I could almost feel sorry for homebirth advocates. Their need for validation is so desperate, so pathetic, that they view other women’s birth choices through the prism of their own need.
Blogger Milli Hill is a perfect example. You may remember Hill as the fool who made this ridiculous statement:
If you believe everything you read, then you probably think that childbirth is one of the riskiest activities any human can undertake.
Actually, it isn’t, and statistically you’re massively more likely to meet your maker behind the wheel of your motor.
When it was demonstrated to Hill that she has no idea what she is talking about, that childbirth is far more dangerous that getting in a car, and is a leading cause of death of young women and the single most dangerous day of the entire 18 years of childhood, she petulantly responded with this gem:
I don’t say birth is not risky. Life is risky. Picking your nose is risky…
Hill’s ignorance is exceeded only by her desperation. Homebirth advocates like to claim that they are “empowered” by homebirth, but how empowered can you be if you are constantly seeking validation by having others mirror your choices back to you. In her latest piece “Dear Kate, please have a home birth this time!” Hill explains her need:
“Everybody has to make their own choices”, you find yourself saying, but the problem is, if you’ve had a baby out of hospital yourself, you’ve got this secret slightly unhinged alter ego hopping around in your head singing, “Have a home birth! Have a home birth!”. You know it’s best not say this out loud, but the problem is, home birth is so wonderful it’s almost impossible not to be evangelical about it.
Here, Milli, let me help you with that:
“Everybody has to make their own choices”, you find yourself saying, but the problem is, if you’ve had a baby out of hospital yourself, you’ve got this secret slightly unhinged alter ego hopping around in your head desperate to have your own choices mirrored back to you, “Have a home birth! Have a home birth!”. You know it’s best not say this out loud, but the problem is, you are so obsessed with your pathetic need for validation and your own lack of confidence that you desperately need to be evangelical about it.
Like most homebirth advocates, Hill isn’t merely aggressively ignorant about childbirth, she’s evidence resistant. She now knows and has admitted that childbirth is far more dangerous that she ever understood. No matter, she simply ignores the new facts that she has learned because she prefers fantasy to reality:
As a culture we’re completely terrified of birth, mostly as a result of TV documentaries and soaps that portray having a baby as an agonising emergency bloodbath that happens so quick you don’t even have time to remove your tights…
As things stand at the moment, we’re pretty convinced that birth is dangerous, and that most women can’t do it without a spinal block and a team of medics. Home birth is therefore, “brave”.
No, Milli, no one thinks you are brave; they think you are stupid and self-absorbed, but are just too polite to say so.
There’s nothing brave about risking your child’s life for your birth “experience.” There’s nothing brave about pretending that you are educated when you are actually profoundly ignorant, lacking the most basic knowledge about science and statistics. And there’s certainly nothing brave about begging other women to copy you so you can feel better about yourself.
Is the Duchess of Cambridge a good candidate for homebirth? Does he Duchess of Cambridge have any interest in homebirth? Who cares? This isn’t about Kate and what is safe; this is about Milli and what she needs.
And this is where Kate comes in. For a sea change in attitudes, home birth needs an ambassador, and who better than a style icon adored by the world’s press?
I don’t know about Milli, but women who are really empowered don’t need ANYONE to validate the choices that are best for them and their families. They have enough confidence in themselves that don’t need style icons to mirror their choices back to them. There’s a word for that attitude; it’s called “maturity.”
Grow up Milli Hill, and stop looking to other women to make you feel good about yourself.
Love Milli Hill 🙂 Amy Tuteur – what an unpleasant fellow woman – to have opinions is a great thing, to remotely attack & bully someone for theirs in such an immature & undignified way, is unacceptable.
Opinions are great-lying in order to push your opinions, hiding nonsense behind pseudo-science, pretending to care about safety and outcomes while ignoring or denying the dangers of what you push: this is what Dr T rails against. Sometimes she’s rude, but I’d suggest not as rude overall as those she’s challenging.
Do you know that most of the swearing that happens on this blog comes from Dr T’s challengers? So if immature and undignified is your concern, it’s coming from the other side of the fence from Dr T. I don’t find it unacceptable, necessarily, just a bit pathetic.
Also, whatever you write here it will stay up, and you won’t be censored. Go to an NCB site and express an opposite opinion and see how fast the site goes private, you are banned or the conversation is closed down.
If you want a high profile so-called “advocate” for homebirth, look no farther than Gisele Bundchen. Lord knows she never shuts up.
From Milli’s blog:
“But Kate certainly proved them wrong. We don’t know the precise details, but we do know that she got the fairytale birth she really wanted – you could tell just from the healthy glow that radiated from her when she emerged from those hospital doors. ”
What an utter load of festering CRAP! It’s nobody’s business what kind of birth little Prince George came into the world in.
I like, as pointed out below, the irony of the “fairytale birth.”
In fact, births are basically never discussed in fairytales, and the indirect references to them are not good at all. Lots and lots of step-mothers and orphans.
An exception that I can think of is Rumpelstiltskin, where the queen promises to give Rumpel her first born baby. That’s a fairytale birth for you!
Infertility too. Sleeping beauty was “long-wished for”. I’m pretty sure there’s other examples outside the bible.
And how come all these fairytale babies are girls?
In folklore and fairytales, it is much more common for females to be the ones getting into or causing trouble due to one moral failing or another. Once they start being appropriately feminine, they get the happily ever after.
From the movie “The Mirror Has Two Faces” (1996), when Barbra Streisand is a prof lecturing on romantic literature:
“Myths and archetypes are alive and well and living in my apartment. As l stood beside the altar beside my sister and her husband to be, it struck me that this ritual, a wedding ceremony, is the last scene of a fairy tale. They never say what happens after. That Cinderella drove the prince mad by obsessively cleaning the castle. They don’t say what happens after because there is no after.”
But that’s not true. At least, my Golden Book version of Cinderella states that after the wedding, they lived happily forever. Is the “they lived happily ever after” really only in the disneyfied version and not actually part of them?
Has that got a basis in the biblical story of origin sin being the woman’s fault, maybe?
There is Hansel and Gretal
I think because a prince would solve the ‘problem’, which is ultimately succession. In that world a woman couldn’t rule, so a boy child-whether son, nephew, cousin-would be the end of the story. It isn’t said explicitly, but the whole idea is to find a king.
She didn’t look all that healthy to me. If anything, she looked exhausted and haggard underneath the makeup and the smile for the cameras. Not that she didn’t have every right to, considering what she’d just been through.
We’ll never know how she actually felt, because like any member of the Royal family, she knows how to behave in front of the cameras.
If the baggy eyes with their droopy lids are anything to go by, she was feeling like any new mom: utterly exhausted, completely elated, and scared shitless.
HG is a nasty ailment to have. I hope Kate feels better soon, and that she and her family aren’t bothered too much by the press or NCB nutters.
“…slightly unhinged alter ego…”
Slightly???
Highlights:
– the exchange with Dr Amy over big Pharma [a few posts down]
– a discussion on explanations for higher intervention rates – further down
– A question for Dr Amy: I do wonder what you think an appropriate comparison would be. I don’t think all home-birhters versus all (? surely not? surely only those of comparable risk profiles?) is that useful. if it is all versus all, home-birth may do better on all accounts (though yes – I know the dutch OB vs midwife data – so maybe not). if it is comparable risk profiles, that would be difficult to set up (case control? in such numbers?) also, I am not sure it is informative. If I want to make an informed choice between A and B, I want to know the data of the people with the closest risk profile to me under options A and B – not people with a risk profile that may or may not be like me, under A and B.
Please can you expand on what you mean by ‘comparing birth systems’ and what you think more informative comparison would be, and why?
– A question for all of you:
I think we have gotten to the rub of the problem here. Hypothetical Kate (low risk, multip, no desire for pain-relief, UK) can choose home or hospital. THere is no measurable risk-difference to the foetus (on the best, and a very large study: place of birth). But planning for hospital means she incurs a 4% extra risk of c-sec (TBC by ccprof) and about 10% extra risk of forceps/episiotomy.
You reason: no matter that the baby has the same low chance of an adverse event, if the baby does so, and if the baby would still be at home (which she may not be – see earlier comments about meconium), then she would have a time and/or expertise delay in treatment. Preventing that is worth the 10% or so extra risk of the mother having c-sec/forceps/epi, that is worth it for me. Those aren’t deal-breakers.
That seems reasonable to me.
But someone might think the opposite. That those chances become so tiny and immeasurable, and that the extra risks for the mother are considerable, real and – whilst not the end of the world – worth avoiding.
And that also seems reasonable to me.
The question is: do you think it is reasonable? and if not, why not?
Enjoy –
” I do wonder what you think an appropriate comparison would be.”
That’s easy. The comparison should be between women who choose homebirth and a group matched for risk factors that choose to give birth in the hospital.
That information is already available and buried in the supplementary materials. The researchers had to go to considerable effort to create a subgroup of homebirthers who met requirements far more restrictive than the actual eligibility requirements. They did that because the comparison between women choosing homebirth and comparable risk women choosing hospital birth showed that homebirth increases the risk of adverse outcomes and they didn’t want to show that.
Women want to know whether homebirth AS PRACTICED within the UK is as safe as hospital birth. I’m having a great deal of difficulty understanding why you don’t see that. Yes, homebirth might be safe for multips if the eligibility requirements were as strict as those in the study, but they are not, so homebirth in the UK is not safe.
It is only reasonable for someone else to make the opposite choice IF and only IF they actually are informed about their decision. I know when I planned my first homebirth I had no idea that my baby could die at home. I was at home primarily to avoid all the “nasty” hospital interventions. I truly did not believe my baby could die. Was my choice “reasonable”? Absolutely not.
Let’s assume that holds for a hypothetical, randomly selected pregnant UK woman. It does not hold for a woman who has the chance to be personally attended by several obstetricians throughout her entire labor, resulting in better than average outcomes for the child.
I was just like hypothetical Kate, low risk, multip with no problems during my first birth, etc. My second pregnancy was perfect, every appointment was perfect. I went into labour at 39+4 weeks, I was active during labour, no pain relief, up in the shower etc. I progressed quickly, babies heartrate was perfect, no signs of any issues, that was until his head came out and he started turtling. Yep, shoulder dystocia. Luckily I chose to birth in hospital so with one push of the button the two midwives in attendance turned into about 5 or more (the OB on call hadn’t even made it to the hospital yet being 3:30am). They eventually got my son out and after a bit of a slow start he was, and still is, fine. Of course I can’t know how this story would have gone at home but it took every one of those midwives to monitor the situation and successfully free my son so I am certainly glad I never found out. I had not one of the factors that the homebirth community usually blame for SD, I was active, no epi, I was upright, etc. Also I did not have any forceps or any of those apparently so terrible interventions that they rattle off, though I would have had them 100 times over if I needed them to save my son.
OBSERVATIONS. [follwoing on from entry below]
– Some (many in fact!) of you are very nice and interesting and engaging. Thank you.
– I am a bit shocked that the hospital associated risks are so unknown amongst many commenters. They are not controversial. I know they tend to be underrepresented (which worries me) but they seem unknown to many – which is much worse. I would have thought on an evidence-focussed blog they are not discussed because knowledge of them is assumed. I find it very worrying that this is not the case, that they seem to be forgotten, and that it has been difficult to get them acknowledged – several people (but also several not) have just not responded to them.
Note that I don’t claim maternal outcomes trump fetal outcomes – merely that they need to weighed and considered (and that in this low-risk multips group, there is very little adverse fetal outcome to weigh against).
– This blog endlessly accuses many people and blogs (who I don’t know and don’t read) of being polarising and focusing on only part of the data. That may well be the case. But I have not found this blog the neutral haven of evidence-based focus either.
But still – a lot of engagement and civilised response, and I have learnt. Thank you. [ I may drag up a few highlights – then log of for the night]
.
Hospital associated risks are not unknown at all among us commenters. We simply don’t consider them “risks”, the way you do. Many women don’t care whether they’d end up with c-section or episiotomy – to them, it would be and for some of them it WAS a minor inconvenience compared to what they stand to lose.
To the majority of women, maternal outcomes INCLUDE fetal outcomes. They don’t get pregnant for the joy of lugging a huge belly around and then avoiding a C-section. And if their baby dies or is injured, it’ll matter to them far more than a c-section or episiotomy card. Those heal. A dead baby doesn’t. A HIE baby often doesn’t. As a commenter here (a mother who had her first, birth-injured baby at home) said, something about the way her subsequent children were born screamed and pink, and without a lifelong injury, made the c-section scars all worth it.
She’s still living her maternal outcome in the face of the continuous and exhausting therapy her first son still needs.
Thanks for saying this. It’s a constant surprise to me that anyone could categorise anything other than optimally well mum and baby as a successful birth, wherever it happens. I don’t mean bouncing out of bed 5 minutes after delivery well either, I mean continent and recovered a couple of months along.
I’d rather heal from a c-section and every other bit of treatment going than heal from the loss of a child, or live with serious damage to the child. And how do people cope knowing that if only they had taken the treatment the baby might be alive and well? How to heal from that I don’t know.
I agree. What I didn’t touch upon was maternal outcomes in terms of, well, maternal outcomes. Physical. Because a low-risk vaginal birth is not always a breeze either. It can end with a very sick mother. It can end with a mother who might be left incontinent in her middle years or… right now. As my mom was told a few weeks after giving birth vaginally to her second calf, err, baby, One day you’ll sneeze and pee. She: One day? Like, yesterday?
FFS, for my wife, a c-section was not even a “minor inconvenience” it was friggin the desired outcome!
Maybe that accounts for the difference in c-section rates between HB and hospital? There are those women in the hospital who are getting c-sections BECAUSE THEY CAN, as opposed to “because they have to”?
I mean, we are talking about 3-4% overall, right? I could easily see that as being in the realm of the number of people who prefer not go through labor again, and are taking advantage of the opportunity.
That’s because your wife clearly didn’t know what was good for her. She had a c-section done to her. Oh the risk! As the commenter said, we aren’t informed about hospital risks. The same clearly holds true for your poor wife.
”We simply don’t consider them “risks”, the way you do”
Exactly. Because we’re looking at OUTCOMES, not just procedures or processes.
And epidurals certainly shouldn’t be considered “risks”. How is asking for and receiving pain medication a harm?! I’ve heard WAY too many home birth stories including the woman begging for transport for pain management and being blocked from it by their “support teams”. I have had conversations with quite a few couples planning natural births about not promising to get her an epidural only after a “safe word” is used, or even refusing her an epidural no matter what she says in labor. Nope. No way. In my world if you ask for pain management, you get it. Hate us for it after the pain is gone, that is a-ok.
One more observation: the ‘paged’ statistician appeared quickly when asked to verify that I was wrong about the fetal outcomes – which I wasn’t (agreed upon caveats about composite measures aside – see below for details).
(S)he was quick to disappear when asked to verify the higher risks posed by hospitals.
– Ok – that is really it. Although I would still be grateful for the reference to the Mayo Study?
Time zones lady, think about the time zones.
One more observation: it would take a more than a newcomer convinced that she’s right to make this “paged” statistician go in hiding. If anything, a statistician is just as good as twisting stats as the people who conducted the Birthplace study which you seem to admire.
Do you really think you’ve cornered her? Sorry to break it to you but asking ridiculous questions (the risk of a c-section! The risk of an epi! compared to the vanishingly small risk of a thing like death or HIE – did you learn in the meantime what HIE is? You know, while continuing to ask questions about the great risk of those other Scary Hospital Things) isn’t going to cut it.
Logging on for half an hour in the morning, going to work. There’s nothing mysterious about my comings and goings.
C-sections, epidurals, pain relief, forceps and even episiotomies are not hospital associated risks. They are medical interventions that are usually deemed medically necessary by the doctor or CNM involved to prevent the death or injury of the baby and/or mother. Some mothers would even prefer to have some of these interventions. Many women go to the hospital and have natural, unmedicated births without intervention. A risk is a nosocomial infection or something similar. Giving birth at home does not negate risks, especially the risk of infection.
That’s the thing I’m getting tripped up with the Ma to Kings. The feeling I’m getting seems to be that s/he thinks you go into the hospital and you just get C-sections and cuts willy-nilly, or by accident (oops! Well, that was the risk you took…) But at least in the US, you have to actually consent to interventions, barring emergency – and is that the case in the UK, as well?
It seems to me that one explanation of the data is that in the hospital, women are made aware of signs of fetal distress that aren’t available to them at home, and then are given the option to have an intervention or not?
In which case – what is being advocated for with home birth is the bliss of ignorance. The woman _not_ being told, “Hey, we’re seeing some signs of distress” and being given the option to have interventions to help get the baby out sooner – or wait and see. These are probably, indeed, more subtle signs, and would be unlikely to lead to the death of the baby – but, given a proper study (unlikely to be done), might have more subtle effects… and I can see women not wanting to risk that, if the information is available.
Or, you know, when things aren’t moving along, even in the absence of signs of fetal distress – women at the hospital have the option to say, “I’m exhausted/uncomfortable/want to meet my baby, what are my options to move things along?” and women at home don’t.
Just my thoughts… I remember in one of the podcasts, Dr Amy mentioning that fetal monitoring has a high false positive rate in return for having a very, very low false negative rate. Kingma asked, below, how many ‘unnecessary’ C-sections are appropriate to save the life of one baby, and it seems like the women themselves make that decision for themselves when faced with the possibility?
This was my argument below. The reason more women have c-sections in hospitals is because THEY CAN!
Kingma’s argument is that it doesn’t lead to improved outcomes, and even if that applied to non-mortality outcomes, how does it apply to issues such as mother satisfaction or comfort? As I noted, with my wife, a c-section was not only not a problem, it was desired! She was happy to have a reason to do the c-section and not have to go through a vaginal delivery.
Shoot, one could argue the 3% incidence of c-section in the hospital birth as being a negative, in fact. If 10% go to the hospital hoping they can have a c-section instead this time, then 70% of them end up unhappy with their experience, and it is a negative outcome not because it is too high, but because it is too low. But delivering at home doesn’t make it any better.
That’s exactly the problem with her logic. She’s talking about interventions like they just randomly happen to a certain percentage of women who walk into the hospital.
Outcomes are things that just happen. Interventions are a choice by the doctor and patient on the basis of individual circumstances, and I’ve seen this problem a lot in NCB research: They consider an intervention to be an outcome in itself.
Yes, a c-section increases the risk of certain adverse outcomes, but it decreases the risk of others. In some situations it’s the best option.
