jacob Wrestled (Danielle G.)

      “Kiddo.” Really? You’re addressing an adult woman, an MD, and a mother of four with “kiddo”?

      • yugaya

        “let’s see your stats on that, kiddo.”

        Whoa, thanx for proving me right when I think that to NCB front runners, childbirth really IS a pissing contest.

    • Stacy21629

      You’re the one making the assertion about “women and baby (sic) die in hospitals”. Seems YOU have the onus to back that up.
      So, please, tell us – how many healthy moms and healthy babies die preventable deaths at term in the hospital?
      Oh, wait, you don’t know. Because you’re just parroting a NCB line and bypassing your brain entirely.

  • Guest

    For a crystal ball view of health care under the ACA one need merely to look at this and the VA

    • The Computer Ate My Nym

      The ACA simply mandates insurance. It doesn’t involve the government in the provision of health care at all. As for the VA, the care is good if a bit low on the frills. (I’m only citing one study comparing the VA to private hospitals for fear of the spambot, but there have been others showing similar outcomes.)

      • Guest

        That is an extraordinarily naive view that has no correlation with reality.

        • The Computer Ate My Nym

          Want to elaborate?

          • ngozi

            I heard the crickets chirping…

          • Guest

            Sorry, it took me the better part of a day to control my hysterical laughter at the sight of somebody placing the adverb “simply” within 10^23 light-years of “ACA/Obamacare” even to venture to type a response. Then I realized that if you couldn’t figure it out for yourself, you didn’t deserve one.

          • The Computer Ate My Nym

            Translation: You have no argument and don’t want to admit it. Typical of opponents of the ACA.

          • The Computer Ate My Nym

            But I should add that I love the oddly specific distance of 10^23 light years.

      • R T

        My experience with the VA medical care has been good WHEN I can get in! I needed a endoscopy and it took an entire year to get an appointment! One entire year! In the meantime I lived in excruciating pain off and on and had to limit my activities to ones I could do near a toilet! It took four months for me to get in to be fitted for custom orthotics due to shin splints and that’s only because they had a cancellation! When I was pregnant the VA had a contract with the local military hospital and I was only allowed to get care there. When I abrupted at 20 weeks the military MFM’s gave me one choice, either wait to miscarry while I bled heavily and contracted or have an abortion and “start over”. I knew I had other options, but the military hospital refused me any other help before 24 weeks. The VA refused to pay for me to even get a second opinion from a civilian doctor or even to travel to another military hospital for a second opinion. The Women Veteran’s Health Coordinator said her hands were tied. The final big “f you!” happened when I said I would just find a way to pay for it myself and go to a civilian perinatologist locally for a second opinion. The VA and military doctors flat out refused to even give me the referral the perinatologist required to see me! They said there was nothing he could do for me that they couldn’t so I didn’t need a second opinion. I had to call every day and beg to be seen without a referral! Yeah the VA is just dandy!

        • Jessica S.

          That’s awful! :(

        • The Computer Ate My Nym

          That’s utterly hideous. The VA’s obstetric care is…shall we say substandard. They’re good at the stuff they see a lot of (COPD, cardiac disease, etc), but can’t cope with obstetrics or gynecology.

          When I had a GI problem that might have been stomach cancer, my (private) hospital (as in the one I work at) gave me an appointment a mere 6 months from when I called. So, that’s better I guess…

          • R T

            They are trying to change that since for the first time in history they have thousands of women veterans of childbearing age to care for. However, like any government process the bureaucracy sucks! They are consistently changing their care guidelines too! Until 2011, you could seek out a civilian doctor for OB care, but now you have to live 50 miles away from a military hospital to be approved for a civilian doctor. I don’t understand why women veteran’s should have to go to military doctors for care if they live up to 49 miles away from a military hospital! That seems like a long way to have to drive when you are in labor! Especially if there is a locally hospital a mile down the street!

          • Young CC Prof

            In some parts of the country, that might be OK. In other areas, 50 miles is way to far to travel on a regular basis, since it could be 2-3 hours.

    • Jessica S.

