Homebirth is a selfish, unsustainable use of resources

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Homebirth advocates, help me out here.

I’m having a problem understanding your math. It’s just arithmetic, so it really shouldn’t be so hard, but I can’t figure it out.

It s widely claimed that there is a midwife shortage in the UK. There aren’t enough midwives to safely care for the women giving birth in hospitals. That’s certainly how the Royal College of Midwives (RCM) rationalizes any and all poor care leading to the preventable deaths of mothers and babies.

Here’s where the arithmetic comes in:

1 midwife in the hospital can take care of multiple laboring women (let’s say 3 for arguments sake, though it is probably more)

but 1 laboring woman at home is supposed to be attended by 2 midwives

If I’m doing the addition correctly that means that 2 midwives can care for 6 women in the hospital, but only 1 woman at home … AND midwives are in short supply.

So, isn’t homebirth a selfish, unsustainable use of scarce resources?

Doesn’t every midwife who heads out to marinate in her own delicious autonomy at homebirth deprive 3 women of hospital based midwifery care?

And how can a selfish, unsustainable use of scarce resources possibly be cost effective?

It can’t, can it? And all the hopping up and down by the RCM and NICE claiming that homebirth saves money is a blatant falsehood since it doesn’t take into account the salaries of all the extra midwives who would have to be hired to provide homebirth services, right?

Let’s put it another way:

If it takes 6 midwives to properly care for 18 laboring women in the hospital, but there are only 5 midwives available, how can it possibly be cost effective, sustainable, or even remotely safe to send 2 of those 5 midwives to a homebirth, leaving just 3 midwives to care fo 18 patients?

The RCM and NICE are like Marie Antoinette who, when told that poor people had no bread, supposedly declared, “Let them eat cake!” Only in their case, when confronted with the fact that a woman often can’t get 1 midwife to care for her in the hospital (whose labor wards are routinely refusing to accept patients when understaffed), declare that she should have stayed home so 2 midwives would come to her.

In a system like the UK, homebirth is selfish, usustainable, saves no money, and compromises the care of everyone except the woman who has a fully staffed homebirth. The only people who appear to benefit from this faulty arithmetic are midwives. Who would have guessed?

  • holliday83

    I’ve had both my babies at home and planning my next birth at home due in 2 weeks. How can u judge someone’s reasons for choosing to have their babies at home? I’m petrified of hospitals and this is the reason I chose to have my babies at home. I am fortunate enough that all my labour’s were only 3-4hours. So didn’t keep the midwifes to long, on my second home birth the second midwife didn’t make it in time as my baby came to quick. All went well and we didn’t need any other services. Kristina hit the nail on the head, home births are cared for by community midwifes and doesn’t affect the staffing in hospital. You are always made aware that they can only care for so many labouring woman at home on a first come first serve basis so if someone else got I. There before u, u need to go into hospital anyway. Please make sure of your facts before calling ladies including myself selfish when you’ve never spoke to one of us and have your facts all wrong! I love having my babies at home and would not change it for the opinion of someone else.

    • Dr Kitty

      Best of luck with your Homebirth. Let us know how it went.

      Dr Tuteur is correct. There is a shortage of midwives in the UK and home births are not an efficient use of midwifery time, compared to a shift system on a labour ward.
      UK midwives rotate through labour ward and community midwifery, in order to ensure everyone’s skills are up to date, nobody is allowed to work only in the community.
      There is a finite pool of midwives- if more are devoted to home births, there will be fewer available on Labour Ward. Maternity services are commissioned as a block, it isn’t as if the budgets are separate, it is a pool, more money and resources spent on one means fewer resources spent on the other.