The women who believe in the homebirth/NCB movement really believe in the so-called risks of hospital birth. Whether they truly understand what they believe is the real question. In my opinion they don’t understand what they believe because they wouldn’t claim c-sections as unnecessary and fetal monitoring as a risk. In the case of fetal monitoring I would rather have a false positive, c-section and live birth as opposed to no fetal monitoring, no way of knowing if the baby is in distress, continuing to labor and delivering a dead baby at home. We must remember that these women really believe that birth is safe, they “trust” their bodies and put 100% faith in a midwife who isn’t qualified to deliver kittens. A few years back I was working in the ER, we had a HB transfer who wouldn’t let the docs check her, put her on a monitor or do anything really & her dumb dumb husband was acting like a line backer anytime one of us walked in the room. Her BP was off the charts, she was evasive about her hx and had a fever. Finally the OB said, ” If you don’t want us to do anything then why are you here? Do you not understand that you are putting your life at risk & we don’t even know if the baby is alive? Please just let us help you!” & even after all that all she kept saying was I don’t want a c-section. Perfect example of how these NCB/HB women really believe but do not understand.
Joining the party a bit late, but what it seems to me you are intentionally doing is equating an episiotomy and c section as the same severity as a life long brain injury or dealing with living when a much wanted baby dies a preventable death at home.
You keep comparing rates for the mother while dismissing the risks to the baby as “small”, but it sure won’t be small if it is your baby or you when tragedy strikes.
This is what NCB does, they claim full consent, while simultaneously dismissing the severity of that small risk, and it’s crap.
It actually is a real, thoughtful question. At what probability of death do we do a c-section, or, how many c-sections is a dead baby worth?
A useful response would have to take into account the probability of serious complications to the mother from a c-section, including effects on future pregnancies. Which can be estimated at a population level, but which also vary at an individual level.
For example, in a 42-year-old woman having a first baby, future pregnancies are probably NOT a consideration, and her personal tolerance of risk to the child may be correspondingly low. In a 23-year-old woman who wants a large family the calculation may be different.
These questions are important and fascinating. Which is why I get cranky when people write articles that bitch and whine about c-section rates without taking any of the real reasons into account.
But number to treat and serious complications are not the only issues when it comes to c-sections. How many women are like my wife and have no interest in a vaginal birth, and would rather have a c-section? How do you count those? Her c-sections cannot at all be counted in the balance, can they? They certainly weren’t a negative.
Dear all,
I have to log of – it has been interesting discussing with you all. But I have to get on with the rest of my life so I will stop responding now (although I may return in a long-distance future).
For those who don’t want to trawl through the lengthy discussions below, here is a recap, and a few observations. But before you start replying, if you are interested you might first want to look if the points you raise have not already been addressed in the LONG conversation below (most probably they have been). As I can’t respond to any comment anymore (which I have diligently done ALL DAY today) you will have to dig out my responses and read the conversation if you are interested.
RECAP
We have been discussing low-risk multips in UK – I have argued based on the Brocklehurst/BIrhtplace study (not perfect, but the best we have)
1) that planning home-birth is a very reasonable choice for the group with this risk profile (though not the only reasonable choice)
2) and that there are good (but not exhaustive or trumping) reasons to plan home-birth in this group.
These reasons are:
1) planning home offers no measurably worse outcome for foetus, and at best (or worst) a potential worse risk due to time-delay in case of a bad outcome. [Note that some (many?) (not all!!!) foetuses with bad outcomes will already be in hospital as labour complications, e.g. meconium, is a reason for transfer].
2) Planning for home offers considerably better outcomes for mothers in at least some respects (0.5. rather than 4-5% c-sec risk, around 10% lower risk of forceps/episiotomies).
These reasons are not exhaustive – e.g. hospitals offer also benefits, most obviously epidurals (which not everyone wants) and there are myriad other relevant reasons to choose hospital (or home) – as I have acknowledged and discussed below.
I know many of you want to disagree with much of that – most of that disagreement has happened below, and I have responded. I cannot respond to repeats of what I already have said – so again, dig in the conversation below if you want. maybe others can repost comments that seem particularly relevant.
[Observations to follow in separate entry]
Kingma, I’m going to re-post something I posted the other day.
Because I am aware how NHS funding works, how allocation of resources works, and how very, very stretched most UK labour wards are at the moment, and I’m not sure you are, given that you think that the NHS is magically able to provide HB to all who want it without somehow affecting any other services.
“When there is a crisis in midwifery staffing levels, the appropriate short term response, surely, is to try and get all the midwives in labour ward, rather than to have two midwives attending every Homebirth.
Every Homebirth in the UK is reducing available midwives from the labour ward rota. When you don’t have enough midwives as it is, and a Homebirth requires two MWs present at all times, while a midwife on a labour ward can look after multiple women at once, do you REALLY think that promoting Homebirth with the current numbers of midwives is compatible with increasing patient safety on a population basis?
Or will promoting Homebirth for low risk women simply increase the risks for high risk women who have to deliver in hospital, by further reducing staffing levels and care provision?
Why should the choice of a low risk woman to be able to deliver at home matter more than the right of a high risk woman to safe care in hospital?
Your thoughts please.
Also, thoughts on the fact that Homebirth automatically excludes many vulnerable women, because the “home” isn’t an appropriate place to deliver.
Women in prison or immigration facilities, young women in Children’s homes, women in hostels and temporary accomodation, young women sharing bedrooms with their siblings, women in high rise flats with unreliable lifts, women from the Travelling Community, women in multiple family dwellings who share their bedroom with their entire family, women in very remote or rural locations….
Again, removing resources from these women and their necessary hospital births and diverting them to support the choice of healthy, well-off women to deliver in their own homes does not strike me as equitable, rather it seems to be a way to further entrench health inequalities.
But I’m open to being proved wrong.”
Would love to hear your thoughts.
I can’t really get behind the promotion of homebirth in the UK at present, because it is not ethically supportable from justice, utility and non maleficence perspectives, when weighed against the harms it may do in terms of service provision.
If one woman has two midwives at home and avoids an episiotomy, that’s lovely for her, but if as a result one midwife has to look after 8 women on labour ward because the rota is short handed and a high risk complication is detected late or poorly managed as a result and somebody dies…it’s not exactly a good trade off.
If the NHS had a limitless number of midwives and a bottomless pit of money then promoting HB would be laudable. As it is, there aren’t the MW numbers to deal with hospital births, never mind the staffing to cope with HB for all low risk women.
I think it’s interesting how different systems will have different cost pressures driving them. I live in Canada, where midwives and labour unit nurses are two distinct fields. Thus, a midwife-attended homebirth will have no real effect on maternity ward resources. It will, however, cost the province significantly less money because hospital resources are not being used. Even midwife-attended hospital births are cheaper because mothers tend to go home within a few hours of the baby’s birth, unlike OB-attended women who stay 24-48 hours postpartum.
There is definitely an argument to be made that one baby born brain-damaged as a result of homebirth will exceed the cost savings achieved by moving births away from hospital, but that has yet to really enter the public debate (I suspect it will take time for the numbers be properly understood – our local midwife-led birth centre is equipped for 450 births a year, or 3% of regional births).
In the meantime, using the Birthplace study as justification for the safety of homebirth and combining it with the short-term cost savings acheived in out-of-hospital births, and you have women who will feel considerable pressure to seek midwife-led care and give birth outside of hospital, whether or not they truly want to do so and regardless of whether they are truly a suitable candidate for ooh birth.
5 years ago a 20 mile radius of where I work there were 5consultant led L&D units.
Things were re structured, two of the units became MLU with no on site OB or anaesthetic cover and a new free standing MLU was built.
Homebirth is also starting to be promoted as an option.
Do you know what? My patients have ZERO interest in the free standing MLUs and continue to choose to deliver in the hospitals with consultants on site. I have had exactly 1 patient opt for Homebirth in the last 3 years.
One of the free standing MLUs is actually doing about 50% of the deliveries that it was projected to do, because women hear “20minute transfer time if you want an epidural or things go wrong” and decide against it.
Can you imagine the amount of money, time and resources that were wasted on a purpose built MLU that is working at 50% of capacity
You couldn’t pay me to have a baby in a free-standing MLU. As midwifery gains power here, I see us moving in that direction and it terrrifies me. It’s a short-sighted waste of resources.
I know things often work a little differently in NI but in the UK do you only get an obstetrician to deliver your baby if you are high risk or if things start to go south? Otherwise you will be taken care of by midwives even on a consultant led ward? I know it is the default low risk = midwife care but what if you just don’t want a midwife? Could you volunteer to be practiced on by student doctors even? I ask because I may be moving to my parent’s home in E.Sussex and was hoping to have another child in the next year or so.. I will in all likelihood go private either way I was just curious about what would happen if I didn’t have wealthy parents who insist on paying for these kind of things
I think on the labour ward, you still get a midwife – but under OB responsibility. I am not sure though – other people here will be.
Even if you go privately you are highly unlikely to have an OB present for the full duration of your labour, although they will usually try to show up for the catch, Many OBs who do private work also have NHS jobs on the side, and if it is your bad luck to deliver in the private hospital while your OB is in the middle of her NHS clinic…tough.
You can request CLC, BUT that means your care will be provided by MWs, under consultant direction. If all goes smoothly you still may never see a Dr at your delivery.
The only way you’re going to guarantee 100% that you don’t have a MW catch your baby is a planned CS.
What you might like is caseload midwifery, where the same
…two midwives see you at every appointment and are at your delivery. That way you have a chance to build up a good rapport and are less likely to be blindsided by unexpected woo. It isn’t available everywhere, but it is a very popular option here.
I did the private consultant antenatal appointment with an elective CS on his NHS list (which is a uniquely NI thing- as no private hospital here offers L&D services). So my only contact with MWs was postnatal.
I know a doctor would never sit with you for the duration. That would be pretty weird. For my first he just popped in every so often to instruct the nurse and chit chat with me and then ‘caught’ the baby. That was ideal imo. If I knew I would have a midwife like Siri or Antigonos I’d be happy but I do occasionally lurk at the UK midwife forums and omg. Woo city. The BBC 2 programme ‘The Midwives’ demonstrated to me that it is widespread. Although it did seem that the case load midwives were very sensible so thank you for that suggestion.
I wouldn’t want to take away an obstetrician from someone whose need is greater either. I thought private doctors were just private doctors but they will actually abandon their private patients to attend nhs patients? Like I said, I have affluent parents so although I am entitled to receive care on the NHS I would prefer not to have to burden an overstretched system when I am more than able to ‘pony up’ and pay a private institution to take care of us.
It’s not abandoning private patients for nhs patients. It’s doing the job the nhs pays them to do. When they are working their nhs job, they can’t just abandon that to deal with a private patient.
but I would be paying them too. I mean if they just have to work overtime unexpectedly and some other doctor deals with me instead then whatever but Dr Kitty said if they’re busy in clinic (not even sure what that is tbh) then ‘tough’. Tough what? A nurse delivers my baby? I cross my legs?
Yeah, that exactly.
If that bothers you you can either choose to see an OB who does no NHS work, or you can book with a private hospital which will guarantee an OB from their rota will attend, but that may still mean “your” OB won’t.
Most private work in the UK is on the basis of consultants working as independent agents and hiring out consulting rooms in private clinics, not usually as part of a team providing 24/7 coverage.
It isn’t the same system.
You want a concierge OB, but they don’t really exist in the UK.
ha, concierge ob sounds ludicrous. Where in the world is obstetrician led care the norm apart from the states and Singapore I wonder. I don’t get attached to “my” doctors so I don’t care which specific one delivers my baby or anything. I go to a big practice here where it is more likely that your OB wont be on call when you deliver. maybe i’ll just stay here then, stick to what I know
ICP was detected in the last five days of my pregnancy and I didn’t get an OB. I had to have continuous monitoring and when the hr started to pick up the OB came in and said they’d like to get the baby out. The midwives tried to get me to stay on pushing, but I had already been pushing for 2 1/2 hours and figured I’d rather have the forceps when it wasn’t an emergency.
I wish I had the option to see the same midwives each time, I never saw the same midwife twice. It was a pain to not have the continuity and the ICP might have been picked up sooner. Although, maybe not as I didn’t get the itch until the 38th week.
Just curious what province you are from? I’ve never heard of a birth centre in mine. The help given to disabled people is very stingy, I know as a disabled person myself. It does cost money for a disabled person to live a healthy and well adjusted a life as possible. It’s too bad no one is bothering to figure out what the long term costs of disabilities caused by childbirth are to society. This should be a priority. It’s something we need to know. We need to fund studies into it and adjust healthcare accordingly.
I’m in Ontario. The birth centres are new. One in Toronto and one in Ottawa that both opened in the last couple of years. And I completely agree, the help provided to the disabled is quite stingy. But aside from the financial costs, I really hate the idea of government encouraging something that could lead to preventable disabilities. The human cost is just too high.
Dear Dr Kitty,
great – thank you, it is really nice to engage with you. Many issues – and this starts a whole new set that I won’t have time to spend as much time on. But here are a series of comments.
1) Yes, I know of understaffing. Terrible.
2) A minor point of correction: I believe Home-birth has mostly one midwife, and nr 2 is only called in for the ‘moment supreme’ – but that does not detract from your overall point which I will address now:
3) I think that the just distribution of staffing levels is a difficult question, the right answer to which should be: enough for everyone. But that is not reality (although it should be. and reality is bad).
GIven that, I think it is not a foregone conclusion that HB (=home birth) takes staff away from LW (labour ward). Yes, there is constant attendance at home, but then also you can leave the woman after birth, (whereas in hospital they hang around for at least 24 hours if not longer – being taken care of by midwives). ALso there is the extra complications/interventions that might result in longer stays – etc. I don’t say it is one way or the other – I genuinely don’t know. And it can’t be determined by us, from the arm-chair – it requires a complicated calculation. the birth-place cost-effectiveness analysis does not quite address this but suggests that it is not necessarily demanding – it certainly shows what a difficult calculation it is (and yes, I know the criticisms. Just saying: this is difficult, and requires proper analyses that noone I think can provide here. unless someone knows of a study?
4) without those data, I think it sucks if the LW becomes more risky for women there because HB demands resources. But I also think it sucks if our low-risk multips need to undergo forceps and c-secs that they would otherwise forego (by doing HB), and without gaining any benefits for their baby, in order to keep resources concentrated on LW. it sucks either way – and either way people suffer higher risks/bad care. Reducing us to point 1.
THis is not about where it is a reasonable place to birth – it is about having an understaffed NHS.
5) ‘for many women home is not suitable’. agree – I have already said so in a comment below. there are MANY reasons to want to go to hospital (or e.g. birth centres, either along, or free – which I haven’t discussed for reasons of simplicity. Which is why women should be free to choose.
6) But this does highlight another point I like to mention: women are very different and in very different circumstances. Sometimes these circumstances point them towards hospital where others would birth at home (e.g. their home-circumstances suck), others point them to home, where others would birth in hospital (e.g. they have private or cultural backgrounds which make them traumatised/terrified of hospital/strangers, or of hands or instruments around their vagina.) I think it is important to recognise that, and overlooked by anyone thinking there is a right place to give birth (whether they advocate home, hospital, or the moon).
7) health inequalities: very good point. I don’t know which way this goes. I know home-birth is associated with middle class, white, rich, educated, etc. But I also here that there are much more disadvantaged groups (often with varying cultural backgrounds) who are keen on home for one reason or the other. But I am not an expert on this, at all – and I think your focus on health inequalities is good and astute. thank you for raising it. see also (4) and (6) .
Those are some thoughts. Very interesting – would be nice to hear yours again. But I am sorry that I can’t give this my full attention – soon I need to return to all the stuff in life I actually should be doing. It would be interesting to be in touch directly but I am a bit reluctant to reveal my details. Perhaps you can give me a hint (or yours) – or Dr Amy (who as moderator presumably sees email addresses) can email me yours, if you consent?
Most low risk women in the UK are discharged 6hrs after delivery. Not 24hrs. They have midwives calling to the house for the first 21 days post-partum, as often as necessary.
Here is how the MW rota works where I am.
Midwives can choose to specialise in community midwifery, hospital care, case load or labour ward, but everyone has to cycle through annual placements in their non specialist areas in order to keep their skills up.
To cover a Homebirth one midwife must be present at all times, and a second has to be on call at all times and not more than 10 minutes away from the labouring woman. If the midwife doesn’t live near the HB mama, her on-call will turn into an on-site. The second on call MW has to be available; not in theatre, not in a clinic, not doing house calls-literally standing by a phone ready to go. More than one of our midwives have told me they do not enjoy HB because they feel
… Feel unsupported, isolated, tired and unsafe.
Kingma, with all due respect, you need to do some reading about how things are actually run. Starting from the premise that there are a finite number of midwives, and at the moment there aren’t enough of them in the UK.
I’m happy to talk publicly here, but I don’t engage in private conversations with perfect strangers which may be made public without my consent. Nothing personal, just a general rule of mine.
fair enough re: private conversations. THough shame.
I take your point about limited knowledge about actual running. as said above, I am arguing about what reasonable choices are based on safety. You bring in the point of justice – which is a relevant consideration (though note above that having higher c-sec risks is also a justice-problem). I can live with justice considerations ultimately speaking against more HB in the UK – although really I would want more midwives then.
But I most discussion on this blog (and everywhere else) is not about resources or justice, but about safety – that has been my focus here. as I said – this is a somewhat different though important strand.
Thank you again for engaging – very interesting. I have learned.
Kingma you’re unlikely to get an actual discussion here really from what I’ve experienced. They are typing their answers before you’ve even finished your comment.
And that’s bc our contributions are so same same but not even different that they tire of doing more than cut and paste and on we go.
Just speculating here….
The reason that you may have read the same replies to different querents is that the people here know the topics discussed and follow the research. They know the difference between what happens in real life as opposed what people desperately believe should happen in an ideal world.
In an ideal world every woman who wanted
a doula,
to labor in water,
to be able to move freely
to have resources necessary for a safe VBAC
to have an OB who will supply every resource that a woman wants…
In an ideal world, that would happen. In the real world doulas cost money, water labors have restrictions, monitoring requires some cooperation, resources are always limited.
Oh get over yourself. Kingma had a great discussion here the other day, and she herself agrees (see her comments about how it is a great discussion).
We don’t take fools lightly, but we have great conversations with others.
Yes, because you’ve been so good about engaging everyone here. Bugger off.
Dr Amy, I think you just posted something about ‘known trick by pharmaceutical industry’ but I did not read it properly as was replying to someone else. now I can’t find it anymore. please can you re-post? Thank you.
I have to go now – attend to other commitments. Thank you all for talking, most instructive, I will try to be back when I can – keep talking.