      The ACA is the insurance industry’s wet dream. (Pardon my vulgarity, but I think corporatism is pretty vulgar, too.) People in favor of single-payer systems/universal healthcare/Medicare-for-all were sold down the river, and the true believers will tell you as much. So trying to compare a national health care system to the ACA is a false equivalence that frankly, makes no statement at all, for or against.

      • The Computer Ate My Nym

        The ACA is the insurance industry’s wet dream.

        Yep. That’s why it passed. The ACA was, in effect, the Republican alternative to “Hillarycare” back in the day. But nothing better was ever going to pass, so might as well take what we could get.

        • Jessica S.

          Exactly, which is why I chuckle when Republicans criticize it. It’s all a big game, politics – too bad real people get hurt in the process. :(

  • GuestS

    Midwives in the UK are able to give some forms of pain relief in the home.

    • The Computer Ate My Nym

      Nitrous oxide. Notoriously dangerous and ineffective. I’d probably go with nothing.

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

        I’ve used it. Effectiveness varies considerably. Most of the time the woman only begins breathing it when the contaction is becoming quite strong, instead of at the onset, so by the time a high enough level is reached the contraction is usually ending. UK midwves can also give IM pethidine (Demerol) in limited doses.

        • The Computer Ate My Nym

          I had it for dental procedures as a kid. Best I can say about it is that the hallucinations were occasionally interesting. Of course, a single person’s experience shouldn’t be extrapolated, etc.

          • GuestS

            I’ve had two babies with it and loved it. I didn’t want an epidural and I didn’t have pethadine or anything else. Lots of people I know have been more than happy with that as their pain relief. Don’t know where you get the idea that it’s ‘notoriously dangerous’ from either.

          • GuestS

            (I know that’s anecdata but I just think that the sweeping ‘it’s barbaric’ and ‘how dangerous’ is a bit melodramatic given that there seem to be plenty of women who choose it and that’s nothing new over here.)

          • http://gamesgirlsgods.blogspot.com/ Feminerd

            Easy to give too much- it was pretty much the first labor anesthesia, and it was notorious for killing women by suffocation.

          • Young CC Prof

            No no, that’s chloroform. And the only way chloroform could be used with any degree of safety was with an expert standing by her head just to monitor it, and women started suffocating when doctors cut corners and tried to administer chloroform and deliver the baby at the same time, which meant the dose was poorly controlled.

            I’ve never heard of modern patient-controlled Entonox suffocating someone.

          • http://gamesgirlsgods.blogspot.com/ Feminerd

            Me either. That’s why I thought it was ‘notoriously dangerous’, even if that’s not accurate anymore.

        • theadequatemother

          agreed. you have to start huffing it before the contraction builds and you have to stop huffing it at the peak or just after the peak of the contraction. Otherwise it hits your brain between contractions and you feel nauseated and dizzy without any pain relief. For transition or when contractions are continuous its not such a problem.

          But then when pushing you cant really huff the nitrous and push. there is too much going on and so if you aren’t one of the women that finds pushing a relief…well there’s that.

  • no longer drinking the koolaid

    Last time I checked, the home birth rate in the UK was about 2%. I think women there are smart enough to know when they need to be in hospital.

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

      The previous Health Minister also blathered on about giving more women the “choice” of having home births, but tha seems to have been glossed over pretty fast when the true lack of community midwives was made apparent. I bet this becomes a “non-subject” quickly too when the real costs of implementing an increased homebirth system are added up.

  • NoLongerCrunching

    Brilliant.

  • Jamie

    Amy, we’ve had this conversation before but I’ll say it again: giving birth at home made an enormous difference in my pain perception. I experienced agony in my first hospital birth and significant pain in my second. One of the many pleasant surprises about giving birth to my younger children at home was the difference in the sensations of birth. Hard work, sure. Agony– not for a minute. My personal experiences accord with the findings of this old but still relevant study: http://auspace.athabascau.ca/bitstream/2149/1378/1/home_birth.pdf

    Of course the NHS should provide women with good choices. But your assertion that they’re consigning women to agony is yet another straw man.