  • Kristina

    I am in the UK, from what I have seen, its the Community midwives that attend the homebirths, not the hospital ones. Both are equally trained (you have a bachelor of science degree in midwifery). However, having a birth at home has no effect on the midwives working in the hospitals as they dont attend them therefore your logic is null and void? Its the community midwives who are on call that cover homebirths and they run a rota that is 24/7 and if needs be can call a community midwife from a neighbouring area to be second in attendance at a home birth. While this may not be true of every trust in the UK (I dont know it equally may be). That is certainly the case in all trusts within my county. Midwives working in the hospital simply arent sent out to attend homebirths. Please get your facts straight.

    • Mer

      If there is a shortage of midwives, then the community pool of midwives is a drain on the total number of midwives available. If there weren’t any midwives attending home births, they would all be at the hospitals, thereby reducing the shortage of midwives there. If there are midwives doing home births that means that there are fewer doing hospital births.

  • Rob C

    I find this entire article a little offensive to midwifery and to both midwives and women.

    Who exactly is selfish? Is it the midwives (independent or otherwise) you say are being selfish, or is it the woman who wants to birth at home that is selfish? Financial constraints have no bearing on the rights of women to birth at home and it’s not right to call a midwife selfish if she chooses to empower women and help them to realise their birth plan.

    There is a lack of midwives the world over. All women should have a choice and a right to birth at home as long as they are low risk; any country that cannot meet this need with it’s midwifery workforce either doesn’t see the importance of giving women this right or they have a midwife shortage (or both) – Instead of denigrating midwives, women, the RCM and NICE you might consider putting the rights of women first and doing something positive, such as lobbying the governments within these countries where the true problem lies.

  • SkepticalGuest

    So is the UK the same as the US with minimally-trained lay midwives overseeing most homebirths while only medically-trained CNMs are allowed to oversee hospital births? If so, this argument doesn’t technically hold water, since most homebirth midwives couldn’t be employed by hospitals anyway.

    On the other hand, if they are all equally trained and employable at hospitals, then I totally agree.

    Given how low the rate of homebirth is, though, I suspect that even if there were no homebirth, there would still be a need for more training of hospital-based midwives.

    • toni

      No, they are the same kind of midwives. I don’t know if all NHS midwives will do home births but nhs home birth midwives in the uk all work in the hospital as well. You can hire independent midwives for home birth but I don’t think any of them are as dismally uneducated as American CPMs.

  • Maria

    Check out Kelly brogan, MD on why you would consider home birth and the importance of microbiome.

  • Dr Kitty

    Something I’m not sure has been considered.
    10,000+ babies are born annually in the city where I live.
    At present the city has between 7 and 10 paramedic staffed ambulances available at any time.
    If they had to transport 3-5 labouring women every day it might have a slight impact on the service.
    But, if an ambulance had to be on call for the duration of each Homebirth, which is best practice, you would have the knock on effect of people with strokes and heart attacks not being transported to hospital in a timely manner, and delayed or non existent responses to major accidents or emergencies. Hey, it’s not like the 95 year old with a fractured hip can’t lie on her bathroom floor for another hour or two, right?

    Any cost saving of Homebirth would be quickly wiped out if you had to double or triple your ambulance provision, and if you DON’T increase your ambulance provision to have dedicated on-call vehicles you’re already providing a less safe service than a hospital L&D, because you’ve built in an 8 minute delay before a 999 ambulance can respond.

    Most of our ambulances meet their 8 minute response times by having a car with a single paramedic arrive first, with the ambulance arriving afterwards.
    I’ve called 999 enough times by now to know that there is almost no chance of you getting to an A&E within 15 minutes of the call unless the ambulance is parked in your driveway, and in most cases getting you out of your front door and into the ambulance will be more than 15 minutes from the 999 call.

    In short…
    I don’t think the policy makers did the right sums, or looked at the implications for other users, when considering transport of failed Homebirth attempts.

  • Cody

    I think what this really points out is that the UK needs more midwives.