The authors of the BirthPlace Study used a tactic beloved of Big Pharma. They prefer to compare the theoretical side effects of using a medication with not using it instead of comparing the real world side effects; Big Pharma does that to hide side effects that happen to real people in the real world.
Don’t you agree that it’s wrong when Big Pharma manipulates data in that way? It’s just as wrong when homebirth advocates do it.
I see your point, but I don’t think the analogy is quite right.
One thing Big Pharma does is have a bad comparison group. E.G compare with placebo, or a non-therapeutic dosis of standard treatment. That is not the case here: the comparison is between four realistic treatment options – home, hospital, AMU, FMU – and compare birth as they happened there, not in manipulated experimental conditions.
The other thing Big Pharma does is test a drug that is mostly given to fragile 80-year olds with tons of morbidities, in robust 50-year olds (or 20 year olds) with no comorbidities. And then claim that the results apply to the 80 year olds. This study – or even narrower, the portion of the study we discuss – is of course, about the birth-equivalent of the robust 50 (or 20) year olds: the low-risk multips. But then it also only claims to apply those data to that group. It does not say: we found x in low risk multips, now everyone – breeches included, x applies to you. No, it says we found x in low-ris multips, y in low-risk primps. So, if you area low-risk multip, x applies, if you are a low-risk primp, y applies, if you are not low-risk, look at different data, this does not apply to you.
There is nothing wrong with that. And if only Big Pharma did that. …….
Or am I missing something?
[I grant that some people have misused the study to overstate the safety of home-birht. But equally, some people misuse it to overstate the risk of home-birth, looking at all births, and claiming that the results apply to low-risk multips. We have seen a lot of that latter mistake, here, today. Neither mistake is the fault of the study – it is the fault of the people interpreting it and writing about it].
When you decide what birth control method to use, do you want to know the theoretical failure rate or the actual failure rate? As for me, I want to know that actual failure rate since that is what I am really worried about.
The same thing applies to homebirth. The authors determined the theoretical death rate, not the actual death rate in practice. And what’s worse, they implied that the theoretical failure rate was the actual failure rate.
The key point is that the study is INTENTIONALLY misleading because the conclusion was pre-determined. What the BirthPlace study showed is that homebirth is both theoretical and actually more dangerous for first time mothers, and theoretically safe for multips, but not safe in actual practice.
I would want to know the failure rate in people like me. So if I was a non-drinking educated woman of high SES, I wanted to know the failure rate in non-drinking educated women of high SES. which is probably higher than the ‘laboratory rate’ or the experimental rate where they probably reminded and checked everyone took their pill, but lower than that in the general population as (my bet is) that the educated non-drinking group of high SES is more punctual and less likely to forget/vomit.
the birthplace did not determine the rate under experimental, high-scrutiny conditions (whatever that means in this case), but in the real group – so for the people in that group – a non-negligble proportion, it DOES give meaningful data.
Perhaps our difference is that you think the 7% higher risk is there because they are misinformed by their midwives. I think it is more likely that they pressed on with their home-birth despite risk and against their midwives’ advice. As said – I think that they are free to do that, and they should be assisted.
But either of our assumptions could be challenged. — on the data we have, however, I think it is reasonable to take the data to apply to the group that they in fact apply to.
Second point: only more dangerous for first-time mothers if you only look at fetal outcomes. if you look at fetal and mother – it depends on how you weigh the harms. I don’t say it is not dangerous – I just say it depends on your weighing – and different people may reasonably differ on that.
it disturbs me that the higher maternal risks in hospital keep being pushed under the table. I don’t say they trump the foetus, I just say they need to be weighed and dismissed afterwards, if appropriate – but they can’t be dismissed out of hand. looking ag
Last time I checked, good, reliable studies didn’t put the predetermined conclusion at the beginning and finagle the “evidence” to suit it. :-/
But isn’t this part of Hilli’s comment quite to the point, Dr Amy, and giving a very good reason for Kate to choose a home-birth?
“And having had this brilliant first birth makes her an absolutely ideal candidate for a home birth this time. The point that seems to continually get missed is that home birth is safer than hospital birth for second time mothers. A very rigorous piece of research called theBirthplace Study showed that women having their second or subsequent babies in hospital were much more likely to have interventions such as instrumental birth and caesareans, with no corresponding improvement in outcomes.”
Hilli is on point with her data here (if we take ‘second time mothers’ to mean ‘low-risk second time mothers), and you yourself, Dr Amy, have granted that for that group identified, low-risk multips, home birth is indeed safe.
The details of the first delivery aren’t public, and her lovely hair and careful make-up during a brief appearance the day after doesn’t give any real insight into how the actual delivery went.
My question though is do you, through all these assumptions, judge her for not choosing a home birth, if indeed she does not? And if so, why? Letting down the sisterhood? Spoiling a marketing opportunity for birth junkies? Not being ‘brave’?
Who knows if your ‘interpretation’ of the ‘data’-the quote marks acknowledge that those words often don’t mean what home birth activists and apologists think they mean-is right or not. I don’t. But I’d be paying close attention to the advice of my medical attendants not some nut on the internet, and I imagine Kate is too.
The Duchess of Cambridge should give birth where and how she wants to, once she has taken advice from her medical team.
Whether or not it is setting a good example for people shouldn’t come into it.
You shouldn’t make life-changing medical decisions based on what complete strangers will think of you.
Everyone, even the Royal family, has a right to confidentiality and privacy about their medical history. There is no need to justify any medical choice to complete strangers.
Of course. See above.
Actually, let me qualify that, I do think the Royal Family has an ‘example’ role in some respects. That is part of their public role.
But I don’t think mode-of delivery is one of them – precisely because birth is about what you do with your (private) body, and exactly because of what you say about medical history.
So we agree.
I’d be much happier if Prince Charles wasn’t so fond of CAM, but he has every right to use and promote it if he wants to.
I agree about 1 (being happier if he did not love CAM), but less sure about 2: in my home country (not UK) Royal Family is much more guarded in pronouncing on any issue; the parliament is responsible for what they say, so a royal endorsing, say, CAM, would be quite a public statement. In private they can do and think whatever they want of course (which is again why their medical choices, above all, should be private and remain so).
Sure. I should add ‘on the assumption that she is, and remains, low-risk’. And indeed, ‘on the assumption that she does not desire any specific hospital-only amenities, such as and epidural’. And so there are a few other assumptions.
Are you asking me whether I would judge her? Of course not. What a strange question. Birth is about what a woman does with her body: deeply private, and that is a right worth defending. The first rule of “the sisterhood” as you call it, is surely never to judge what a woman does with HER body. 😉
I’d also suggest that it goes without saying that Kate (or anyone in the public eye) does not take advice from what the internet says about them.
But it is also not illegitimate to use this public event – the pregnancy announcement – to highlight the group that does tend to get overlooked in what seems a pretty polarised discussion: the group of very low-risk women for whose foetuses home-birth not only appears safe, but who themselves much lower their risk of physical harm by planning a home-birth.
“The group of very low-risk women for whose foetuses home-birth not only appears safe, but who themselves much lower their risk of physical harm by planning a home-birth.”
PROVIDED
a) they have appropriate antenatal care and screening to ensure they are genuinely low risk
b) they have appropriate intrapartum care and monitoring provided by a trained, accountable professionals with access to resuscitation equipment and drugs
c) there is a collaborative relationship with the hospital-based Obstetric team enabling rapid transfer of care should risks change or an emergency develop, and clear protocols followed indicating when transfer is indicated
d) there are no logistical issues preventing transfer to hospital in the event of an emergency (snowstorms, traffic jams, rural or remote location etc)
e) the woman herself desires to give birth at home, remote from access to the best quality pain relief, paediatric and obstetric care
Yes. Agreed.
A,b,c & d apply to the vast majority of women in the UK.
E: some do, some don’t. that’s why we need to provide choice
C) of course is something that is under the control of the health-care system. If it takes safety of mothers and babies seriously, it provides for this.
You do realize that, for women who are actually decent candidates for home birth (multips with uneventful pregnancy and previous uneventful deliveries) the probability of c-section is quite small even if they do go to the hospital? For that group, the c-section rate at hospital birth is 2-3%.
Home birth doesn’t prevent nearly as many c-sections as its supporters believe.
I realise (and I agree that people often fail to stratify between c-sec rates per se, and c-sec rates for low-risk populations.)
But I thought the Brocklehurst said 4-5% for low-risk multips planning for hospital, dropping to 0.5% for planning home. That is not a negligible difference. a 1 in 20 risk of an operation is, I think, high if it does not correspond with an improved risk-profile for the foetus. It is, after all, abdominal surgery. Not the end of the world (like a dead /disabled foetus or mother). But by no means negligible either
I’d have to look at the individual situations, and how much drop-out there was in each group. However, I do know that various sources in various developed countries show the same thing:
When a multip with previous successful vaginal births waddles into the hospital in spontaneous labor at term, with a single head-down fetus, probability of c-section is 2-3%.
Keep in mind that women who need to be induced, including post-dates inductions, will all be in the hospital
Yes, but they won’t be included in the ‘low-risk’ comparison hospital-group. Only women who qualified for home-birht are included in the hospital comparison group – so not post-date inductions.
I am pretty sure it is 4-5% in Brocklehurst – have you double checked?
Thank you, I have been repeating myself on this point, and you made it much more clear than I could.
Even assuming it is true that she had a “brilliant first birth,” that is not a “good reason” to choose a home-birth. It makes a home birth not necessarily a bad decision, and says it is about as safe as a hospital, but that doesn’t make it a good reason to do it. It just means it’s not a reason not to do it.
With all respect, it seems Kate (again, assuming low risk + no desire for pain-relief), would have reasons: per the same study, planning for home rather than hospital reduces her risk of getting c-sections, forceps & episiotomy. C-sec alone drops from 5% in planned-hospital to 0.5% in planned-home birth [of the top of my head]. Now if both options are equally safe for the foetus, I’d think that avoiding surgery & other physical cuts are some pretty good reasons.
Well of course her “risk” would be reduced if she is not in a place where those things can be done. But, her risk is probably about the same as any other 2nd time mother for a Csection or episiotomy, regardless of where she gives birth. If something arises at home, she’ll have to go to the hospital in order to get those treatments anyway. If she (or any woman) is in the hospital, and everything is textbook, then she won’t have a Csection or whatever, because the doctors aren’t going to section someone who is doing just fine vaginally, unless maybe the woman herself, requests it.
I am sorry, but that is not what the Place of Birth Study says.
First, the study analyses birth by where they were planned. Thus planned home-birth are analysed at home-births, even if they end up in hospital (which they often do : 12% for low-risk multips, ~43% for primips]. Planned hospital births are analysed as hospital birth, even if they happen elsewhere (sometimes babies are faster than traffic!]
Second, the study is quite clear that your risk for c-secion, episiotomy, forceps, is much lower if you plan a home-birth. So it is simply not true that the risks are the same.
Incidentally, this is a very robust finding – all big analyses find it (not just place of birth study, but also the Wax study): if you plan birth in hospital, your risks of these interventions shoots up.
So, all being equal, our hypothetical low-risk multip ‘Kate’ does have legitimate reasons, I think, to plan a home-birth
What I am trying to say is: the risk for Csections, etc are not reduced BECAUSE the woman is at home, its more that the homebirthing population has been thoroughly screened and is WAY less likely to need those things. There is nothing inherently special about birth location that can, in and of itself, cause or prevent problems. Walking into a hospital doesn’t turn a vertex baby breech and being at home doesn’t prevent a knot in the umbilical cord, to use some examples.
The difference is that in the hospital they can foresee problems earlier (monitoring) and intervene more readily. That’s why being in the hospital is safer, even in the UK. Sure, there are women, who, in retrospect, probably would have been fine at home and didn’t really need the interventions. But doctors would rather play it safe and hand the living woman a living baby, and everyone goes home with all brain cells intact, and many women would rather have a Csection than risk a dead baby. The only way to know for sure, who really needs a Csection, is to stop doing them and see who dies.
Please look at the study. It compares thoroughly screened planned home-birth against equally thoroughly screened low-risk hospital births. It compares like with like.
Also, why are “interventions” bad? The whole point of them is to prevent an emergency, or worse, attempt to reduce the damage if an emergency occurs anyway. Interventions, including Csections, are not bad outcomes. A bad outcome is a dead mother, and a dead or damaged baby.
I would say that all else being equal a forceps, episiotomy or c-seciton is pretty bad. You don’t ordinarily volunteer for these. Unless you have a reason: preventing a worse outcome.
But the point is that amongst our hypothetical Kate’s, the low-risk multips, planning hospital birhts does not reduce the risks for the foetus, but does increase their risks of the above. Considerably.
And then, I think, these interventions are bad.
If I had known that I would wind up with a cervical laceration and 2nd degree tearing that has left me with pelvic floor problems at the age of 36, you can bet your ass I would have preferred to have a c-section. You are also woefully misinformed if you think that episiotomies are routine; in the U.S., the rate is approximately 12%, and they are done when the baby needs to be delivered immediately.
I don’t say they are routine. I say they are considerably higher in planned hospital than planned home-birht. And that is what the data show (5-10% higher, if I am not mistaken. absolute risks. Not earth-shattering. but not negligible.)
I am very sorry to hear about your experience. I don’t want to dismiss it. But I also don’t want it to trump the data. Often, with hindsight information, we would choose different from what we did.
What I am trying to do is figure what are reasonable decisions looking forward.
I worry this makes me sounds like an insensitive dick. I am so sorry. As I said elsewhere, my heart goes out to whoever has a horrible birth experience, harm or after-effects. but we find those either side of the spectrum.
You don’t sound like an insensitive dick. You ARE an insensitive dick. Pelvic floor problems are far more common than you realize, and when they occur in younger women, it is directly correlated to vaginal birth. Yet NO ONE talks about this significant moribidity related to vaginal birth.
Given your complete inability to admit that the studies you are citing have significant flaws, I find it rather amusing that you accuse me of using my anecdote to trump the data.
I am very sorry. It is difficult to get this right on the internet. I really am sorry.
I have in many responses [look around, I have been commenting for a while today] acknowledged there are problems in this study.
The choice being discussed here, is between home or hospital birth in low-risk UK multips. In both options the initial trial of labour is for vaginal birth – so in both cases pelvic floor damage associated with vaginal brith is a risk. In both groups 3rd degree tearing was the same. planned hospital had considerably higher risk of c-sec, but also forceps – which as I am sure you know has a particularly bad association with pelvic floor damage.
I recognise that some people think, for reasons you mention, that it is best to opt straight for elective c-sec. Particulalry in small family size. I support people’s freedom to choose that, and I think they should get what they want. I have not in detail looked into or thought about that particular trade-off, so can’t comment on it. But precisely for the reason you mention, (and several others) I can understand and imagine why people are attracted to an elective c-sec.
I fear this does not help much. I am sorry. My main worry about birth discussion is that we forget maternal outcomes too easily. that includes pelvic floor damage.
“I would say that all else being equal a forceps, episiotomy or c-seciton is pretty bad. You don’t ordinarily volunteer for these. Unless you have a reason: preventing a worse outcome.”
I’ll be doing more than “volunteering” for a CS, I will be seeking and pushing for one for my first child. I am not even pregnant yet, so I don’t know whether I will be low or high risk. Either way, I want a planned, pre-labor CS for precisely the reason you stated – to avoid the possibility of a worse outcome (things like shoulder dystocia, brain damage, nerve damage, brain bleeds for the baby and things like tearing, forceps and pelvic floor damage for myself).
The key word in the above, to me, is safe. What do you mean by that? Safe is a mirage: with birth, like sex, there is only safer.
And if you do some reading on this board, you will hear the stories of
several women who had no identifiable risk factors, and in many cases
previous uncomplicated births, who had sudden and catastrophic
situations arise. A child can suffocate or a mother bleed out in less
time than it takes to transport to the hospital. Even if the odds are
good that neither child nor mother will encounter a life-threatening
complication, I would never risk it at home. Because if you’re that unlucky one
out of a hundred, or a thousand, or ten thousand, the risk may have
been small, but to you and/or your child it is 100%. No one can turn
back the clock once your baby or you is injured or dead. I can’t think of anything I’d risk my child’s health and life for, but if it exists, it sure isn’t giving birth at home.
Thank you. I agree that safety can only be comparative – good point. So let me clarify: with ‘safe’ I meant, ‘as safe as hospital birth’. Or even better: ‘not measurably safer or less safe than hospital birth’.
That, of course, is only about the foetus. For the (low-risk, multip, no pain-relief desiring, UK) mother, home birth is indeed measurably safer: a much lower risk of emerging un-cut. [See details in comment below].
I think you completely misinterpreted me. The risk to the mother in the hospital is being ‘cut’? Please. The risk to mother and baby at home may be small, but when things go bad, and they do, it can be life-destroying, and the fact that in retrospect the chance you took was statistically justified matters not a jot. My whole point is that these things are ‘rare’, but they do happen – they’ve happened to people who post here. And when rare is you or your child, suddenly it isn’t rare any more. It’s a grief for the rest of your life (assuming rare didn’t kill you, which also happens).
I am sorry if I did.
But I don’t understand. we are talking low-risk UK multis here. the data say no difference in risk can be measured in this group.
sure, if things go bad at home, that is life-destroying. If things go bad in hospital, it is too. But the data say, those risks (for the foetus) are the same.
Why would it be more life-destroying if it happened in a planned home-birth?
I am arguing from ignorance here. But I have to seriously doubt that a fetus with meconium aspiration has the same prognosis at home as at the hospital.
Good point. That is extremely difficult to tease out. Not least because many (I imagine most, but that is a wild guess) home-birth foetuses with meconium aspiration will in fact be born in the hospital. For meconium is normally a reason for immediate in-labour transfer. [which makes it so important to analyse by planned (not actual) place of birth. as this study does.]. [Let’s also assume Kate would listen to her midwives, when they call the ambulance]
What ‘Kate’ has to weigh-up, then, is her much increased risk of c-sec, etc, against the unknown difference in prognosis should her foetus have an adverse event (small risk) and still be at home when that happens (even smaller).
If Kate’s pregnancy is textbook and she already had one baby vaginally, her personal risk for a Csection is pretty low, and does not increase by going to a hospital.
I am sorry – look at the Brocklehurst place of birth study. low-risk multip, planned home-birth. C-sec risk: 0.5%.
Low-risk multip, planned hospital-birth. c-sec risk: 5% [maybe 4.5%. I have not double checked today!]
I am continuously surprised at how little this is known. People spend a lot of time looking at outcomes for the foetus. But mothers matter too! And their outcomes are relevant, and differ by place of birth.
What about Apgar scores and HIE comparisons? What about tearing? What about the pain?