    • Amy Tuteur, MD

      How is your personal experience even remotely relevant? So you experienced less pain at home; are you the exemplar of what all women will experience? How on earth does your personal experience affect the fact that women are being forced to choose between personalized care at home and effective pain relief?

      • Sara Maimon

        only personal experiences that jive with amy’s agenda welcome?
        and stop the over the top exxaggeration. no one is being FORCED to homebirth.

        • Amy Tuteur, MD

          Really? Do you know another way to have two midwives attend you in labor, and you alone?

        • The Computer Ate My Nym

          Actually, if you read the post, they kind of are. Or, if not forced, strongly encouraged. A similar situation occurs in the Netherlands where women who are “low risk” are forced into the midwife track which has a higher morbidity and mortality than the high risk women on the OB track.

        • fiftyfifty1

          ” no one is being FORCED to homebirth.”

          Correct. Women in the UK are only being forced to make the following choice: personalized care at home by 2 midwives vs. going to the midwife-run hospital ward where there is notorious understaffing. That’s Dr. Amy’s point. If you missed it you should read the piece again.

      • Jamie

        Oh, I had forgotten one of the rules of engagement here: your lack of personal experience with homebirth doesn’t disqualify you from making sweeping assertions about it, while the personal experiences of people who’ve had or attended homebirths are irrelevant. And let me guess — the perceptions of the 400 people assessed in the study are also irrelevant, because you disagree with the authors’ findings.

        I think I’ll leave you to your echo chamber, Amy.

        • Amy Tuteur, MD

          You can’t answer the question, so you are flouncing. Typical.

        • NoLongerCrunching

          Then why not give women the choice, rather than pressuring them to comply with the NHS’ agenda? Do you believe in respecting women’s choices, or do you believe in the patriarchal idea that you know better what’s best for women than they themselves do?

        • Jenny_from_da_Bloc

          How about the fact that nobody should be denied a safe birth with pain relief in a hospital because of archaic guidelines suggesting home birth is better, more pleasant and painless?! Those guidelines don’t remove the risks involved with birth. Maybe you got lucky with your home births, but not everybody is going to be that lucky and have the same results as you. Your argument only applies to you and is therefore moot. So listen to that in your echo chamber of woo!

        • Jessica S.

          Jesus, what kind of “experience” with homebirth would an experienced OB need? Other than a deep steep in pseudoscience? I think she – and anyone trained to deliver babies (correspondence classes don’t count) – is quite qualified to critique HB.

    • moto_librarian

      So each birth was less painful than the previous one? That sounds more like the natural progression of labors for most women with the first typically being the longest and most painful.

      • Jamie

        Nope, it wasn’t linear. My fifth child’s birth was the most painful of the three homebirths. Still very different (in terms of pain) from being in the hospital.

        • OttawaAlison

          But that wasn’t Dr. Amy’s point. No one is stopping you from forgoeing pain relief, however whether it’s true for you or not, birth is effing painful and people should have access to adequate pain relief.

          • Irène Delse

            ^ So much this! Why does it seem so hard for homebirth fans to understand?

        • fiftyfifty1

          Your fifth labor was more painful than your 3rd and 4th? It sounds like maybe you were in some way emotionally inhibiting the birth. That can translate into physical inhibition. Maybe you felt you family size had become too large, or were unconsciously afraid you were too depleted emotionally and wouldn’t be able to fully mother a 5th?

          • Young CC Prof

            Hey, just because the NCB nuts spread that particular brand of poison doesn’t mean we need to. (I know you’re kidding, but still.)

          • fiftyfifty1

            Who says I’m kidding? I’m trying to be supportive. The pain Jamie experienced in her first 2 labors was not due to physical factors (e.g. baby coming through pelvis) but rather was due to emotional factors–she felt more emotionally comfortable at home and so her perception totally changed from “agony” to “hard work”. These are her words, not mine. I’m just trying to help her get some insight into what might have been inhibiting her for her 5th birth. Not every woman automatically has insight into the psychology of her own pain (just look at all the women who claim that their labors were painful and seem to have no clue at all that it was a perception problem caused by being in the hospital). Jamie clearly was inhibited for her 5th birth. So I brought up the idea she might possibly be feeling overwhelmed with such a large brood because that is a fear that *a lot* of modern women have as they have had so little experience seeing large families and have been told by the media that it is “exhausting”. That’s the most logical explanation (granted not the only explanation, it might have been a sexual hang-up or something similar).