  • sdsures

    @AmyTuteur:disqus Do the numbers here account for the jobs done by nurses’ aides? The reason I ask is because nurses’ aides during labour can do the non-medical stuff (fetching ice chips, taking patient to the loo) that then would free up the nurses to do more medical stuff. Same as having a nurse-led unit that frees up the OB’s time to oversee that unit or to be available for emergencies.

  • Samantha06
    • Young CC Prof

      I hope that 40 years from now, we really will have births without fear. That we will be able to diagnose almost all complications in advance, and cure them, and that these advances (and the technologies that already exist) will be available to all women. I want to have my babies in a hospital where a crash c-section sounds as brutal and outdated as amputations without anesthesia sound to us.

      Unfortunately, we don’t live in that world, we live in a world where things go wrong during birth with distressing frequency, and I find it a whole lot less patronizing to be pressured TOWARDS good care than to be pressured away from it in the name of ideology.

      • Vg2010

        Can somebody tell me what are the risks of induction and/or medical procedures? Besides the babies not choosing the time of their borthb and being dragged through life?

        • sdsures

          Babies don’t choose. They haven’t got the neurological network developed enough to do that.

          • Vg2010

            I was joking about that… But seriously, i know the risks of homebirth or not being induced… According to midwives, what are the risks of inductions?

          • sdsures

            OK.

            I don’t know. I’m not a HCP.

          • Young CC Prof

            According to NCB advocates, induction causes more painful labor and increases the risk of c-section.

            In fact, the effect of induction or augmentation on labor pain varies enormously from person to person, and induction when used judiciously can reduce the chances of c-section.

          • Sarah

            Additionally, augmentation is typically used when a woman has been experiencing ineffective contractions. One explanation for an increase in pain would be that effective contractions, ones that are causing dilation, hurt more.

          • Cobalt

            According to midwives, an induction increases your cesarean risk to 99% and will make your uterus explode. An induction is frequently seen as a good enough excuse for an epidural though, which they also call a risk.

          • Poogles

            Besides the rest of what has been mentioned here, a big “risk” I see being talked about is a premature baby; the midwives really like to insist that a due date is “just a guess” and can be “off” by 2 weeks in either direction, so if you get induced at 39 weeks you’re baby might actually be 37 weeks. Similar to how they always assume the estimated fetal weight is always higher than the actual weight, they also seem to assume the due date is only ever off going in the direction of prematurity, but not post-dates.

          • Cobalt

            I really a book a few years ago (I want to say David Bainbridge was the author) that included a chapter on the mechanics of the timing of labor.

            The short version is that some change in the placental hormones is what triggers the initiation of labor (assuming other factors are sufficiently appropriate). The “placental trigger” can be impacted by several conditions (high blood pressure, ROM, etc.), but there is also a genetic component for duration of pregnancy. The fun part is that much of the genetic influence on the placental contribution to the onset of labor is from the baby’s father.

            Now, the book is probably 10 to15 years old, and the research probably older, so maybe new discoveries have been made that invalidate the above. But I thought it was really cool.

          • Young CC Prof

            One thing I know has been added since is the dramatic effective of bacterial colonization on things like the timing of labor, since we now know the placenta isn’t sterile. This may explain the link between minor infections and preterm labor.

        • Sarah

          In the UK, induction at 41 weeks is associated with a lower risk of EMCS. I’m in no way anti-section, but obviously most people want to avoid the emergency variety if possible. So far from being a risk, induction is more likely on average to be of benefit in this scenario.

        • Cobalt

          Specific to hormonal induction, there is a risk of hyperstimulation of the uterus, which increases the risk of rupture and is very painful. That’s why inductions are monitored and VBACs typically aren’t induced. The meds can be reduced or stopped if they are working too well, and are typically started and increased slowly.

          Induction also carries the usual labor risks. In some circumstances it reduces your risk of needing surgical delivery (avoiding CPD or deteriorating placenta, for example).