You are an excellent commenter. I have enjoyed reading your point of view, but you are ignoring a key factor. What about pain relief? What about PTSD from the pain of a homebirth?
CCProf, can you find this Brocklehurst study? (she’s one of our stats prof here).
I can’t remember from top of my head the APGAR, but I am pretty sure it would have been included in the composite outcome.
What is HIE?
Tearing, from memory, was the same in both groups.
Brocklehurst = the place of birth study.
Re: Pain: as I repeatedly said: provided she has no desire for pain-relief and other hospital amenities. Sure, if you want an epidural, go to hospital. In fact, if you live with an extended family of 15 in a crowded flat, then totally go to hospital – get some privacy! There are many relevant reasons.
I don’t think pain is not a relevant consideration, but I don’t mention it because it is so different for different people. Some are adamant they don’t want it, others don’t mind giving it a try. Don’t forget that if you are at home and find it too painful, you can still go to hospital and be plugged in half an hour later. That is why the transfer rate for primps is so high. Most transfer in because they want pain-relief.
I think it can be reasonable to want to attempt the pain and thereby lower the c-sec/forceps chances. But everyone is different about this – and I think that is right.
Another reason is that for most people who consider home-birth, they seem to have already decided they are willing to try the pain. Besides, in multips, they can make this decision informed: they know what they are in for (roughly!)
PTSD: I love it. At least we are taking maternal outcomes seriously. If we do that we have to compare PTSD due to home birth pain with PTSD due to hospital experiences. We know stories about both (see earlier comment about stories). But do you know of any data? I don’t.
Thank you very much for the complement, and for engaging. I look forward to hearing what CCProf has to say.
embarrassing: that should be compliment. Oops…
Empliau and Amy M,
I think we have gotten to the rub of the problem here. Hypothetical Kate (low risk, multip, no desire for pain-relief, UK) can choose home or hospital. THere is no measurable risk-difference to the foetus (on the best, and a very large study: place of birth). But planning for hospital means she incurs a 4% extra risk of c-sec (TBC by ccprof) and about 10% extra risk of forceps/episiotomy.
You reason: no matter that the baby has the same low chance of an adverse event, if the baby does so, and if the baby would still be at home (which she may not be – see earlier comments about meconium), then she would have a time and/or expertise delay in treatment. Preventing that is worth the 10% or so extra risk of the mother having c-sec/forceps/epi, that is worth it for me. Those aren’t deal-breakers.
That seems reasonable to me.
But someone might think the opposite. That those chances become so tiny and immeasurable, and that the extra risks for the mother are considerable, real and – whilst not the end of the world – worth avoiding.
And that also seems reasonable to me.
The question is: do you think it is reasonable? and if not, why not?
It’s all about the risk/reward ratio. If you get a c-section or an episiotomy, the risk is small, and the reward is a live baby. If you deliver at home, the risk is small (if you’re the low-risk multip under discussion, but I believe in childbirth, risk is properly retrospective). However, the downside if something goes wrong at home is way more catastrophic than an unwanted scar and some discomfort – thus the reward, to me, cannot outweigh the risk.
And count me as Team Episiotomy. I had an easy labor until the very end, when after two hours of pushing my baby’s heartbeat started to drop. I didn’t arrive in the hospital with a birth plan that said “Yes! I want an episiotomy! A big one, please!”, but when they told me that the heartbeat was dropping (thank you EFM) and my baby needed to be born now, the dreaded episiotomy made it possible. My child is healthy. Episiotomy is not to be avoided at all costs. It should be used when needed, and I’m glad it was available.
Thank you for responding. As said, I think your reasoning is reasonable. I just think that someone who thinks the risk to foetus is so low, that the frequency-difference outweighs the severity difference, is also reasonable.
Do you agree, or do you think they are unreasonable. If so, why?
ps – glad your birth went in a way that you feel was well-managed, and the epi was neither too early nor too late. Perfect. I agree epi’s should not be avoided at all cost, but neither should they be employed nilly-willy.
In UK, midwives to epi’s btw – is only c-sec and forceps and ventouse that is OB-only.
I don’t see (from my limited perspective) how anyone could think it reasonable. Bambi’s story, and Liz’s story, and the other mothers and fathers who have told their story, have all had one common thread: if they had known the danger, they would never have chosen home birth. I think anyone who says that their child is avoidably dead or seriously injured, but they made the right choice and they’d do it again, is not reasonable. In my opinion, those who give birth at home and have a healthy child have been lucky. I’m not willing to bet my child’s life and health – and a lifetime of overwhelming grief and guilt for myself – on the chance that I’ll be lucky, even if statistically it is a good chance.
OK. Thank you. That is clear. I think that there comes a quantity of c-sections you need to do to avoid one death, at which it may no longer be reasonable – in fact there must be such a point, because c-secs make future births more risky.
I also think that on other blogs, there are many stories about people who severely regret having gone to hospital.
I think that you make a reasonable choice on the data, to go for a home-birth.
But I respect your view. Thank you for responding & engaging
I agree with Empliau (sorry didn’t see your question until now).
Also, why is the risk of Csection higher, just by being in a hospital? My guess is the cEFM, and mothers and doctors not willing to take a chance on an iffy strip. Sure avoiding cEFM will eliminate that “risk,” but then you are lacking information about the fetus and wouldn’t know if something did go wrong. Like most people here, including you I believe, I’d rather have an unnecessary Csection if there was the slightest doubt about my baby’s wellbeing.
I have twins, they were vaginally delivered. I was continuously monitored. They used the ventouse on Twin A because he started having late decels. If there was no monitoring, no one would have known about the decels and if it went on long enough, he could have been brain damaged. The ventouse caused a minor tear, which I was happy to trade for my son being healthy. Granted, I was considered high-risk, but any baby can have late decels and if that happens, the doctors will (should) always do what is necessary to get that baby out asap. If that’s an episiotomy, ventouse or Csection, well, the mother would accept any of those to make sure her baby was safely out in time.
I just realized — NCB types think a baby is Schrodinger’s cat! cEFM collapses the wave form!
THe data say the risk of c-sec is higher – the explanation for that is up for grabs. there is an interesting thread on this higher up – sorry to be brief.
“What is HIE?”
I haven’t gone through all of the responses yet, but I haven’t seen anyone answer this yet, so….
HIE is Hypoxic-Ischemic Encephalopathy: “Perinatal asphyxia, more appropriately known as hypoxic-ischemic encephalopathy (HIE), is characterized by clinical and laboratory evidence of acute or subacute brain injury due to asphyxia. The primary causes of this condition are systemic hypoxemia and/or reduced cerebral blood flow (CBF). Birth asphyxia causes 840,000 or 23% of all neonatal deaths worldwide.”
http://emedicine.medscape.com/article/973501-overview
A fetus who is not being continously monitored during birth (not just intermittantly as is done at home) is at more risk of having unrecognized oxygen deprivation which can cause brain damage.
You are looking at stats for a population. The same number doesn’t apply to all individuals in the population.
sure – but you have to make your decision on the data that you have! that holds for any decision under risk.
But you would have your personal data if you discuss it with your OB or midwife.
yes, but they will give you no more information than putting you in the best risk-stratification group in the best study. which is why we need to stratify risk. but then you still have the population level-data (for people most like you!) as the best one to decide upon.
Not necessarily. A good OB or midwife should have as much information about a given patient that is possible, so her individual risk can be assessed.
We see this all the time with Csections in general–30% of births are Csections!! But, that includes 10-15% of first time mothers with no previous indication and the rest are either repeats or there was some issue either before or during the birth.
Maybe VBACs is a better comparison. The overall risk of rupture cannot be equally applied to all women. Women with a vertical scar have higher risk, so are women who have large babies, and the reason for the original Csection—some of the factors may recur, some won’t. A doctor or midwife can take all of those factors into account for a given woman and tell her what her personal risk is. Then, the woman is fully informed (hopefully) of all the risks and benefits, and can make a decision.
Because of the time delay in getting to help.
Then, secondly, your point about individual’s stories. I read this board and I read those stories. My heart goes out to those women. I also read other boards and other stories – people who desperately regret the things that happened to them in hospital. My heart goes out to those people too.
There will always be horrible stories – horrible experiences – on either side, whatever we do, that is the nature of risk.
This blog, however, is about making the best decision possible, in the face of risk, based on the data. Those data seem to say that a low-risk multip in the UK has nothing to gain for her foetus by choosing hospital, but much to loose for herself.
I can see why you’d want to avoid a small extra risk to your baby by incurring risks yourself. But a choice that involves not avoiding any extra risk for your baby, whilst still incurring significant risks yourself, is not something I would recommend.
[Though I stress: there are many more legitimate reasons than physical safety, and I above all support people’s freedom to choose however they want.]
Nothing to gain for her foetus? How about monitoring which can show, very early in the process, that her child isn’t receiving enough blood to the brain? Early enough that the child can be safely born without significant loss of brain function? And skilled people who can take care of the baby if s/he needs help to breathe? Me, I’d call that a gain. And I’d risk being ‘cut’ every day, twice on Sunday, for that.
Midwives do intermittent monitoring by auscultation, so I take it you mean Continuous Fetal monitoring?
You are aware of the Cochrane review (about the highest authority in EBM) on this? http://summaries.cochrane.org/CD006066/PREG_comparing-continuous-electronic-fetal-monitoring-in-labour-cardiotocography-ctg-with-intermittent-listening-intermittent-auscultation-ia
— increases c-sec and other interventions, but no differences in deaths and cerebral palsy (although small difference in neonatal seizures.
But back to place of birth: she may gain continuous monitoring, but the data shows that this does not improve fetal outcomes, but will increase her chance of c-sec, etc. Don’t ask me how that happens, but the whole point of following the evidence (this blog’s point?) is to look at the ultimate outcomes, not reason from mechanism or look at intermediate points of measurements. yes she would get the monitoring, not it would not reduce fetal harm.
as to the trade-off: I don’t say that that your’s is an unreasonable choice. But if Kate says the opposite: I don’t want to take a 5% c-sec risk, plus a 10% forceps and episiotomy risk, to avoid a possible 1/1000 or so risk that my child might be in a place where it has a better prognosis – for which I don’t’ really have evidence as it might be there already.
– Well if she says that, I can’t call that unreasonable either. Can you?
I am no scientist, but Dr. Amy and Orac have scathing reviews of Cochrane. Then where do I get the gall to comment? Well, I’m on the internet. We all have the gall to comment. More important, perhaps, is logic. Yes, there is a small chance that a mother or a child will need help. But if the choice is a small chance with many skilled people and the tools they need right at hand, or a reasonably skilled person with stone knives and bearskins (Bofa! Pop culture reference! Please deposit my PCM points) I choose the skilled people with the necessary equipment.
People with knowledge of obstetrics have weighed in on the data available from CFM as being far more useful than intermittent auscultation. I rely on the expertise of attitude devant, Dr. Amy, Antigonos, and others.
And finally: the bad consequences in your scenario, caesarian and episiotomy, are not deal-breakers compared to the injury or death of a child in my eyes. Are OBs really using forceps frequently where you are? Here I believe the vacuum and C-section have replaced them (though I should welcome correction. Not a doctor.)
In the UK, the overall c-section rate is a few points lower, and the instrumental delivery rate higher. In the US, obstetricians usually prefer sections to assisted deliveries.
I did not know this. Interesting. Thank you.
‘Failed ventouse – proceeded to forceps’ is a common thing to hear at handover and observe at deliveries. Vacuum has a high failure rate in my experience.
Interesting. I only know Gawande’s piece in the New Yorker which says that forceps are declining in the US because fewer people know how to use them skillfully and the risk to the baby of injury or death is relatively high. Nobody, perhaps understandably, wants to be the learning experience when the damage can’t be undone; Gawande points out that young doctors training in c-sections have experienced OBs there to help, but forceps are of necessity one-on-one.
No – that Cochrane review does not say what you say it does. It says ” Fits (neonatal seizures) in babies were rare (about one in 500 births),
but they occurred significantly less often when continuous CTG was used
to monitor the fetal heart rate. There was no difference in the
incidence of cerebral palsy, however, other possible long-term effects
have not been fully assessed and need further study.”
Correct – that is what I intended to briefly summarise, thank you for expanding.
I think the focus is on whether the hospital offered benefits in a low-risk multip population, however, looking at ultimate outcomes. I repeat: “But back to place of birth: she may gain continuous monitoring, but the data [I mean Brocklehurst data] shows that this does not improve fetal outcomes, but will increase her chance of c-sec, etc. Don’t ask me how that happens, but the whole point of following the evidence (this blog’s point?) is to look at the ultimate outcomes, not reason from mechanism or look at intermediate points of measurements. yes she would get the monitoring, not it would not reduce fetal harm.
as to the trade-off: I don’t say that that your’s is an unreasonable choice. But if Kate says the opposite: I don’t want to take a 5% c-sec risk, plus a 10% forceps and episiotomy risk, to avoid a possible 1/1000 or so risk that my child might be in a place where it has a better prognosis – for which I don’t’ really have evidence as it might be there already.
– Well if she says that, I can’t call that unreasonable either. Can you?”
Well, we have already established that the Brocklehurst data actually draws no conclusions about fetal death or other very serious outcomes like brain injury or brachial plexus injury, although the data suggest that the risk is much higher at home. So we’re left with an increase “risk” of c section on the one hand, with an unestablished risk of fetal death and serious injury on the other hand (assuming that we’re only relying on Brocklehurst.) So you have to start looking at other ways to make the decision … like common sense, and studies in other places like the US. Which establish a very much increased risk of death. Most mothers will chose a risk to themselves over that risk to their babies — unless they are improperly informed or fearful about hospitals.
What the data ‘suggests’ is up for dispute – if you look at the composite outcome the risk is slightly lower for home than hospital in this group. It is not significant, I would base no conclusion on it – I merely mention it to point out that if you look at ‘suggestions’ in the data, then you go beyond it – and you can always find something to support whichever side you pick. [the same holds for pointing out it is a composite outcome].
I admire that mothers are so self-sacrificing. And I think that is insufficiently celebrated. But what we do know is that the absolute additional risks of fetal death and serious injury in the home in this group – which we are by now guessing at, since the study could find no difference – are – must be – very small, if there is a difference at all. Whereas the risk of c-sec, forceps, epi, etc is considerable and well-measured.
How many abdominal surgeries & forceps to save one baby? 100? 1000? 10000? what is reasonable? I don’t know. Surely there comes a point where the sheer frequency of moderate harms outweighs the very severe harm of one death? I don’t think it is unreasonable to think so.
I think every mother should choose what she deems right, but I think it is important to realise that there is room for a large variety in decisions here, that I cannot dismiss as unreasonable.
Certainly endlessly emphasising the potential risk of planning the home-birth, without mentioning the very real and measurable risks that the woman incurs in avoiding that – which seems to happen a lot on this blog (and elsewhere) is unlikely, I think, to lead to good decision making.
Given that most women in the developed world are opting for smaller families, having a c-section simply does not seem all that problematic to me. Additionally, many of us are older when we conceived, and some face significant barriers to getting pregnant in the first place. I didn’t endure pregnancy for 9 months for my baby to be one of those rare statistics.
Sure, as I said, every person choose what they want, and there are many additional reasons to consider. You mention: family-size, and investment in the foetus. good. there are many more.
But the question remains: I think it is reasonable to think that the c-sec (abdominal surgery, after all. not a blood prick! every other branch of medicine you’d get a LOOONG leaflet with all the associated risks, and a small-print consent form) — that the risk of c-sec and forceps is not worth your while to avoid an immeasurably small potential risk to the foetus – and remember that we have tried to hard to measure it.
I think that is reasonable (though I don’t think that other choices aren’t reasonable, or that you have to choose this). The question is: do you think it is reasonable? if not, why not?
If you, personally, don’t want to have a c-section, it is your right to decline it. The same with forceps. But the longer that you continue to labor with a distressed fetus, the greater the chance of a bad outcome. I don’t agree that it is usually an “immeasurably small risk” to the baby. I know of far too many women who “trusted birth,” and found the consequences to be catastrophic.
I do have huge issues with people like you who are willing to gloss over what can happen when you fail to intervene at the appropriate time. The overall risk may indeed be small, but the reality of what happens when you play the odds and lose is life-changing. I think you are being unreasonable and disingenuous.
Have you read the other post about the particular case and risk-profile we are discussing here? Where the additional risks, if they exist, are so small we have not been able to measure them?
But if a baby indicates distress on the cEFM, the mother will have a Csection–in order to prevent a poor outcome. If all the strips were ignored, there would certainly be a increase in neonatal death and/or brain injury.
I can only look at final outcomes – which on the birthplace study (caveat limited data on soft outcomes – and all the other caveats) can measure no difference.
The rest is guesswork. YOu may be interested in above interesting discussion about possible explanations for differences in interventions
You know what they say about Cochrane reviews: “Garbage in – garbage out!”
Also, the homebirths that are generally discussed here take place in America, where the homebirth midwives are untrained charlatans. Homebirth is a different story in the UK, where the midwives are trained and integrated into the system. That is what makes homebirth in the UK (or other European countries, and Canada) acceptable…it is made as safe as possible, and they try to risk out anyone who is not a good candidate or suddenly develops complications.
As for Kate Middleton, if she were any other schmo in England, she might be a good candidate for a homebirth, but since she is a royal now, and her babies are very important, there is no doubt in my mind that they will have doctors on hand, and an OR down the hall should anything go pear-shaped.
I agree that in fact Kate, sadly, will be denied the freedom to choose the circumstances of her own birth – an important human right. So yes, I too have no doubt there in fact will be doctors at hand.
Re: UK and USA: I appreciate the differences, but I think the UK data are worth discussing because everyone wants to make birth as safe as possible for all involved, and the UK data suggest that for low-risk multips that involves a home-birth option (with well-trained, integrated, risk-stratisfying, etc midwives). Which could exist in the USA.
And Dr Amy brought this up!
Also: please enlighten me: are all USA home-birth midwives charlatans?
Well, probably not ALL, but quite a number. See the Gavin Michael story. What a trainwreck. Ultimately, which you have acknowledged somewhere, home birth will always be slightly less safe, because if the need to go to the hospital arises, the time lost in getting there could be detrimental.
Her grandmother in law ( ie Queen Elizabeth 2) had all four of her babies at home, including the Heir Prince Charles. Good enough for her…
Did you know that they set up an operating theatre in the palace for all of the queen’s births? Did you know that she had penthidine as a pain killer? Did you know she relied on a DOCTOR, not a midwife, to deliver her children?
Unless these things are typical of home birth in the UK, you’ve chosen a ridiculously poor example to try to illustrate your point.