          • R T

            I see what you did there! Makes as much sense as her original logic!

        • R T

          How old were you when you had your last? I ask because age certainly can make a difference during labor? I still think ever birth is different and there’s no way to know whether birthing at home had anything to do with a decreased level of pain. I’ll be honest with you, I was 7cm dilated and in full active labor and never felt any pain. The nurses would look at the contraction monitor and tell me one was coming and start telling me how to breath through it. I just smiled and told them it didn’t hurt at all! They couldn’t believe it! I had to have a csection due to some really serious complications with my placenta during my pregnancy, but the labor I did experience was completely painless. Before they placed the my spinal in the OR the doctor checked my dilation and I asked how dilated I was. The doctor told me I didn’t want to know because I’m pretty sure I was complete. My son came out of the csection with a ring around his head and a cone head. Until the spinal was placed, I had no pain medication of any kind! I could feel an intense tightening with each contraction, but no pain! I felt uncomfortable, like I just couldn’t find a position to suit me, but no pain. I know my experience is unusual and it has nothing to do with anyone else’s. My perception of pain and where I felt safe are different than every single other person’s. I think its horrible any woman has to choose between excellent individualized care or pain relief. It’s seems very unfair to me even though labor caused me no pain at all!

    • LovleAnjel

      Half of the samples in that study were men. How on earth did they find over two hundred men that gave birth, hospital or not? Oh wait, they didn’t, they asked people who did not give birth to rate how they THOUGHT it felt to the person giving birth.

      Nice try, though.

      • Jamie

        They asked the women’s spouses to rate the pain they thought their wives had experienced. The men in the hospital didn’t realize how much their wives had been hurting. The men at home thought their wives were in more pain than they really were. Again, FWIW, that lines up perfectly with my own experience.

        • pj

          Did the women self-select into home/hospital groups? Because I’d imagine someone choosing homebirth has an (unconscious or not) incentive to interpret or report their pain as being less severe than other women might.

        • Jenny_from_da_Bloc

          Exactly, your OWN experience.Just because you perceive home birth to be less painful or near painless doesn’t mean Jane, Stacy and Suzie will find their experience to be the same. Regardless of the pain relief issue home birth is dangerous and there is no access to a NICU, pediatricians, operating room or other medical services in case of the multitude of complications that can occur. This guideline will increase maternal and neonatal deaths and is in no way logical or safe.

        • LovleAnjel

          I really don’t give a shit how anyone else perceives my pain. I give a shit how I perceive my pain. Don’t ask my husband if I should get the epidural now, ask me!

          The husband data should not have been mixed with the data from the people actually giving birth. That seems as though the data from the laboring women did not support their hypothesis very well so they tossed in irrelevant crap to bolster their numbers.

          • yugaya

            Ask the doula instead. Or even better, wait for the doula to explain to the mom in pain asking for an epidural that she does not really want or need epidural:

            http://doulamatch.net/profile/2404/gina-crosley-corcoran

            And if you happen to be a real healthcare professional who hears that same woman request an epidural keep your mouth shut and deny her the pain relief that she is requesting – anything you say is coercion and bullying. Plain and simple.

            Hypocrites.

          • Aki Hinata

            “Babywearing Education.” Huh. I didn’t need any “education” to put my kid in a carrier when the stroller was too inconvenient. I hope I didn’t do it wrong.

          • R T

            I didn’t read it, but some of the baby wraps are more freaking complicated than the hardest origami I’ve ever done! I worked up a good sweat trying to figure out some of those wrapping techniques!

          • Stacy21629

            Baby K’Tan.

            My FAV. So much easier than a Moby or other wrap.

          • R T

            Oh yeah, I gave up on all the others and got myself one of those long ago, lol! It’s great!

          • Young CC Prof

            My husband just takes an infinity scarf and wraps it around his neck twice, then slides the baby in. This works better with smaller, less active babies, though.