      • Samantha06

        I know! I couldn’t believe the part where a doctor (supposedly) said something like he had seen harm result from interventions like fetal monitoring, etc. I thought, this is such BS!!! I could never see an OB doc spouting that crap!

  • KarenJJ

    Maybe it’s cheaper in the creative accounting “cost shifting” way? Like companies who lay off an internal department and then spend money contracting out the same work. Column A has now shifted to Column B and somewhere someone looks good for “reducing costs” whether or not the actual costs have reduced or not.

    • Sarah

      Sort of, yes. Costs associated with complications don’t necessarily come out of the same budget or the same accounting period. If we’re talking about a child with complex care needs, the state will pay for a lot of it but it won’t necessarily all be NHS. Some would be the local council’s care team, then associated disability benefits would be the Department for Work and Pensions etc. Aka Someone Else’s Problem.

  • Guest

    OT: I can’t remember if this particular death was discussed before…

    https://www.yahoo.com/parenting/infant-dies-of-legionairres-disease-after-water-104936635732.html

  • Sarah

    While I’m glad to see the numbers being interrogated, I’m pretty uncomfortable with the idea that women are being selfish for choosing the more expensive mode of care. I’m pregnant, I’m as likely to choose a homebirth as I am to make the next Olympics, but one thing I certainly won’t be doing is thinking about the cheapest option for the NHS. I don’t think that makes me selfish. As a low risk second timer with a previous vaginal delivery, odds are that I’ll have a straightforward delivery, of the sort that could be accomplished more cheaply in an MLU than the CLU I’ll be going to in order to get an epidural. There isn’t a chance in hell I’ll be willing to forego my chance of adequate pain relief to save the NHS a few hundred, though. It’s not ok to put the onus on patients to choose the cheapest treatment option, be that home or hospital birth, and suggesting they’re selfish for putting their own wants first is doing that. I would rather have seen Dr Amy stick to questioning the numbers.

    • deafgimp

      Honestly, I didn’t feel like she was saying that the women choosing homebirth are the ones who are creating the financial burden. Rather, it’s RCM and NICE who are adding to their financial burden while saying that it’s saving money and they are scattering their resources.

      • Sarah

        Saying ‘homebirth is selfish… and compromises the care of everyone except the woman who has a fully staffed homebirth’ wasn’t a great way to put it, if that’s the case.

        • Vg2010

          I don’t see the problem. NBC are constantly talking about how expensive and resource-consuming c-sections are… and we know the reason they are so controlled in countries like Canada and the UK is because they are seen as an expensive alternative. If my choice is criticized in terms of taxpayer dollars, then Dr. Amy has the right to talk about the hypocrisy of the homebirth movement

    • araikwao

      I took it more as selfishness on the part of MWs for promoting a resource-hungry, ideology-driven model of birth.

  • junebug

    Maybe it’s cheaper because the babies that would be in NICU running up a million dollars (like mine did after a perfectly low risk pregnancy) are all dead.

    • mostlyclueless

      Oh did you not say enough positive affirmations?

      • junebug

        They put the singing whales cd on instead of the enya. Ruined everything.

        • Vg2010

          I will play Taylor Swift’s “Shake it off”… I think the part about the haters gonna hate will make me concentrate my energy on how the evil medical staff ant to rush the birth of the baby, pump me full of chemicals and will help me shake off the need for an epidural…

  • MLE

    They will save by having the midwife rush in as baby is crowning or just after birth, a la American CPM s.

  • AlexisRT

    FWIW, the NHS goal is supposed to be 1:1 in active labor, though this goal is not met as far as I know, at least not in most hospitals.

    The wrinkle is that other evidence showed, IIRC, that safety was better at units that did at least 3,000 births a year (which makes it a large unit in NHS parlance). This is part of the reason there’s been a drive to centralize units. But as you do that, you actually reduce the number of potential home births, because transit time starts to become a factor. And if you keep reducing hospital births, more units would become marginal.