She had them when? Back in the 50s? There have been significant medical advances since then.
The people who desperately regret what happened to them in a homebirth generally have a dead or injured child. A great many of the people who desperately regret their hospital experience have a healthy child. Not all, of course, but the odds are still in favor of the hospital birth. And we still haven’t found the children dead in the hospital who would have been safer at home.
(Statistician has arrived as paged)
I do not agree that the Brocklehurst study (also known as UK Birthplace study) proves there is no difference in adverse events. It shows no statistically significant difference on a composite measure of harm which includes both dire harms such as death and brain damage and lesser harms such as broken collarbone.
As a statistician, I do not like composite measures, because the way they are put together is extremely vulnerable to interpretation and opinion. How much worse is a brachial plexus injury than a broken collarbone that heals, or MAS that’s treated without complications? How much worse than a brachial plexus injury is the loss of the child? How does one even answer questions like these, and how do I know that my answers agree with those of the study authors?
The specific outcomes were hidden in an appendix, and one of the interesting facts in this appendix is that the total risk of intrapartum or neonatal death is more than twice as high in a freestanding midwifery unit or home, compared to alongside MU or hospital. (I find that adding up sub-categories is a useful technique for reading work put out by midwives, since they like to slice and dice by category to avoid showing statistically significant differences in risk.)
I thought you were a number theorist?
Depends on the week.
Let me ask you this: Have you ever presented as JSM?
(I have…:))
I have not. I’ve only done statistics-related talks at community-college fora, and primarily from an educational point of view rather than pure research. I’d like to do JSM, but travel funding is extremely tight around here.
Bofa, I thought you were a physicist? Sorry I could have paged you 🙂
Physical sciences, yes, but not a physicist. However, I HAVE presented at the Joint Statistical Meeting.
On a topic that had NOTHING to do with my work, however, and actually a result of a hobby
Thank you.
As I qualified somewhere else: by home-birth (in UK low-risk multips) is ‘as safe’ I mean ‘not measurably less or more safe ‘ than hospital birth. Of course the study does not prove there is no difference – no study could prove that (in an absolute sense of prove). But on its primary outcome measure it fails to measure a statistically significant difference between home and hospital in this group. And that is not due to lack of power – this was an extremely large and well-designed study, and provides the best data we have for the UK. It would be difficult to improve upon it. If we are going to look at the evidence, we have to go with the evidence we have – which will always be imperfect. It is a fair interpretation that it found home and hospital to be equally safe for fetal outcomes in the group we are discussing.
As to the composite outcome measure: noone likes those. But you also know full well why it was chosen. Fetal deaths are so rare, that without a composite outcome, the study – despite its size – would have been underpowered. That is to say, it would have been difficult to detect small differences and find them to be statistically significant.
I find that itself interesting: the differences we are talking about are so small that they are (almost) impossible to measure – even on such a large study. [I don’t meant that to mean they are not important – I shall return to this].
But that aside, yes, the composite outcome measure means we are still less sure than we would like to be – but that does not prove whether the advantage lies with hospital or the home (I have heard people say the same thing to argue that home could still be equally safe for primps!). To draw such a conclusion goes beyond the data.
I have looked at the appendixes, but overlooked the datum you mention: is that for low-risk multips only, or for both primps and multips combined? for if the latter it gives no additional information – we already knew that from the overall analysis, because primps have higher risks than multips. Also was it statistically significant?.
Second, as the paged statistician, perhaps you might also speak to the risks the multip low-risk mother faces in terms of c-sec, forceps and epi’s, according to this study?
Please? Sorry – I realise my tone is less than civilised. I apologise – too much material to write and too many comments to deal with! I appreciate your input.
I don’t consider epidurals to be a risk. In fact, most women who choose them consider them a benefit of hospital birth.
And keep in mind, women who do home birth don’t get the benefits of active management of the third stage, including IV pitocin if indicated, to minimize bleeding. Which means, although fatal hemorrhage is still almost always preventable with transfer, women who give birth at home are more likely to suffer the kind of hemorrhage that makes for a really awful recovery.
Sorry, by epi’s I mean episiotomies. I also don’t consider epidurals a risk (but a choice, desired by some, undesired by others) as I explained below in a reply about pain.
As far as I am aware active management in the UK is standard protocol, including in home-birth, where some form of synthetic oxytocin (I believe it is called syntocin [?] here) is delivered by injection. unless the woman does not want to, of course.
Still, we should look at data and final outcomes: we cannot assume that home-birth increases blood-loss. If the ‘oxytocin’ crowd is right, than home-birth (associated with more immediate breastfeeding) might do its own to assist a smooth third phase. I am not saying this is correct – I am saying we should look at the data.
And they do tell us something quite significant for those not terrible keen on caesareans and forceps – or rather those who would rather only undergo those if there is a good reason – and not for the hell of it.
[But as I said, there are always more reasons than the one I mention.]
I am a bit surprised that this is not picked up upon. Most people find forceps pretty horrible, I am told, and the recovery from a c-sec (and future pregnancy-risks) is hardly desirable. Sure, these are not OVERRIDING concerns – but they are relevant. And the differences in frequency are not small here, but considerable. Why is this not spoken about?
yes they do! Midwives can perform active management if needed/chosen. They carry both syntometrin for IM use & syntocinon for IV.
Interesting! Midwives in the USA do not do that, resulting in a 15% hemorrhage rate, according to their own records.
It is physically possible for American homebirth midwives to do active management, but they overwhelmingly do not.
Many of them try to claim that a “physiologic third stage” is a selling point of their care.
Next, the manufacturers of lousy umbrellas will be selling an “all-natural storm experience.”
The only bad outcome associated with home birth (according to home birth advocates) is the death of a baby. In reality, there are many, many other issues that they can’t be bothered to track. Since they do not have EFM (and in the States, plenty of them don’t seem to understand how to do ascultation properly), they can miss subtle signs of stress in the baby. I can’t tell you how many photos of blue babies I have seen posted on the internet after a “successful” home birth. How many of these babies suffered some sort of deficit that was not noticeable until later in life? No one knows, because in the realm of the true believers of home birth, these issues are unimportant.
If you are in a hospital and signs of fetal distress are detected, you may well have a c-section and deliver a healthy, screaming, pink baby. NCBers call these “unnecesaereans,” because in their minds, c-sections should only be performed when the baby is near death. The whole point of intervention is to prevent the situation to getting to such a dire point. I think most women would prefer to have a c-section to protect their babies brains from lifelong damage. That this is not even a concern to many NCB advocates should be a red flag to everyone.
I was not aware that Kate had “this brilliant first birth”. As far as I am aware, no details have been released. Kate might have had a horrifying first birth with a complication resolved smoothly and efficiently like they get done every day in a hospital.
The healthy glow that she radiated when she left the hospital is now something Milly Hill is competent to make calls based on? Please. Kate has a team of people whose only job was make her look nice.
I’ve seen pictures of my mom leaving hospital with brand new me. Kate’s glowing is nothing compared to hers. The reason might be that my mom had a terrible birth and knew how close I came to not making it. With a team of people she might have even had a healthy glow, not just a happy one.
Who knows, Kate might have not wanted to whine how hard she’s had it.
Thank you: see replies below about assuming (which indeed we don’t know) Kate is and remains low-risk, and about Kate probably, hopefully and rightly, ignoring everything said to her on the internet – but that it is nevertheless appropriate to discuss a woman with her (assumed) risk-profile – whilst Kate can proceed to do whatever she wishes.
The problem with sticking a name and face to a woman with her assumed low-risk profile is that in doing this, we go out of the way of hypothetical and general. I don’t see anything wrong discussing her pregnancy and birth among ourselves – and “among ourselves” is quite expanded nowadays, with internet and all.
However, I find such pleas as Hill’s a terrifying intruding onto a public person’s very limited private space… and with no care and responsibility for the outcome.
Kate can proceed to do whatever she wishes but we all know she’s a pregnant woman – a vulnerable state by itself. She’s also pressured to be the face or this or that. She might feel obliged to do something going despite her wishes, in fact.
And if she does, and something goes wrong, you can be sure Milly Hill wouldn’t be there to help moving the disabled child’s chair up and downstairs.
I think I agree. I had similar worries about when they discussed her breastfeeding (and anything else really) first time around. I have already been speaking about ‘hypothetical Kate’. Let’s just discuss a low-risk UK multip fromm now now on.
“A very rigorous piece of research called theBirthplace Study showed that women having their second or subsequent babies in hospital were much more likely to have interventions such as instrumental birth and caesareans, with no corresponding improvement in outcomes”
I agree that the UK Birthplace study is the best study we have. And it does show that rigorously screened women giving birth to baby #2,3, or 4, who *chose* homebirth had fetal outcomes indistinguishable from hospital outcomes while at the same time a lower chance of C-section and instrumented birth and epis. But the Birthplace study has significant limitations the 2 biggest being 1. not studying longterm fetal “soft” outcomes such as learning disabilities and 2. non-randomized study.
This is where we have to ask ourselves WHY did the at-home women have lower interventions? There are 2 leading theories:
1. Fetal distress is less able to be picked up at home. The vast majority of babies with distress who are being bourne by multips can be delivered rapidly enough that the distress has not yet had time to turn into permanent measurable damage. But in the hopital, the distress is picked up earlier and women are given expidited deliveries by CS, instrumented delivery or epis just to err on the side of caution.
2. Self selection. The Birthplace study was not randomized. Women who planned birth at home *chose* it. Two women can be equally low risk on paper, but actually differ in significant ways. For instance a woman who has a 5 hour first labor without need for pain meds and pushed 30 minutes is much more likely to be willing to choose to birth out of the hospital than a woman who had a 24 hour labor with 2 hours of pushing who needed pitocin and an epidural. But both will be labeled “low risk”. A woman who barely managed to deliver without forceps or CS, is at a higher risk of needing forceps or CS at future births than a woman who deliverd easily with room to spare.
In my opinion the decreased “risk” of maternal intervention in homebirth for low risk multips is likely a combination of both #1 and #2.
Thank you. Glad we agree on the data!!!
Now for the explanations – I am going to list some, and add some more that, depending on who you ask, other people might consider ‘leading’
1. (as you list) hospital measures cases of imminent/developing distress and intervenes, which at home would have come out without help and before becoming serious/leading to permanent damage.
2. (as you list) Women self-select based on ‘ease’ of previous birth. Thus the home-group is in fact slightly lower risk than the hospital birth.
3. (added – heard amongst some home-birth supporters): Women’s physiology works better at home because she is more relaxed/left undisturbed/in home environment/not amongst strangers, etc. Thus her base-line risk of problems, and therefore need for interventions is lower at home.
4. (added – mentioned in some sociology literature). OB’s are trained on and have their perceptions coloured by a comparative high-risk population, and particularly driven by avoiding rare but dreadful outcomes which they have seen (dead babies/mothers). Midwives are trained on and have their perception coloured by a comparatively low-risk population, and are more attuned to and motivated by the benefits of a ‘physiological’ birth (everyone happy and glowing in a bed together) and aware of the aftermath of interventions (they see the women after brith with their c-sec scars and dpi-pains). This makes OB’s threshold for intervening lower than that of midwives.
5. (added – also sometimes heard). Ob’s are cynical bastards who just like to stick their knife in, particularly when already late for their weekend/dinner party.
1. Seems to me part of the explanation – but I think would give someone reason to trust the data and choose home (all else being equal): if (in this risk-group) the extra interventions picks up on distress that would not have materialised as damage, than avoid the interventions!
2. Seems to me part of the explanation – but very difficult to quantify. Only an RCT would help – but I don’t think that would ever happen, and if it did it would have its own problems (high drop-out). This explanation favours erring on the side of hospital.
3. I think has plausibility. I am willing to believe that the whole mammalian birth-physiology works best undisturbed. THere is some (mechanistic) evidence to back this up. That does not mean it should never be undisturbed – when the benefits of disturbing outweigh the benefits of non-disturbance (as in high risk populations), clearly go with the disturbance!. But in low-risk multips, maybe non-disturbance is better – favour erring on the side of home (here).
4. I think has plausibility. It does not really tell us what to choose, though as it depends on your baseline risk, and how you want to trade maternal and fetal outcomes, which style you prefer. But I do think this does quite a lot of explaining.
5. I am sure this very occasionally happens – there are dreadful – or simply sometimes tired and stressed – OB’s as there are midwives. But I don’t think this can do very much explaining.
So I think a mixture of 1,2,3,4. How much of each is of course very difficult to figure out, and I think we have some data (if you want to call mechanism and sociology ‘data’), but nothing like good or conclusive ones. My impression is that people lean home or hospital in part based on which explanations they favour/give more emphasis. And that seems to involve always a leap of faith.
I am very interested to hear what you think.
Finally: yes, the soft outcomes is a problem – for any study. I asked a paediatrician about encephalopathy, I tried to figure out how bad it was. And the answer basically was: impossible to predict and you won’t know for years after. We will never have completely conclusive data, I think, meaning that I think there will always be some disagreement depending on what side people prefer to err upon, and what explanations they favour.
Sorry – this is quite long.
thank you
My thoughts:
#1 is important because we do have some evidence that “soft outcomes” do happen. e.g. Mayo Clinic population study that showed that babies born by vaginal delivery or emergency CS had higher rates of learning disabilities than babies born by elective CS. A distressed fetus may look fine as a newborn, but later develop problems that are subtle but make a difference in life functioning. This is why when kids come in for LD or ADHD assessments the birth history is explored in depth. Now some women may be willing to risk this, but I would guess most would not.
#2 I think you are underplaying this.It’s not “slightly lower risk”. Confounding is likely to be a large factor in this study, not small. The Birthplace study did not measure “ease of previous deliveries” but it should have. As it was, the Birthplace study DID find that its hospital group was higher risk for factors like low SES, which does correlate to poor birth outcomes.
#3 NCB advocates can believe this all they want. But there is not one shred of proof. And doing a study on this would actually be easy, even in the hospital: just randomize the things they claim matter e.g. low lights, private room etc.
#4 Plausible, but this brings us back to #1. Shall we err on the side of caution or on the side of “well most of my patients are low risk, so all is likely to end well for you too”? Depends on the woman and her values. With the trend toward smaller families, older moms and the increase of “brain jobs” as opposed to “brawn jobs” in our economy, it seems to me that most moms will not want to risk brain cells.
#5 I agree. Probably only a very small factor.
Thank you so much for engaging with this. Please can you give me a link/reference to the Mayo Clinic study? I assume they corrected for SES which would be a confounder?
re: 2 and 3, I think this is where people differ, and the data are up for multiple interpretation. I think the birth-physiolgoy story is not wholly quatch. E.g. there is aggregate data that home-births happen at different times of day than hospital birth – and it is inferred that they progress quicker; we do know oxytocin to be important to birth and inhibited by adrenaline. I am not sure a study would be that easy because the ‘true’ uninterfered with birth is kind of difficult to get good data on/randomise too – that would be interfering!. But I like your suggestion of randomising to different light-settings. IN a sense, perhaps the birth-centres versus labour ward is such a study – in the UK birth-centres (AMU’s) usually have birth pools, private rooms, ability to play your own music, birth-balls – whatever it is. But doctors are down the hall-way (in the labour-ward, with much smaller rooms full of scary-looking equipment – sorry, slight exaggeration. but you get the idea]. And we do find lower interventions int eh birth-centre. but obviously – there are confounders.
4 – yes – quite right. brings us back to 1. — so ultimately this is about women and their values.
I am giving more credence to 3 than you do, but you make me rethink 1 and 2 —- I think there is legitimate room for disagreement. We just have to make inferences that are not fully determined by our data.
I just think it is so important to emphasise that. That there is space for reasonable disagreement, that does not need to be polarising .
I’ve read the study and the hundreds of pages of the indices. It does not say what you think it does:
http://www.skepticalob.com/2011/12/birthplace-study-yields-additional.html
THank you. So have I, and I have read your review you link to.
So of course, and as you point out, some people (7% of those giving birth at home) do so despite having some risk factors, meaning the study is about women of lower risk than in fact give birth at home. But the study is about those women that are advised they are low-risk.
Some women want to give birth at home despite being advised otherwise. I think that is their right – and I would still rather the NHS sends a (two, in fact) midwifes to be there (if not for them, then for the newborn), rather than leaving them on their own, or escorting them to hospital under police force.
But it is right that those women are excluded from a study that looks at outcomes for low-risk women, and tries to give information about different outcomes by planned birthplace, based on good risk-stratification.
I am not making sweeping statements, I am merely arguing that for a low-risk multips on the brocklehurst criteria, there appears no measurable reduction of adverse event-risk for foetus in hospital, but a real and considerable increase of interventions for the mother. All else being equal, that is a reason for preferring a home-birth.
we have done a lot of work below hashing out the assumptions and uncertainties involved.
In other words, it does say what I think it does. (though maybe not what you think that I think it does)
In other words, it says “I am a worthless study” because in real life, those criteria aren’t nearly as strict.
Look, here is the thing. I love discussing hypothetical and ideally perfect situations. But I think that here, it should be done with a huge disclaimer that gets repeated often: it’s a hypotherical and ideally perfect situation, not the way things ARE. It isn’t real life. Because in real life, consequences can be very real and very damaging.
I am always ready to discuss the perfect way to read into a fiction text. Or apply a perfect makeup. Or achieve the perfect shade of an impossible nail polish colour. Without disclaimers. Because even if someone takes our discussion to be a valid one, regarding currently existing things, the worst thing that can happen is to say, “Damn it, I’ll try it again with the next book/next mascara/next time I grow long enough nails.”
I don’t think it makes the study worthless. At all. If we go that route, we have no good data on birth at all. This is one of the best studies we have.
It just mean we have to be nuanced in interpreting the data.
Whilst not all women are low-risk multips, there are enough that fit those criteria – the Brocklehurs criteria for low-risk multips, that make this worth discussing. I think about 10% of the UK birthing population is in this group (rough & conservative estimate). Their case is worth thinking about. You can ask your health care professional if you fit the data or not – this is not about ‘ideal’ ‘hypothetical’ situations. These are real women we are talking about.
Look, people expecting twins, breeches, etc are also relatively small groups – but nobody thinks they should be lumped with all other groups; we figure out the best, evidence based treatment plan for them, with their risk profile. That goes for low-risk multips too.
Good Birth Care & good birth evidence is all about risk stratification. That applies to the higher risks groups, but also the lower-risk groups.
It absolutely makes it worthless, as far as we as laypeople are concerned. It’s one thing to discuss it with your health care provider – the person who knows YOU and YOUR individual circumstances, whether YOU fit the study and if not, then why not.