          • R T

            I’m going to have to try that if I have another newborn to carry around! The first time I got an infinity scarf I remarked it reminded me of a baby sling, lol!

          • Jessica S.

            I’ll have to try one of those when the little miss arrives. I tried a Moby with my son and, like RT, by the time I had it on right I was too sweaty to want a baby plastered up against me!!

            But my son, as a baby, was not into the wraps anyhow. I think they made him too hot and constricted and he’d just freak out. Maybe this one will be different!

        • Irène Delse

          In other words, they didn’t measure pain perception in the very people experiencing birth. That says a lot.

    • Young CC Prof

      There is a tendency for the later births to be faster, easier, and less painful than the first one. It’s not a guarantee, but it usually works out that way.

      Also, as far as that study goes, keep in mind that women may choose home birth because they tend to have easy labors. It wasn’t randomized.

    • laywer jane

      I can believe this, but it really only reinforces what Dr Amy is saying. Home birth pain is probably perceived as less painful for two reasons: ideological indoctrination about how to interpret the pain retrospectively, and better labor support to help cope with the pain. The former (ideology) is not really an appropriate reason to force people to homebirth and deny them pain relief — especially since “less pain than the hospital” may still be considerable pain for the home birth mother. The latter (better labor support) ought to be available in hospitals, not just at home.

      • saramaimon

        interesting, i might suggest the opposite…
        my own experience does not a scientific study make; but i found the fetal monitor belt really painful.
        many women find restrictions on movement to increase their pain, whether actual restrictions, or being restricted due to merely feeling inhibited.
        emotional stress also plays a role in pain perception. for some women that may be greater in a hospital (probably a minority, but homebirthers are a minority)
        access to bath or shower may be greater at home.
        not every woman wants an epidural.
        as for labor support at the hospital, i believe most hospitals allow the patient to have two companions at a time? but a professional labor support person is at the patients expense. although i know a couple of hospittals that have had volunteer doulas.

        • lawyer jane

          I agree, the fetal monitoring was painful for me because it meant I had to lie down. But the answer to that is not homebirth – it’s better labor support to coach you through the pain and things like telemetry monitors. Also, once I got the epidural there was no pain at all. Unless your end policy goal is no epidural, then I think the pain relief of the epidural in the hospital outweighs the possibly increased pain in the hospital pre-epidural!

        • fiftyfifty1

          Wow, the fetal monitor belt didn’t bug me one bit. I barely noticed it, it certainly isn’t painful. Maybe it felt painful to you because you have some sort of emotional “block” regarding it, or it represents something to you subconsciously?

          • Trixie

            The belts were highly irritating to me because they never worked right, particularly the contraction monitor. It never picked up my contractions properly either time, so nurses were constantly trying to rearrange them. The top of my uterus never gets hard during contractions, so there’s something funny with my anatomy that caused it not to work.
            But, in the end, who cares. They exist for a reason and are generally beneficial. And despite that irritation, I have two healthy children.

          • fiftyfifty1

            Well Trixie, you found the belts “highly irritating” and that is fine with me. I’m okay with a person feeling irritated or annoyed–because that is a form of Anger which is an emotion that is empowering. But saramaimon’s case is different. She found the belt “really painful”. I’m just trying to help her understand why that would be. As she says herself, emotional inhibition and emotional stress play a role in pain perception. Those are her words, not mine! I’m trying to help her figure out what exactly she was emotionally inhibited about that would have caused her to take a neutral (or at worst irritating) sensation and blow it up in her mind to be “really painful”. Let’s be frank, she’s acting pretty hysterical about it. I’m trying to help her understand her psyche so she can do better next time.

          • Jessica S.

            My little stinker of a son kept knocking it askew every time they repositioned it. I swear to the almighty, he knew where it was and was messing with everyone. It’s quite fitting, given his love of provoking me. :)

        • theadequatemother

          I didn’t even notice the belts (on for HR one for toco). And they had really long cords so I was walking around the room and bouncing on the ball no problem. And the nice nurses were always there to manage the cords when I wanted to move.