    • Ash

      There are other folks that are certainly more knowledgeable about the system than I. but centralized units you can easily do in Manchester and London, but once you get to isolated areas like the Hebrides a centralized unit, it might not be possible to build a unit that does at least 3000 births a year within a reasonable distance.

      Here’s an explanation of what’s going on in Cumbria. Given the distance between these units, I’m not sure if it would be wise to close 1 unit and combine the 2 units so they would possibly get to over 3000 births/year

      http://www.ncuh.nhs.uk/patients-and-visitors/talk-to-us/Obstetric-and-midwifery-care.pdf

      • AlexisRT

        Yes, of course, in more rural areas that isn’t feasible. My in-laws live in South Devon. Google says Torbay does 2300 births a year. But it will stay the way it is (and that area is already known for a relatively high home birth rate) because they’re not going to make everyone go to Exeter or Plymouth.

        A friend of mine gave birth in Carlisle around the same time I had my first (2007) and at the time they couldn’t provide epidural unless you were having a C-section.

        I was in London, and transit times then were bad enough–one of the units near where I lived has since been closed.

  • Mariana Baca

    maybe their facilities shortage is actually worse/more expensive than the midwife shortage?

    ETA: by facilities I mean the buildings, all the other support staff, NICU, pain management, anesthesiologist, etc. Not just the main attending.

  • Ash

    Even if NICE doesn’t meet its “goal”, let’s say that that the number of women attempting to do HB doubles. How the heck would that work? Rather than having midwives leave their unit to attend a homebirth, in order to guarantee immediate availability of midwives to do a homebirth, that means that the midwives should be on call. They can’t be seeing patients at the same time. While being on call, the most they could do would be stuff like case management and administrative tasks. An extremely inefficient use of resources!

    I have also heard that in the UK, midwives on the unit take on much more of the responsibilites that would normally be covered by RNs in the US, such as inserting IVs. Is this true?

    • Dr Kitty

      Yes.
      There are no nurses on UK L&D or postnatal wards. All nursing tasks are done by midwives (or healthcare assistants).

      • Ash

        That seems like such a bizarre system to me.

        Do you think that OB wards would provide better care if there were RNs to supplement the midwives?

        • Dr Kitty

          I don’t see what value nurses would add. Midwives are perfectly able to do the nursing tasks.

          Having nurses who can’t do the midwifery tasks would be less useful than having extra midwives.

          • Ash

            Is it less expensive to staff more RNs rather than a greater number of midwives needed? Certainly in the US, a certified nurse midwife has a higher salary, and it makes sense for the unit to be staffed by nursing assistants registered nurses, midwives and other mid-level providers, and physicians. If nurses are cheaper than midwives, it would free up the midwives for other tasks.

          • Dr Kitty

            No. Nurses and midwives are paid the same, as in the UK midwifery is a bachelor’s degree, like nursing and not a postgraduate additional degree to nursing, like in the USA.

          • Roadstergal

            But wasn’t it noted in a recent thread that nurses can serve throughout the hospital, while midwives who aren’t nurses can’t? So it seems like the most bang for the buck would be nurses and nurse-midwives, while non-nurse midwives are the least useful asset?

          • Dr Kitty

            But the UK doesn’t train nurse-midwives, and the shortage is not nurses, or healthcare assistants, it is midwives, specifically, to do midwifery on L&D and community midwifery.

            Most low-risk women in the UK go home within 24 hrs of an uncomplicated delivery, many go home within 12 hrs. There isn’t a lot of postnatal nursing going on where nurses would be most useful.

            You’re also not counting the cost of training nurse midwives for the extra 3 years in your cost-benefit analysis.

            There isn’t a general nursing shortage. There is an unwillingness to employ nurses on full time contracts when bank staff or healthcare assistants can be employed instead.

            There is an actual shortage of midwives, as in there are vacancies and no one to fill them.