But it isn’t the way the study is being used. It’s used for touting the supposed superior safety of homebirths for second time mothers. In general. And since the people who tout it are basically the same who love the term “variations of normal”, this being twins, postdates, gestational diabetes and so on, the study is worse than useless. It’s being used in a way meant to mislead. Even Hill, in the quote you initially cites, uses it in this way, without making the very important note that it is so for low-risk second time mothers. In fact, for second time mothers who are so low-risk that they are included in the study but are higher risk than the general homebirth polulation in the UK.
People like feeling informed. And they think they understand the information. I’ve been through it more than once – I read something, and I think it applies to me before my GP lands me back to earth explaining why it doesn’t. It’s the same with this study. It might be useful on an individual point but it’s misleading in general, especially when it gives women false confidence that no matter how low risk they truly are, they can give birth at home just as safely as a chosen population made by the lowest risk of low risk who neer had a whiff of a problem.
The study says that homebirth is no riskier than hospital birth if nothing goes wrong. Well, yeah. Of course. Then it just becomes a matter of ‘how can we be sure nothing will go wrong’? We can’t tell in advance. If you only look at the lowest of the absolutely low risk folk, then you’re looking at the lowest risk of anything at all going wrong, so of course you’re looking at the lowest risk of home birth… I like the metaphor Dr Amy used in the previous post. You can definitely make a case that driving very slowly down a residential street at a low-traffic time during the day is not statistically riskier without a seatbelt than with. Does that mean driving without a seatbelt is a sensible choice?
If you avoid a ten percent additional risk of forceps and epidural by driving without the seatbelt, than yes it is. ABSOLUTELY.
The problem is focussing only on fetal outcomes. But mothers matter too. And when risks are high(er), the risk of rare but dreadful fetal outcomes for most women trumps their risk for more frequent but more moderate harms. But when (additional) risks for foetus are very low, and become immeasurable, then it is rather poor thinking to not consider maternal outcomes.
Which is exactly what Dr Amy does. – see other replies for details on harms, interventions, numbers and pain.
Who says mothers don’t matter? No one. If you think it’s worth risking your baby’s life to avoid obstetric interventions, knock yourself out and choose that. Just don’t lie to yourself and others by pretending that having a forceps delivery is equally as bad as having a dead baby.
Homebirth is not as safe as hospital birth, period! Have a homebirth if you want, but don’t lie about the risks.
I have not said that trading one dead baby for once forceps delivery is reasonable, or that a dead baby is as bad as a forceps. I have been very careful in my articulating here – please don’t put words in my mouth.
But I have raised the question how many c-secs, forceps, episiotomies one should trade. 100? 1000? more?
I have also pointed out that in low-risk UK multips we have at best the potential of a risk for the foetus, and considerable risks for the mother going the other way. I think that if in ‘safety’ you only mean ‘safety for the baby, not safety for the mother’ you are at significant risks of letting mothers not matter. and that precisely leads to the problematic view (this all started with) that if there is no measurable differences to foetus, you still would have no reason to go for the home. You do have a reason: better maternal outcomes.
I am not lying about the stats – look at my careful replies scattered all over this site. But I do worry that you only focus on half of them.
I think we are disagreeing about what are the actual risks for the mother. Of course they should be taken into account.
The risks of instrumental delivery being tearing, future (or current) incontinence for example. The risks of C section, which I think the anesthesia is considered the biggest one, especially GA. Of course there are always risks with surgery, but the surgery itself is not considered an adverse outcome, it is a means to an end. I know lots of women don’t want Csections. I didn’t because I was afraid of a hard recovery. But my recovery sucked anyway because I had a bad PPH which left me weakened and anemic for months. If I’d had a Csection when I walked into the hospital, that probably wouldn’t have happened. I would have consented immediately if the doctor thought there was any need for a Csection, though, and then been thankful at the end that I finally had my two healthy babies in arms.
The risks of vaginal birth should also be included–(tearing, incontinence, pelvic floor issues, etc.)
“but the surgery itself is not considered an adverse outcome, it is a means to an end”
exactly – but the means need to be proportional to the end. In low-risk multips, there appears to be no end at all – as there is no measurable difference between fetal outcomes, but 4% additional c-secs. That is not proportional – then it is a harm (i mean – they did just cut open your abdomen!!! and it has risks for future pregnancies, on top of GA)
In other groups, we need to weigh the proportionality, which we can only do if we take the risks (c-sec) and their frequency into account, and weigh them against fetal outcomes and their frequency. We may find that the c-secs risks are justified – probably often they are. But now, very often – including often on this blog, the weighing is not done. the justification is assumed. that is a problem and leads to the reasoning errors about e.g. low-risk multips identified..
I am not comparing elective c-sec vs TOL (including risk of the worse emergency c-sec). I can see why people see benefits in elective, particularly if facing high emergency c-sec rates – but that is not the case for the group we are discussing.
In this comparison, the elective is not really on the table. and both groups (low risk hospital, and low-risk home birth) have a majority vaginal delivery (with associated risks). I imagine the real big difference for pelvic floor, incontincenc, etc is the forceps (and perhaps ventouse – i have omitted that as am not sure – but it is also higher in hospital) which is much more likely to happen in hospital birth.
But yes, we lack good data on pelvic floors, and many others that have been mentioned- but we need to go on the data we have.
no difference in third degree tears between groups.
Try again?
Sorry Amy M, I though you were Dr Amy – my tone was a bit abrupt. I apologise.
Why do you keep calling epidurals a risk? I’ve had uncontrolled pain, and I’ve had adequate pain relief. I think of the latter as rather a benefit…
Sorry – epi = episiotomy. SOrry to be confusing. I have addressed this point elsewhere – I ‘ll see if I can copy it in.
here it is: (well, this is about pain).
— see below. but I am not talking about epidurals. if you want an epidural, go for it. Seems reasonable to me! If you don’t want an epidural – fine with me to.
“Re: Pain: as I repeatedly said: provided she has no desire for pain-relief and other hospital amenities. Sure, if you want an epidural, go to hospital. In fact, if you live with an extended family of 15 in a crowded flat, then totally go to hospital – get some privacy! There are many relevant reasons.
I don’t think pain is not a relevant consideration, but I don’t mention it because it is so different for different people. Some are adamant they don’t want it, others don’t mind giving it a try. Don’t forget that if you are at home and find it too painful, you can still go to hospital and be plugged in half an hour later. That is why the transfer rate for primps is so high. Most transfer in because they want pain-relief.
I think it can be reasonable to want to attempt the pain and thereby lower the c-sec/forceps chances. But everyone is different about this – and I think that is right.
Another reason not to focus on pain is that for most people who consider home-birth, they seem to have already decided they are willing to try the pain. Besides, in multips, they can make this decision informed: they know what they are in for (roughly!)”
“Willing to try the pain” – which you can do in a hospital! They don’t force an epidural on you. Then, if you try it and decide you can’t take it, you have the option – which you don’t have at home.
Episiotomy – yes, not fun. Neither are tears. I remember sending my UK friend a link to that Dara O’Briain bit where he and his wife are told in the childbirthing class that ‘a tear heals better than a cut,’ and making a joke about how his (surgeon) wife always uses a bear for the initial incision. My friend told me very seriously that no, the midwives did indeed assure her that a tear will always heal better than a cut. I asked her if they had any studies to back that up, and of course not. She (college-educated, science degree) just trusts the midwives, like a lot of women in the UK. If they can’t get that right, how are they supposed to get the real message of the birthplace study right? I saw all of her retweets at the time it was released, so many women taking the message that ‘Homebirth is just as safe as hospital birth.’ Full stop.
And why is a C-section a bad outcome? I know this isn’t a popular view, but I knew, growing up, what childbirth was all about. I had seen births. And the idea of having that happen to my body was _horrifying_ to me. If I ever do decide to reverse course and have children, a C-section is the only way I could contemplate it. I’ve had surgeries, probably too many, and they’ve all been very predictable, civilized things that didn’t wreck my body for sex or give me incontinence… but I know that if I wanted a C-section, I probably wouldn’t be able to get one based on request alone, because everyone ‘knows’ that C-section rates are too high and need to come down, and MRCS is an obvious way to do that. (And instrumental deliveries. Although why they don’t follow the science and induce more to reduce the rate, I dunno.)
– But according to the birthplace study, if you try the pain in hospital you already have exposed yourself to the higher risk. [see interesting thread about explanations higher up].
Also (mentioned elsewhere) if you try home and don’t like pain, you can go to hospital and be plugged in 30 mins later. that is why the primps have such a high transferral rate 😉
– Right at the bottom of thread there are some interesting exchanges about PTSD (the tears) – indeed, no data.
– C-sec (also covered elsewhere, but quickly) if you want that, if you think it outweighs e.g. the effort, pain, pelvic floor damage, whatever. be my guest. all seem reasonable reasons. haven’t looked in to them in great detail as I am not considering elective c-s versus TOL.
But if you don’t want it, and it does not buy you any baby safety, it is simply an unnecessary abdominal surgery. we do not ordinarily go and randomly get those, for fun. They have risks. Any other abdominal surgery: big risk leaflets, long consent forms….
Hope that helps. SOrry to be brief. much of this been covered elsewhere.
In what other situation is adequate pain relief considered a “risk”? Morphine for a broken bone carries a much higher risk of death than an epidural yet no one considers pain relief optional for post the pain of a broken bone.
– if you go to the hospital, your risks (of intervention increases). iI don’t say it is the epidural – all we can measure is the association with the location. That is what the data say. i am shocked that is not common knowledge on a blog claiming to be devoted to the data. Once again, for some that risk is outweighed, for some it is not – (like the group we discuss).
– “Morphine for a broken bone carries a much higher risk of death than an epidural yet no one considers pain relief optional for post the pain of a broken bone.” Are you suggesting labouring women should be given pain relief against their will???????? Presumably not. It is a fact that some women don’t want the epidural – or at least want to see if they can manage without. I think that can be reasonable – especially if doing so allows you to stay at home which lowers your chances of e.g. forceps/c-sec (not fun either).
I also think going for an epidural is reasonable. I wrote about this in more detail elsewhere. no pressure, no judgment.
PEOPLE DIFFER.
” if you go to the hospital, your risks (of intervention increases)”
What a bizarre use of the word ”risks” – when the reality is that your ACCESS increases.
Think of it like this: when you go to the hospital with (infection, pain, injury, anything), your access to effective intervention increases. There, fixed.
Where I have worked CS use exactly the same consent forms as any other surgery and the risks are clearly documented.
7 years since I last filled one of those suckers in by hand I still remember the risks by heart: “bleeding which may requires transfusion, infection, organ damage which may require temporary or permanent colostomy or catheterisation, life saving procedures to stop bleeding which may reduce future fertility up to and including hysterectomy, possible complications in future pregnancies, accidental cuts to the baby, death”.
Then the anaesthetists did a separate consent form for the anaesthetic which was spinal, GA or epidural.
The difference was that for a truly emergency CS you’re writing the form and giving the spiel as you push the bed as fast as you can down a corridor to an OR. For most other emergency surgeries the patient is too unwell to consent, or has more than a few minutes to discuss things with their surgeon.
“it does not buy you any baby safety, it is simply an unnecessary abdominal surgery.”
But it DOES “buy” the baby additional safety – especially elective, pre-labor CS. Think of the risks the baby completey avoids from bypassing the vaginal canal – no chance of shoulder dystocia, practically no chance of erb’s palsy (or other nerve damage), broken bones, brain damage cause by oxygen deprivation during labor…probably a few I’m not thinking of off the top of my head. Since you canNOT predict which baby will experience those complications in advance, the absolute safest mode of birth for the baby is a planned, pre-labor CS after 39 weeks.
Epidural anesthesia is one of the greatest advances in modern medicine!!! It allows women to be mentally focused and present for the births of their children without writhing in excruciating pain. I am so fucking tired of this new machismo surrounding childbirth! Of course women can give birth without pain medication – it happens every single minute in the developing world where women have no other option – yet women in the developed world have made making a conscious choice into some sort of idiotic competition. There are no risks to the baby when an epidural is administered. The mother can have a drop in blood pressure (which is usually easily corrected with a bolus of I.V. fluids) or a spinal headache (which can also be mended with a blood patch). Epidurals have been proven to not increase your risk of c-section or assisted delivery, they do not lengthen labor demonstrably, they are not responsible for the mythical “cascade of interventions.” I refuse to take anyone seriously who portrays epidurals as some sort of risky intervention that should be refused by women. I am also sick to death of the idea that women are too “weak” to give birth in a hospital without an epidural. Is natural childbirth some amazing accomplishment that can only be achieved by strong women, or is it something that can be easily done? It can’t be both, so which is it, ladies?
I don’t present epidurals as a risk.
I don’t say they raise your risk for other interventions.
I think going for an epidural is a erasable choice.
But you do need to go to hospital to get them. and according to the birthplace study (and nearly every other study out there) that means your risk of intervention goes up. Which for low-risk multips may be a poor trade-off.
So i think it can be reasonable to prefer the labour-pain at home instead of the hospital package (increased risk, but also epidurals!).
again – up to the individual though.
This is what you said:
“If you avoid a ten percent additional risk of forceps and epidural by driving without the seatbelt, than yes it is. ABSOLUTELY.”
Since you spelled out the word “epidural,” I do not see this as a mistake for “episiotomy” (you were using the abbreviation “epis” in that case).
Ah – you are right, I am so sorry. I did mean episiotomies (you will see in all other post I keep talking about c-sec, forceps and episiotomies) — too many posts to respond to at once. Thank you for correction, and sorry for confusion.
erasable should be reasonable….. — typing to fast.
Interesting. I don’t think the study itself is misleading. But yes, people use it in misleading ways. Hill, for example, might have started of “assuming Kate is low-risk..etc”
But then people also use it in misleading ways the other way round. I find a lot of people touting it in favour of hospital birth, failing to stratify primps and multips, and touting it as ‘safest for mother and babies’ without mentioning the very real increased risk in c-section.
I think that neither is a very careful interpretation, or gives due consideration to the many legitimate reasons that feed into this. I think we need to recognise that the data allow for more than one reasonable decision
No, the study is DELIBERATELY misleading. Instead of looking at whether homebirth as practiced in the UK is as safe as hospital birth as practiced in the UK, the authors looked at homebirth as it is practiced nowhere and then used the results to justify current UK homebirth practice.
More than that, it is supposed to mislead people like you, people who don’t actually read the study and the thousands of pages of supporting material, or aren’t qualified to understand it if they read it. The authors set out to trick you and they succeeded.
Dear Amy,
Thank you for your answer. I don’t know what you base your judgment on my qualifications and the extent of my reading on.
I disagree. The study should not look at the practice, because if you look at practice, you do not compare like with like. E.G. you end up with more higher risk-birth in the hospital group.
Instead the study should look at appropriate risk-stratification, in groups that can be compared.
If a low-risk multip woman wants best information on her prospects, she needs information on low-risk multips, not on ‘low-risk multips plus other people who aren’t low risk multips but chose to birth at home anyway’.
I am NOT discussing the “practice” of Home birth in UK – whatever you mean with that precisely. I am discussing what reasonable choices are for low-risk multips. For that question, this study is perfectly appropriate.
Thank you.
You can easily look at like vs. like if you compare homebirth as it is practiced with hospital birth as it is practiced.
The authors of the BirthPlace Study used a tactic beloved of Big Pharma. They compared the theoretical side effects of using medication with not using it instead of comparing the real world side effects; Big Pharma does that to hide side effects that happen to real people in the real world.
Don’t you agree that it’s wrong when Big Pharma manipulates data in that way? It’s just as wrong when homebirth advocates do it.
Ah, i found the original comment . I address Big Pharma above. I do wonder what you think an appropriate comparison would be. I don’t think all home-birhters versus all (? surely not? surely only those of comparable risk profiles?) is that useful. if it is all versus all, home-birth may do better on all accounts (though yes – I know the dutch OB vs midwife data – so maybe not). if it is comparable risk profiles, that would be difficult to set up (case control? in such numbers?) also, I am not sure it is informative. If I want to make an informed choice between A and B, I want to know the data of the people with the closest risk profile to me under options A and B – not people with a risk profile that may or may not be like me, under A and B.
Please can you expand on what you mean by ‘comparing birth systems’ and what you think more informative comparison would be, and why?
This study is useful in the UK for the women who meet the strict criteria and *who want to homebirth*. However it must NOT be used for women in the US as the situation is not comparable. It also should NOT be used by policy makers in the UK to try to convince more women to homebirth. Remember that the women in the Birthplace study were *self selected* and were likely substantially lower in risk than even the 10% of low risk women who could meet criteria. “Encouraging” women to homebirth will increase the risk level of the homebirthing pool and is unethical.
We have already covered USA vs UK – I don’t think the data can be transferred. I do think it means that it gives reason to think that home-birth can be a reasonable choice for some women in a birth-system that makes it safe and that birth-systems should strive to provide that choices.
I disagree that the policy-makers in the Uk can’t (gently) encourage home-birth for low-risk multips – or at least make it accessible (which it is not everywhere) based on this study. Home-birth is widely believed to be very unsafe for foetuses, which this study denies for the low-risk multips. Hospital-birth is widely believed to be very safe for mothers, and I think (as stated repeatedly) that that is only because the forceps/c-sec risks are not given any spotlight.
but – IN CAPS – EVERY WOMEN SHOULD CHOOSE AS SHE WISHES. NO PRESSURE.
You say “NO PRESSURE” should be applied but you think the government should apply “encouragement”. Why exactly should they “encourage” women into a choice they wouldn’t otherwise choose and where do you draw the line?
I think [roughly]that
1) they should make the option available, which it is not everywhere (I will say more above in response to Kitty)
and
2) they should present it as a reasonable choice (for the group we are discussing), which it often is not presented as.
– First, there is a perception that home-birth is a crazy choice anytime for anyone. that is false – as discussed at length here. for some groups it is at the very least reasonable.
. Second, many women do not even realise the option exists, it had never been mentioned and they had never thought of it. That is not informed choice or even adequate choice. – so that I think that that is what I mean by encouragement: presenting and providing the option. and with government, I mean NHS. not the actual government.]
3. I also think that data about fetal and maternal outcomes should be provided. Everyone always mentions fetal risks, not matter how small or ill-supported by the evidence. I don’t say that they should not be mentioned, they should. But the risks to the mother should also be presented, for a meaningful choice to be possible. And those risks are routinely omitted – even unknown as again the discussion on this blog has been good example of.
But as I have repeated over and over again, anyone should choose whatever they want. NO PRESSURE. and NO JUDGMENT
Does that help?