        • OBPI Mama

          I walked around and just “had” to move during my 30 hour homebirth. Laying down was so painful even to get checked (back labor)… I can respect that it can be more painful to have movement restricted for some women. Guess it all depends because some women prefer to not move at all! Labor was still excruciatingly painful at home though.

          • CognitiveDissonaceHurts

            Yes, I found back labour to be the most agonizing pain ever experienced – 4x- regardless of location. I spent a lot of time on my hands and knees trying to get pressure off my back and receiving counterpressure during the contractions. If I’d had to be confined to my back due to the belts, I really don’t know how I could have managed the pain.

            Despite being a NCB promoter, I didn’t WANT the pain and would have happily taken relief for it if I hadn’t been convinced that it would slow the labour, and have risks for me and baby.

    • The Computer Ate My Nym

      I’m glad things worked out well for you. However, I would caution you about the risks of generalizing your experience. I experienced agonizing pain when I was at home in early labor, agonizing pain while I was being evaluated when I first got to the hospital, and no pain at all once the epidural was placed.

      Also, are you sure it was the site of birth and not the birth order that made the difference? My mother reports having agonizing pain with her first birth and only mild pain with her second. Both in the hospital. You report going from agonizing pain to significant pain between first and second with no change in location. Perhaps the decrease in pain from second to third was also about the later births being easier?

    • MaineJen

      So nice for you, that your second and subsequent births were easier and less painful. This is not the case for everyone. You cannot take your personal experience and extrapolate that to apply to all women.

      • yugaya

        Or base standard of care on it.

    • The Computer Ate My Nym

      A few initial critiques of the article:
      1. There were more first time mothers in the hospital birth category. First births are notoriously more painful than later births.
      2. Those are weird comparators. A tooth ache is zero pain? According to whom? And how many young women giving birth have also experienced a heart attack or kidney stones? Essentially, they were asking the participants to match their pain perception against what they thought another pain would be like, not, in most cases, against another pain they had perceived at some point in their lives.
      3. It’s hard to know whether the groups were really well balanced or not since they provide no statistics on them at all. No percentages, no p-value, nothing.
      4. I’m a bit confused about the sample group. Were the male respondents the partners of the pregnant women or men who responded but whose partners didn’t? The data in table 1 seem to indicate that there were 473 pregnancies involved, which means that the men who responded were not the partners of the women who were pregnant and thus there is no way to conclude whether they over or under estimated their partners’ pain.
      5. Home births are, presumably, all low risk. A delivery that has no complications is likely to be less painful than a complicated delivery, for example, obstructed labor.
      6. Their discussion makes it clear that they’re pulling from a highly political population that had a lot of interest in making home birth appear positive.

    • Stacy21629

      And I experienced my pain as worse the second time around because I desperately WANTED to be in a hospital with an epidural and I couldn’t be (pre-transfer). I want to be in the hospital with an epidural this time TYVM.

    • Bomb

      I perceived my first birth as terrifying, agonizing, brutal, and couldn’t walk for days afterward. The second two pain was minimal with 8 minutes of pushing for #2 and only one push for #3. Felt so good after them I was discharged early.

      First birth was homebirth, second two in the hospital.

      • yugaya

        When I read stories about birth trauma from hospital births, I have empathy for women who experienced trauma from things I would have just brushed off as no big deal.

        When natural child birth advocates read stories of women experiencing agonising pain in labour, they never fail to acknowledge that it was somehow the fault of the woman that her birth was so painful that she needed an epidural – because properly ‘educated’ women can give birth without it.

        Fucking hypocrites.

    • R T

      Couldn’t it be a possibility that your later births were just easier and would have been less painful even in the hospital? I mean you had already given birth several times, knew what to expect and were a proven birther. Growing up on a farm, animals who had given birth multiple times always seemed to have an easier time unless they had complications like multiple gestation or had become aged. I’ve watched many women give birth at home at most of them were in agony. My mother had three children at home unassisted and says it hurt like “Fucking Hell!” And it’s the only time I’ve heard her use the “f word”. My aunt who had a homebirth said she thought it was incredible a person could endure that much pain and live to tell the tell!

    • Jessica S.

      I’ll bet a lot of women would consider their first delivery more painful than subsequent deliveries, if all the factors are essentially the same. So your logic is a bit flawed.