Homebirth is ALWAYS a gamble in the same way that not wearing your seatbelt is always a gamble. Most of the time nothing will go wrong. However, when someone goes wrong, someone will die.
If you wish to gamble with your child’s life, you have every right to do so. Just don’t tell us that you are not gambling.
Of course – birth is always a gamble. AND IN LOW-RISK MULTIPS, we have no data to show that the gamble offers worse odds at home than in hospital. But we have excellent evidence that the odds for the mother are worse in hospital in this group.
If you want to buy the same lottery ticket for your foetus at a much worse price to yourself (namely – more forceps, c-sec, etc) then do so. Be my guest. And of course if you fancy and epidural, it is even a great decision. But don’t tell people that they are fools if they buy the same lottery ticket at much lower cost.
[with all the qualifications I made elsewhere about reasons, pain, variation in desires, etc etc etc].
Why is it is so hard to acknowledge that there is a trade-off? that multiple choices are reasonable? That hospital offers some drawback too, that at least need too be weighed?
“So of course, and as you point out, some people (7% of those giving
birth at home) do so despite having some risk factors, meaning the study
is about women of lower risk than in fact give birth at home.”
Why do you think they left those women out of the study? What possible justification is there to ignore what actually happens at homebirth in favor of what might happen in a theoretically perfect world?
You need to understand that the Birthplace Study left those women out because that’s what was required to bolster existing government policy. Never mind that the study doesn’t reflect existing government policy. The authors refused to acknowledge the real result that homebirth increases the risk of perinatal death.
The BirthPlace Study is the equivalent of doing a study on whether refusing to use a seatbelt has the same death rate as using one and then restricting the study by removing anyone who had ever been in an auto accident in the past. There’s no justifiable reason to take those people out except to make the results look better than they really are.
WOW! calm down! You saying that risk stratification is not sensible?
Surely birth is ALL about risk stratification! we don’t lump the breeches with the CBAC’s and some normal births and then say “look, elective c-sec is best for EVERYONE’.
No, we stratisfy to give people the best risk-outcome estimate, and the best treatment and information based on that.
whether you have had a previous low-risk birth is an accessible piece of data, and a useful risk stratifier. Given the costs/risks of hospital [increase risk of c-sec/forceps – which everyone on this evidence based (?) site seems super-reluctant to acknowledge], it is worth knowing whether there are people from whom incurring that costs yields no measurable benefits.
Driving with a seatbelt incurs no costs/harms – planning a hospital birth does. THat is too often overlooked, and that is a problem. For many people that cost is worth it. For some, it is not clear that it is. Those people also deserve good information.
“WOW! calm down! You saying that risk stratification is not sensible?”
No, risk stratification is very sensible. So why not actually do it then? They have the outcome data for ALL of their homebirth women. Why not publish ALL the data in a stratified fashion just as you suggest? Why suppress the results of everyone except the “cream of the crop”?
First, they published some of it in appendixes, as ccprof discusses (I think) and Dr Amy refers to in another post.
Second, I don’t think that was the study question, which was about low-risk.
Third, I imagine it would be difficult to have sufficient data to generate significant result. only 3% of births in the Uk, most of those will be low-risk.
But really: ask the authors. My point has been about reasonable choices for low-risk multips.
I understand your point, but we already knew that OOH birth is safer for low-risk women who have already had a baby than for primiparas, or various other risk factors. This information from the study confirms it, but it isn’t some great revelation. Basically, I agree that low risk multips should have the choice and in the UK, they do. The major risk for any homebirth is the distance from the hospital and if the women are willing to take that on, good for them.
Great, thank you. Did you know that for those women (indeed for all women, but in this group they are more difficult to justify) hospital presented the additional risks I presented? Because my big worry is that so many people don’t know, realise or mention (and that has been the case on this blog, clearly, today – it has been difficult to get it acknowledged.
As has been stated before: I don’t consider medical interventions risks, and neither do many of the other people here. Those medical interventions carry risks, which are outlined so the patient has/should have informed consent. Sometimes, the information is not complete in an emergency situation, due to lack of time. I know its anecdotal, but every time a doctor wanted to do something while I was giving birth, he or she took the time to explain it and let me consent or not. Before going to the hospital to have my babies, I was well aware of the risks and benefits to epidurals, pitocin and Csections, thanks to my doctor.
“Driving with a seatbelt incurs no costs/harms”
Sure it does – it limits your movement, can be uncomfortable/restricting, and in the case of an accident it can cause bruising, lacerations, organ damage, broken bones or even, in the very rare case, death. It is still vastly better than driving without one. Just like being in the hospital may mean you are uncomfortable, restricted in movement, may have lacerations, etc, but, in my opinion, is still vastly better than not having all of the resources and help you could possibly need right where you are – no transfer necessary.
In addition to the fact that it absolutely incurs “costs,” as in, they cost money. Cars could be cheaper without all those darn safety features, including seat belts.
So you damn straight seatbelts come with a cost. That Kingma could make that claim shows a serious lack of thought.
Seatbelts and airbags definitely add to the price of a car. Child safety seats can be quite pricey. And if you’re in an accident, even a minor one that probably didn’t require those fancy safety gadgets, you need to pay a professional to “reset” your airbags and buy a new carseat again!
Guess what. I still like my airbags.
Totally off topic, but has anyone seen the finale of Archer Vice? There is this amazing moment when Lana goes into labor and Archer immediately asks “What’s your bishop score??!” when people are confused he says “I didn’t tell you guys; I got certified as a doula! It wasn’t that hard!”
I think that having Sterling Archer as my doula while Pam makes me Green Russians (and drinks them herself) while regaling me with stories of life in the underground Fight Club scene is probably the only way I would even contemplate having a VBAC.
Archer seems more knowledgeable than many of the CPMs we’ve encountered.
Does it still count as a homebirth when your home is a castle?
Meanwhile , back on Planet Crazy , MIlli HIll thinks the 3rd in line to the throne is going to be born at home with just a mob of midwives there ? Yeah right !
4th in line. Don’t forget Prince George. Charles, William, George, new baby. An heir and a spare.
I had an amazing first birth. I was on a high for days. It was probably the most euphoric I’ve ever been. I had an emergency c-section at the hospital. Everyone should have an emergency c-section just like me!!!!
Every birth should include Life Flight, just like mine did!
Lol this is hilarious, Amy Tuteur, you’re hilarious. What kind of pathetic person writes this about a lovely birth advocate? Well done for publicising Milli though, she’s doing great. Its kinda sad that you Amy, have to sit behind a computer screen and pretty much cyber bully people. Did you really have to write horrid stuff about a well known, popular person like Milli just to get some publicity for yourself? Its amusing how you, Amy, have to stoop to an all time low just to have a little bit of fun for yourself. As far as I’m aware Amy you’re not even practising in the medical field are you. Haha.
So Mili is an angel though she’s trying to convince a woman she’s never met to have a homebirth, because Mili thinks they’re the bee’s knees? Really I’m happy for Kate and William but their birthing choices shouldn’t be up for public discussion.
Milli Hill shouldnt be up for public discussion.
But she wrote an article, Dr. Amy is merely critiquing it. Do you understand when most of us hear that our friends/acquaintances/personalities are pregnant we don’t spend time wondering how they’re going to birth and/or publically comment on how they should birth? It’s more like awesome, they’re going to have a new family member.
I don’t know if this satire or not, but assuming you are serious, then the answer is that if Mill Hill doesn’t want to be “up for public discussion” then she should shut her pie hole and not make public proclamations.
She is the one who WENT PUBLIC.
Why? Because she kept her opinion private and refrained from begging a woman she knows next to nothing about to possibly harm her baby because of Milly’s agenda?
I win, stick with your original screen name and stop trying to make it look like someone agrees with you.
Then she should stop writing articles in which presumes to try to sway the medical choices of one of the most famous women in the world.
Notice how “publishing” and “public” have the same linguistic root? There’s a reason for that. You don’t get to deliberate make something public, and demand the public not discuss it. Publishing articles full of biased opinions is exactly the kind of thing that gets you discussed by the public.
“Cyberbullying.”
Writing an article in response to another article is cyberbullying? Um, no, it isn’t.
Aaaand the Most Stupid Fanatical Poster Award goes to…
… You win.
Another own-goal !
It’s hard to “win” when you’re kicking for the wrong side…
Oh yeah. I can tell you’re soooooooo amused. It’s just hilarious! It’s so funny! You’re totally convincing me. Tell me more about how funny.
Oh! Or tell me about how popular and well-liked Milli is! Does her article still have two comments, or is it all the way up to three, now? Go count the responses, and then count the responses here, and then evaluate the relative popularity and likability of Milli and Amy.
I’d never heard of Amy before today, yet Milli is way more ‘on the up’ than Amy. Amy clearly needs a psychiatrist.
That’s what I so admire about those of you who don’t like Dr T. Never seen or heard of her before, but you know she’s crazy!
With that kind of thorough review, intense and thoughtful consideration, and powerful rhetorical skills, those of us who do think live babies are more important than mum’s ‘experience’ are well and truly put in our place.
who’s Milli Hill?
She’s that blithering idiot who Dr Amy talked about last summer.
(that was going to be my response. Well, I HAVE heard of Milli Hill before, but because Dr Amy told us about her lunacy once before)
Well, there’s only really one direction when you’re at the bottom.
Sweetie, “popularity” is not determined by who you, personally, know. It’s determined by who a lot of people know. And given the number of people talking on Amy’s blog, versus the number of people on Milli’s little opinion piece, a hell of a lot more people know and trust Amy. Probably because she has actual medical credentials.
As for the psychiatrist comment, it just shows that you are par for the course with home birthers. You think you have the expertise to make medical judgments despite having no proper knowledge or training.
“[H]ome birth needs an ambassador, and who better than a style icon adored by the world’s press?”
Um….I sincerely hope that this is not the criteria by which one decides whether or not a patient is low-risk and thus a “good” candidate for a home birth. This nut job doesn’t know the first thing about the Duchess of Cambridge’s medical history, so it’s completely irresponsible to suggest that she should try to have her baby at home. (I mean, it is completely irresponsible anyway, but EVEN MORE SO knowing nothing about the patient.)
But is anyone surprised? Not me…
So…is she arguing that since homebirth isn’t risky, and homebirthers are not “brave”, then actually women who give birth in hospitals are the brave ones? And HBers are a bunch of chickens? Really empowerin.
Just because someone is famous, it does _not_ mean that that person must become a spokesperson for (and/or embrace whole-heartedly) quack science.
Oh wait, I suppose that Jenny McCarthy never got that message.
Have you read this?
http://wholewoman.hubgarden.com/vicarious-birth-trauma-when-your-friend-is-induced/
Reason 97 why every woman should have a natural childbirth away from the hospital:
You might traumatize your friends in the NCB movement and hit them with an invalidation stick if you’re happy with your medicalised birth.
I like the picture of the basket for going to hell.
I particularly liked this bit:
“No matter how much good advice you give, or how many studies you share to debunk the recommendations of an over zealous care provider, she will follow her own plan.”
Sure, be offended that the person listened to her OB instead of to you. Makes sense.
GET OVER IT!!
Oh my gosh – that article was completely disturbing. I am equally amused and appalled to realize that my son’s happily medicated birth – with an epidural by choice – may have invalidated the feelings of the all-natural crowd. What on earth does someone else’s birth have to do with them?
Now, if I knew my friend was attempting a home birth and had already been in labor over a day, or had glaring risk factors, I might be a bit anxious on her behalf…
Good point!
Holy GOD. This article is a how-to for bad boundaries and co-dependency. Consistent with the cult like mentality of NCB. YUCK.
I have this helpful (and all natural) remedy I would like to sugest to anyone who nods long in agreement with that piece.
Go and sit somewhere quiet. Take some deep cleansing breaths.
Repeat the following mantra, letting it soak into your consciousness.
“Not everything is about me. Not every feeling is valid. Emotional reactions should be examined and I should work on overcoming them if they are unhelpful or disproportionate. It is not up to other people to validate my feelings and experiences.”
Then for goodness sake, go and play with your kids, go and do something useful and stop obsessing about your friends’ obstetric histories.
I can hear my grandmother:
“So if all your friends went and jumped off a bridge…”
She left out the most important bit of advice:
GET OVER YOURSELF!!
Dear Milli Hill,
My first birth did indeed turn into an “agonising emergency bloodbath.” Since I was fortunate enough to be in a hospital, it didn’t end up resulting in my death. Whenever I bring up the fact that rare complications can and do present at any time during even the most “textbook” of childbirths, I am told to stop “fear mongering” by people like you. And before you make any assumptions, I did not have any anesthesia at all, not even a fucking heplock, and I delivered with CNMs. I would have given my right arm for pain relief once the manual examination of my uterus started – it was every bit as bad as actually giving birth, with the added bonus of being aware that I was in serious trouble. When birth goes well, a monkey can catch the baby. When it goes sideways, you had better be somewhere where there are enough people and resources to save you and your baby’s life.
Sincerely,
A Fed-Up Mother of Two
Ha! Mine was an emergency blood-bath too! Though by the time the PPH happened, it didn’t really hurt. Maybe it did, but I was barely conscious, and didn’t feel it?
Manual examination of the uterus? Is that when the doc goes in elbow deep and feels around inside the uterus for leftover bits?
Yup, that’s what it is, Cobalt. I had just delivered the placenta, and I felt everything until I passed out. I came to as they said they were starting pain medication. The only memory I have after that is of watching the lights as they wheeled me to the OR.
I didn’t know the technical term. With this last baby, after the placenta finally let go and came out, which took too much time, lots of pushing on my belly, and some pitocin in the IV, it was like delivering a rock. A big rock. Then the OB looks the placenta over, looks at me and says she has to go in and get the rest out now or I would end up needing surgery to remove it later, which involves a separate surgical recovery. Cue the up to the elbow treatment. That hurt way more than the baby’s exit did.
Question for the medical professionals on here – why is it necessary to remove the placenta by hand rather than with a curette or suction? I had a foley catheter induction and just that was quite painful. Having someone “elbow deep” sounds utterly horrific. 🙁
It is utterly horrific (it happened to me too – fortunately, I had an epidural, and some of it was still working).
Not a doctor, but here are the points I notice:
1. Until the placenta is removed, the uterus cannot effectively contract to clamp down the blood vessels that used to run into the placenta, which means that suction can vacuum a whole lot of blood out of the patient in a hurry.
2. Another reason they stick their hands up there is to check that no pieces remain. Suction devices cannot report back on this point.
Even a small piece of the amniotic membranes which are not always completely expelled with the placenta can cause a severe hemorrhage because the uterus can’t contract properly.
As to the use of suction or curettage, the danger of perforation is too great just after birth.
In my case, they needed to determine the cause of the heavy bleeding. Often, it is due to retained chunks of the placenta. In my case, it was because my cervix was torn. I think they have to rely on feel in these cases.
It was utterly horrific. We almost didn’t have a second child because of it. Thanks to a freshly dosed epidural when I was complete, I felt absolutely no pain when our second child was born. In that regard, it was a “healing birth.”
At term, the placenta is huge and “meat like” in consistancy. You could never suck it up with a tube and scraping it out bit by bit with a curette would take hours. Contrast this with how the placenta is during first trimester when you CAN use suction or a curette: small size and soft tissue.
So sorry you’re part of the club on this one. I hope you had some pain medication.
I didn’t have an epidural, so I got the full experience. Thankfully it was fairly quick, 3 handfuls of what turned out to be clots and no further issues. It HURT.
The real kicker is that I ended up having urgent surgery a week later anyway for a strangulated hernia. I had general anesthesia for that, and highly recommend it. In that experience I found my own personal ’10’ on the pain scale.
I had a half dose of morphine during my manual exam. Still excruciating and creepy, felt hand touching my fundus from the inside and started involuntary pushing. I was worried someone was going to punch a hole in my uterus on accident. I can’t imagine undergoing that with zero analgesia.
When OBs emerged historically, they were added to the births of women who could afford them. Midwives were not subtracted, but, women who could afford them had both. I am 100% positive that Kate will have an OB in attendance @ her birth. She can certainly afford the priveledge.
She had it for the last delivery and they even gave the OB some special honor for it. They will not leave that up to chance.
Oh no she had THREE OB according to recent reporting. Apparently one in the room and two outside on standby with one being an OB that “specializes in high risk” (=? MFM). Now some might say that was because it was the birth of the heir to the British monarchy but it is also possible that there were risk factors that were never made public. Anyway, I hope it all goes smoothly and I think the woman is under enough various pressures that she doesn’t need extra from NCB zealots or homebirth advocates.
I would be interested to know just home much her “style icon” status goes when it comes to personal health decisions anyway. Are there wen trying to RepliKate her birth choices the way they try to copy her clothes? Maybe appealng to kate is a poor strategy for Milli. For example, was there a rush to birth in the Lindo wing after July of last year? Have her OBs been besieged with requests? Are other women who thought they’d wait a couple years now trying for closer child spacing?
Dang. I did not know that. I would love to know everything just because I am curious but I realize it is not my business. It would be interesting to know if people did try to follow in her footsteps health wise. I also hope it works out for her too.
Fast forward a few months…
Dear Kate,
I am so sorry your baby didn’t make it. Some babies are not meant to live. Stay strong, mama!
Or,
Dear Kate,
I am so sorry your baby didn’t make it. But who knows, he/she might have died in hospital, too. Did you have a controlled pushing? Did you surrender control? See? It’s all your fault! Now please kindly crawl under your rock and don’t scare future mamas away with your negativity.
Here. That’s more like it.
Not that I am wishing it on Kate. But hey, I would have never wished it to Danielle Yeager either.
“For a sea change in attitudes, home birth needs an ambassador, and who better than a style icon adored by the world’s press?”
Gosh, Milli. You’re right. Who better? I mean, you’re definitely not going to get a doctor to start that “sea change in attitudes.” And you’re not going to get a statistician to do it, either.
So when you can’t get any people who are even remotely qualified in medicine to promote your cause, a “style icon” absolutely is the best choice to guide women’s medical decisions.
How insensitive. Kate is apparently very ill with hyperemsis. The pregnancy is not even 12 weeks. There’s a good chance this baby won’t make it. I think the least of Kate’s worries is the exact mode in which she gives birth right now!
HG is not associated with an increased risk of miscarriage, in fact an HG diagnosis may be associated with a reduced risk of miscarriage up to 20 weeks.
Women with HG may suffer so much that they opt to end the pregnancy, or they may very rarely suffer dehydration or malnutrition related organ damage and be advised to end the pregnancy for medical reasons.
There is no reason why a woman with HG receiving expert medical attention should necessarily suffer a poor foetal outcome, although her baby may be small for gestational age (related to poor maternal weight gain in pregnancy) and the risk of a prematurity is higher.
It is a horrible, miserable, awful condition, but just for the mum. The babies are usually quite happy.
http://www.helpher.org
As one might expect, there’s a relationship between HG that persists into or recurs during the later part of the pregnancy and low birth weight. Weirdly, the relationship may not work in the obvious way: A bad or leaky placenta is causing both conditions, rather than malnutrition leading to low birth weight.
Of course, that doesn’t stop “helpful” aunts and grandmothers from pointing out that the baby would be bigger if only you’d eaten more, dear.
Thanks for the clarification! I was thinking more about the possibility of abortion, plus the fact that this may still be a very early pregnancy with miscarriage risk. Though I doubt that she would ever be able to have an abortion, no matter how sick she is, which is another sort of creepy thought.
Having only seen televised deliveries before, I actually had no idea how bloody an enterprise birth would be. I knew there would be blood, but I didn’t expect the place to look like an abattoir.
Read the linked article to see if there was any care for Kate’s (or baby’s safety). Aside from quoting the Birthplace study, the author concluded that Kate must have had a brilliant first labour and birth because she looked happy when she emerged from hospital. Thus, we can safely assume that she had a complication-free vaginal birth and that she’s a good candidate for homebirth.
The mind boggles. Here’s what we know about George’s birth.
1) Kate enters hospital pregnant.
2) ???
3) Kate emerges from hospital no longer pregnant and with a baby in hand.
Given that we know nothing about what happened when George was born, I think anyone who isn’t Kate or her doctors should take a giant step back and stfu. Ugh.
She also has a team of people making sure she looks nice for the bazillion cameras she knows will be waiting for her when steps outside the hospital. I’d look a lot happier too, if I had people whose job it was to make me look nice.
I am glad that her dress showed her post-birth belly after having Prince George, because it seems to have helped other people feel good about their bodies.
I assume that there was a hair and makeup team right behind the door that Kate and Wills stood in front of for that press conference. And the real-world equivalent of Effie Trinket who had the whole thing scheduled out to the second, including (if needed) exactly when to give the Duchess painkillers so that she’d be high but still coherent for the correct five minutes.
I also appreciate that she had a visible post-partum belly. I don’t grudge her the hair and makeup team in the least, and it was really nice of her to have the belly in common with those of us who checked out of the hospital, post-partum, in our pajamas.
I know, lol! Plus, she might not have been “happy” when she left the hospital. Unfortunately for her (and truth be told, she’s an amazing person for handling things the way she does considering she’s a commoner who had no reason to believe her life would turn out the way it did), she has to be “on” all the time. Her entire life is acting.
I mean, of course I’m sure she’s projecting the real Kate. But it’s an always “on” Kate. For all we know, she might have been screaming inside while those pics were being taken.
Eh, she signed up for it. Her contractual responsibilies are to smile and look pretty and breed. She’s accomplishing that pretty well, but I don’t think that puts her very high up on the list of amazing people.
I don’t mean amazing like “ooooh she’s super special compared to everyone else.” I think a lot of people are amazing for lots of different reasons. I just really meant she handles the stress of it well. Even if you sign up for something, doesn’t mean it’s easy to handle day in and day out. And that applies to everyone. We all have our stresses. A lot of people just happen to live their stresses publicly.
I feel like it’s really important to remember that, to the extent that Kate Middleton has contractual obligations, they are not obligations to the general public.
It’s nice for the royal family that she looks pretty, and that she’s so willing to be a public persona. She’s amazing for them, PR-wise. However, the path she’s chosen (which I’m going to summarize as “Will Wear Dresses For Charity”) is far from the only path open to her, and she could choose to change it. There’s the Camilla Parker-Bowles route, the Princess Anne route, and the Zara Phillips route all hanging around.
Which brings us to the point about having children. Again, it’s great for the royal family, PR-wise, but it’s *not* actually required. In 1818, the royal family contained NO legitimate grandchildren, and the monarch was expected to actually govern. The current queen has 8 legitimate grandchildren and at least three great-grandchildren, and her government role is largely ceremonial. If all the British royalty you know about were to drop dead tomorrow, experts have identified a psychologist in Germany who would be asked to come to England and wear fancy hats for the good of the Commonwealth.
It’s interesting to me that there was a two-year gap between William and Kate’s wedding and their first baby. That suggests either fertility problems, or some kind of thought and planning. If fertility problems couldn’t be solved, or the couple ran out of patience with treatments, a divorce would make the royal family look absolutely awful (especially as Kate is so popular). They might prefer to keep her around for PR.
Or, crazy to consider, they might be human beings who like Kate MIddleton (she is awfully likeable), and are glad to have her in the family regardless.
“If all the British royalty you know about were to drop dead tomorrow, experts have identified a psychologist in Germany who would be asked to come to England and wear fancy hats for the good of the Commonwealth.”
King Ralph!! I enjoyed that movie as a child.
If the royal family doesn’t remain popular, and draw in tourist dollars, they risk losing huge chunks of their vast stores of tax-free wealth.
There are SO many complications which, if managed promptly and carefully, can still result in a happy healthy mom and baby a couple days later.
Sir Marcus Setchell delivered Prince George, and was knighted in the 2014 New Years Honours List.
Perhaps he did more than just catch a baby after a natural, straightforward labour. Who knows.
Personally, the idea of pacing the halls of Kensington Palace while in labour with lots of staff looking on would be less appealing than labouring in private in a hospital room with just my medical team and husband.
I’m not sure Milli has considered how different a royal palace is from an average home, and how different a royal HB would be from an average one.
Just so you know, at the court of the Bourbon kings in France, all the courtiers attended the birth of a potential heir. True. Marie Antoinette quite famously avoided this lovely custom by sneaking away to her own bed (she had short labors).
I believe that someone official always had to attend births of the nobility to determine, if necessary, who died first.
Gasp! You’re right! I always thought they were trying to avoid someone substituting a live non-royal infant for a stillborn royal infant.
That too, but in the case where both parents are titled, and dowry/estate is in the cards, it mattered.
Yes, this was certainly true for the potential heir to the throne, and the practice was only discontinued after the birth of the current queen and her sister, at whose births the home secretary attended, although he apparently waited outside the door and was not actually in the room.
According to Madame Campan (Marie Antionette’s First Chambermaid), the Queen’s first birth followed “etiquette” and “etiquette allow[ed] all persons indiscriminately to enter at the moment of the delivery of a queen […] It was impossible to move about the chamber, which was filled with so motley a crowd that one might have fancied himself in some place of public amusement. Two chimney-sweeps climbed upon the furniture for a better sight of the Queen […] This cruel custom was abolished afterwards. The Princes of the family, the Princes of the blood, the Chancellor, and the ministers are surely sufficient to attest the legitimacy of a prince.”
You get KNIGHTED for delivering a baby? Imagine how many dames and knights there must be in this group!
There aren’t THAT many in the direct line of succession, and they tend not to reproduce super young, and there is also the tendency not to doctor swap, so… not that many, would be my guess. (from this particular source, anyway)
Oh, hey, here’s an idea: MAYBE IT’S NONE OF OUR FUCKING BUSINESS HOW GEORGE GOT HERE. And maybe it’s nobody’s business how my kid got here, either.
At least it’s obvious what Milli Hill is promoting. In her own words:
“fairytale birth”
Yes replying to myself, just to qualify.
By fairytale, I mean the happy, Disney version.
I grew up on Anderson and Brothers Grimm. Births weren’t mentioned. Neither were birth mothers: they had usually died in the process.
Fairytale birth. Note that most fairytales involve an orphan or at least a stepmother.
And what if Kate had a HB and something went terribly wrong? That would send a great message to all the NCB’ers.
Kate would be attended by at least two university trained midwives who have hospital privileges and can administer medication. There would be an ambulance standing by and traffic could be stopped and roads cleared if the ambulance had to be used. Not at all like an American home birth scenario. I am getting sick of home birth advocates thinking everyone should have a home birth and their opinion why.
Of course it would be different there… at least they’ve got medically trained midwives. But it sounds like Milli wants Kate to do a regular HB, not a “royal” HB. Of course that family would NEVER let her have a baby at her home in the country with just one NHS midwife around. It’s a ridiculous comment.
And I’m so offended by Milli’s statement that HB is so awesome that it’s practically a religious experience. Thank you SO MUCH for talking for the rest of us, Milli. I, for one, have absolutely no desire to ever experience labor of any sort. Ever. EVER. Nor do I want my vagina stitched up after tearing. It would be a nightmare for me. It would be the antithesis of an evangelical experience. I hate that high and mighty attitude.
Yeah, I didn’t find laboring without the benefit of pain medication to be anything short of a nightmare. When I had my second child and I didn’t even realize I was in labor (thought I was having Braxton Hicks, that is the night and day difference between first and second labors sometimes), I arrived at the hospital after PROM only to be told I was dilated to 9 and was rushed into a room and THAT was no religious experience either. I much prefer the experiences I have now, for example I took my seven month old to his first “infant story time”. Seeing his face when everyone sang his name and his reaction to the bubbles and blocks and other babies was not religious but it was joyous. I would take that any day over birthing in a plastic pool in my living room
Yes, lets ask Milli HIll what she thinks about the lovely home birth of Princess Charlotte’s son in 1817…the Princess was 21 years old and the heir to the British throne. She was in labor for 2 days with a 9 pound baby boy. The midwife(Sir Richard Croft) who delivered her son let her push for 24 hours (he was afraid to use forceps as there was a chance the child could be damaged/killed in a high forceps delivery)
He son was stillborn and Charlotte died soon after of Post Postpartum Hemorrhage and shock.
Sir Richard Croft, her midwife or accoucheur, committed suicide several months later.
Well now you’re just fear mongering 😉
My OB prof always referred to this case as the Triple Obstetrical Tragedy.
LOL! I just googled that phrase and it turns out that is what everyone else calls it too! Silly me!
A cascade of non-intervention with a 300% mortality. Fetal monitoring and a timely c-section could have altered history.
There are so many points in that story where small amounts of modern tech would have made a huge difference. Induction at term (Charlotte was believed to be about two weeks overdue). Fetal monitoring and a timely c-section. Blood transfusions.
Question for Those More Educated Than I: A childhood friend, K, has been posting on Facebook this week about how her birth was ruined by the “cascade of hospital interventions.” Long story short: K was 38 weeks pregnant and planning a homebirth. She had severe epigastric pain and was not in labor. Husband convinced her to go to the hospital rather than calling the homebirth midwife. Hospital found that K had HELLP and induced labor. After a few hours of pitocin, OB came in to break her water, and a cord prolapse occured, resulting in a STAT c/section. Now she’s convinced that if she had called the midwife and “naturally induced” labor, nothing bad would have happened. Thoughts? Wouldn’t the cord prolapse still have occured unless she happened to deliver with baby still in the caul (not to mention the ramifications of untreated HELLP syndrome)?
The HELLP would have been the problem. If the homebirth midwife didn’t recognize the HELLP, then your friend could have died, along wit the baby. The cord shouldn’t prolapse if the sac is completely intact, because its held in by the sac. In prolapse, it falls out when the sac is ruptured. And how would she “naturally induce” labor? By giving various herbs, some of which can be harmful, or nipple stimulation or sex? None of those things are shown to induce labor if it wasn’t already starting on its own, plus depending on the herbs, the treatment could add complications of its own.
If there had been no AROM and the induction was not progressing without it they would have gone to CS anyway.
HELLP requires close monitoring in labour.
Not a HB candidate.
Cascade of non-intervention, more like. A doctor or real midwife would have probably caught the problem before it turned into HELLP.
She could have died of untreated HELLP syndrome. Easily.
Since cord prolapse is generally unpredictable, I would think the ‘safest’ time for it would be during an AROM, since it would be known immediately by the OB and you would already be at L&D.
In any other country she’d have been risked out of a homebirth and sent to the hospital anyway.
It’s possible the cord prolapse wouldn’t have happened. It’s also possible it would have happened anyway in an environment where an emergency c-section wouldn’t have been possible. Or something else could have happened. There’s no way to be sure.
Compare: “My vacation was ruined by a cascade of medical interventions. I was driving down the highway on my way to the beach when another car rear ended mine. The paramedics convinced me to go to the hospital where the doctors drew some blood and did some x-rays. Well, the chest x-ray showed I didn’t have broken ribs, but the doctor said I had pneumonia! I’ve been fighting off a bad cold for 3 weeks, but it was getting better. Now instead of going to the beach I’m stuck at home with a bottle of horse pill sized antibiotics and an inhaler, drinking hot tea. I think I would have been better off skipping the hospital and just going to the beach. I’m sure the fresh air and relaxation would have helped me kick that cold.”
Said it before, say it again…
Birth was recognized 3000 years ago as being so painful that the pain was attributed to punishment from God.
No TV documentaries needed.
Something, something, African women, something, something.
Because what a life/death decision-making process really needs a style icon to act as an ambassador. Hmmm-kayy.
Actually I feel for any royal type person. Such a personal thing made so public. Ugh.
This seems like a rerun. Haven’t you posted this recently?
Hill’s piece is dated yesterday.
Dr Amy wrote about another piece by Milli Hill back in July this year.
http://www.skepticalob.com/2014/07/milli-hill-and-cathy-warwick-on-the-dangers-of-childbirth-lying-or-ignorant.html
I thought the part about picking your nose sounded familiar.
Birth is scary!! I learned that from tv. After seeing a fictional birth on television, I made sure to ask for an epidural as soon as I walked into the hospital, because I knew my baby would be born in 27 minutes or less. No commercials after all. After I was pacified and drugged up, I was a little less scared, but I still needed a doctor to help get the baby out. I’ve seen that no one on tv goes wo/a birth attendant, so I made sure to have at least one.
(not really, it’s pretty clear from data collected from the WHO, CDC and looking at old graveyards, that birth is a huge killer of women and babies wo/appropriate medical care.)
Homebirth advocates like to claim that they are “empowered” by
homebirth, but how empowered can you be if you are constantly seeking
validation by having others mirror your choices back to you.
Thought I had on reading this: I agree and also wonder how doing something that isn’t difficult is empowering. There are two mutually contradictory narratives running through the homebirth movement’s arguments:
1. Birth is easy and there’s no need to get excited about it.
2. Home birth is empowering.
But if pregnancy and birth are no big deal, how is it empowering to do them without assistance? I got dressed without assistance this morning. It wasn’t empowering it was just routine. If pregnancy is so simple and labor doesn’t hurt if you’re not afraid of it, what’s the big deal with a home birth? How is it empowering to do something that should be easy?
They confuse “empowering” with “feeling physically powerful.” If they are properly physically powerful, (and every woman is! Trust birth!), they can have a successful homebirth.
We need to start asking them what power do they have now that they didn’t have before. Of course, some will claim that they are now empowered (when they actually mean physically powerful, strong) but if they gave birth in the first place, they were already strong. Some will probably say they are “empowered as women” but that doesn’t really mean anything. Again, what can they do now that they couldn’t before they gave birth? The only thing is: be a parent.
I can understand doing something difficult and feeling empowered by it. Marathons have been mentioned on this blog before, and when I did my first one, I absolutely felt empowered – I challenged myself to do something that would be difficult for me, and I did it. It definitely gives me a sense of “I did that, so I can deal with *current difficult thing I’m dealing with*,” and it makes me feel more calm and capable in the moment. The difference being, as we’ve noted, that a marathon is a lot more predictable than childbirth, a lot safer, and even so, we have medical people on-hand to deal with any emergencies that arise. Homebirth seems like it would be more like… doing a motorcycle race naked, with no corner workers or EMT staff on hand. With your baby strapped to your back. If you survive, is that empowerment, or ‘Jesus, _why_?’
But empowerment means “gaining power.” Feeling powerful and like you can conquer anything is not the same thing.
Hm. For me, confidence is a great part of my power, because early on in life, I lacked confidence, and it severely impacted my performance in many aspects of life. Having a reasonable amount of confidence, partially fed by various personal stretch goals that I have successfully met, gives me the power to assert myself and make a difference in my own lives and in others’. And in setting and meeting these goals, I have increased my knowledge, various skill-sets, and physical fitness, all of which I have also found empowering.
I suppose, to me, it’s the difference between setting a high goal and working to meet it, developing skills and strengths as well as gaining confidence, versus making a dangerous situation more dangerous, lucking your way out of it, and feeling empowered by that. Because you’ve gained confidence without also gaining skills and knowledge, which makes it false confidence.
I see what you mean. And we seem to agree that one can’t compare birth to a marathon in terms of empowerment.
I love the whole “I’m a birth warrior!” when regardless of how its done, every pregnant woman gives birth. But other women aren’t empowered by giving birth, only homebirthers.
But the thing with a marathon is that *most* of the difficulty is in the training. There is no training in birth. The empowerment comes from developing strength and perseverance, not from tolerating pain for no reason, and definitely not from putting yourself in needless danger (thus training properly and being properly hydrated, and knowing to quit if conditions are not adequate).
Actually, the natural childbirth movement says you CAN train for birth, by doing the right exercises, eating the right foods during pregnancy, taking the right herbs, reading the right books, doing your Spinning Babies to ensure the baby is positioned correctly, and practicing your breathing techniques to endure pain.
There’s a grain of truth to this, but just a grain, and a large percentage of the things that can go wrong during birth are simply not modifiable.
Right, I think the NCB movement sees them at similar even though they are really not.
“a large percentage of the things that can go wrong during birth are simply not modifiable.”
Exactly right…I learned this in my third trimester, when despite being a healthy 30-something who regularly exercised and ate well, pregnancy complications landed me on 10+ weeks of bed rest. I had done everything “correctly,” and it didn’t matter.
Through this experience, I’ve learned to keep my distance from people who claim to be in control of their pregnancy health and/or L&D…the ones I’ve met tend to remain pretty self-righteous as parents. Yes, there are no doubt things you can do to remain as healthy as possible…but there are also a LOT of pregnancy unknowns that are beyond our control. To assume that we can control it with just simple lifestyle actions strikes me as a combination of both arrogant and ignorant.
I guess I’m just nitpicking the definition of “empowerment” to a very narrow one. I see what you mean: with training, a person could empower herself to run a marathon. However, since there’s no equivalent for birth (except for what Young CC Prof says below), no power is actually gained.
Exactly, that is what I mean.
And every now and then someone who seemed perfectly healthy drops dead of a previously unknown cardiac issue while running a marathon. And marathon organizers tend to have medics on site, just in case, and there’s always someone who ends up in the medics tent.
And when things go wrong at marathons, the people in charge are called upon to account for it.
Empowerment is manifested in the ability to make choices, not in the choices one makes.