  • Mel

    That’s horrifying.

    If you don’t have enough staffing, figure out a way to get more staffing rather than half-ass a solution that may well end in more PTSD and neonatal complications.

    • Wren

      I don’t think it is entirely about staffing, as home births require more not less staff. Staffing is a huge issue but I do think this is also in response to maternal request. NCBers may be leading women to make the wrong requests, but they are still making them. The hospital I gave birth in added a midwife led birth centre in between my two. I was risked out of it due to a prior c-section. I know that there was some encouragement to use it, but women were free to say no and go with a hospital or a home birth too. For the record, the birth centre was in the hospital and staffed by some of the same midwives as the regular labour ward and the home births.

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

    Disgusting. Will we ever stop demanding women suffer in the name of vague “for their own good” justifications?

  • Stacy21629

    I found out on Sunday, Mother’s Day, that I am (unexpectedly) expecting again. I spent a while watching epidural births on YouTube last night. What was I thinking, screaming through my last 2 unmedicated births?! I can’t wait to have an epidural this time! :)

    • moto_librarian

      Congratulations! I loved my epidural birth! No screaming like a whelping animal like during my first unmedicated one.

      • Stacy21629

        Thanks. :)

        • yugaya

          Aw congrats. And remember, epidural is the only legal high that lasts for years, sometimes lifetime even, according to people who ‘do reasearch’ :D

          • Young CC Prof

            I thought parenthood was the legal intoxicant that lasts for years?

    • OBPI Mama

      My mom said that after watching my older sister give birth 3 times with epidurals. So relaxed, peaceful, calm. She said, “What was I thinking giving birth without meds 7x?” haha. I don’t know if it’s a spinal or epidural that I get during my c-sections, but I’ve gotten a spinal headache 2 out of 3 times. Apparently some women are prone to them and that’d be the only thing I’d be hesitant about if I had the option for one or natural childbirth (which will never happen ever again after my 1st). Congratulations! Going from 2 to 3 kids was a bigger adjustment than going from 3 to 4 kids, but I love my #3′s babyhood the most! All my friends with 3 kids say the same thing! Something about that third baby!

      • Jenny_from_da_Bloc

        I didn’t get the spinal headache with my c-section, but I am worried about it the second go around. My cousin is a an anesthesiologist and she said sitting up or at an incline helps to prevent the headache. I do remember sitting up most of the time after my c-section, so maybe?

        • OBPI Mama

          I wonder if it had something to do with how hard of time they had placing the needle during the procedure. The 2 out of 3 times, it took a lot of sticks and roaming. The easiest placement resulted in no spinal headache… it was heaven.

          My only suggestion would be to ask for a blood patch at the first sign of a headache. The first sign. That procedure took the headaches away within 20 minutes. heaven.

      • Stacy21629

        Thanks. :)
        I was amazed at these women laying there, laughing “the nurse says I’m ready to push!” I was in agony, haha.
        Going from 1 to 2 kids wan’t bad, but #1 was already 4. I’m more nervous about 2 to 3 because #2 will only be 16 months at the time. :)

        • Jessica S.

          Eek! That’s unexpected, indeed! :) My first will turn 4 about two months after this one arrives in July. I’m terrified. I can barely handle him, but I’m trying to convince myself it’s his age (the tumultuous threes) and my waning energy/increasing discomfort. I’m kicking myself for not having him in preschool or something similar. :/

        • OBPI Mama

          You will adjust. My last two kids are 16 months apart and I, honestly, thought it was easier than my middle kids being 19 months apart. I had my first 3 kids in 2-1/2 years and no twins… it was whirlwind days, but assembly line everything… assembly line diaper changes, assembly line feedings… haha. By the time I had my 4th in 4 years, I was ready for a break; but now that she is 2 years old, I’m ready for a 5th… I’m starting to look around and every woman is pregnant, there are newborns everywhere, I wander the baby aisles in stores, etc! SO I’m happy for you and totally jealous!

      • An Actual Attorney

        My brother describes that transition (from 2 to 3) as going from man-to-man defense to a zone defense.