            Of course the NHS typical response to that is to employ staff from current and former Commonwealth countries and the Phillipines to plug gaps rather than investing in long term workforce planning in the UK.

          • Ash

            That is interesting. Does the UK have the equivalent of US mid-level providers, like physician assistants, anesthesiology assistants, or nurse practitioners?

            In the UK, can nurses be trained to do procedures such as placing central lines?

          • Dr Kitty

            We have mid level providers and they are being used more, but there is resistance, mostly from doctors who feel that their own training opportunities are negatively impacted. If non- doctors manage all the straightforward stuff and the complex things can only be managed by fully trained doctors, it leaves trainee doctors SOL because they are scrambling for the left over straight forward cases to build competence, or managing complex cases when they don’t have the necessary skills to do so.

            IME nurse specialists, nurse practitioners and midwives are excellent at following well defined protocols. Which are core nursing skills.
            They are NOT good at managing cases which don’t fit neatly into the pre-defined boxes, nor at managing diagnostic uncertainty, nor at managing complicated or unexpected outcomes, which are core medical skills.

            Nurses and doctors have different skills.
            A nurse, no matter how highly trained, unless they have had the same training as a doctor, will not be a doctor, just as a doctor, no matter how highly trained, will never be a nurse.

            Using mid level providers is often seen as a cheap way of reducing staffing costs by employing fewer Doctors, on the basis that the care provided by mid level providers will be equivalent. That is not always the best way of looking at it.

          • Ash

            I agree with you, Dr. K. I get the sense that there are a greater ratio of midlevel providers to physicians in the USA than in the UK. The adult cardiothoracic service here has 8 physicians, 12 midlevels (does not include residents, interns, and fellows)

          • I think it is not just about different skills. Having audited a year of med school [in the US], I can say that doctors and nurses, with the same goals, are educated in different approaches, disciplines, and philosophical modes. They are meant to complement one another, not compete for the same territory. A nurse is NOT a diluted doctor.

            One of the things that was brought home to me when I had my hip replaced two years ago was how badly simple nursing care has languished as nurses spend longer and longer in classrooms and less with the patients. Following the operation, I wanted badly to brush my teeth but was immobilized in bed. After 48 hours on my back, I was desperate to have my back massaged and the sheets changed. When my catheter was removed, I initially needed assistance with a bedpan [even getting someone to bring me one was a considerable effort] I could not reach the tray the dietary staff simply dumped on a table across the room from my bed. The nurses were too grand to do such menial tasks*. Apart from giving meds, and changing my dressing, I hardly saw them. The nurses’ aides meant well but lacked most of the skills to make a patient comfortable. When I complained, I was informed that I should have arranged for “a relative” to help me

            *When I was up and about, I saw that they were almost entirely absorbed in paperwork.

          • Young CC Prof

            I think the issue isn’t so much time in classrooms as excessive patient loads, plus documentation requirements that were put together by payers, not experts.

          • During my interview as an applicant to the Queen Charlotte Maternity Hospital, the Principal Nursing Officer [who used to be called “the Matron”] observed: “I have a problem with applicants from the US. Nurses from there know everything there is to know about the theories of pillow placement, but they can’t arrange the pillows to make the patient comfortable”. This was in 1974.

            Theory without practice really doesn’t work. And while US nurses complain about patient loads, they are very light compared to staff/patient ratios in Israel and some other countries. The paperwork in the US is unbelievable, and the nurses cling to it. When offered, as part of an EMR, ways of streamlining the paper burden, they often demand reinstatement of reams of old forms which are made obsolete by the EMR. It is part of the terror of the lawsuit which permeates US medicine.

          • Cait

            It’s not that long since midwifery was only a post-graduate nursing specialism, and I believe that many midwives working today did train as nurses first. But to work as a nurse, you have to maintain your nursing registration.

            There are some dual-registered nurse-midwives, but most let their nursing registration lapse after they train as midwives — probably because it requires you to work a certain number of hours in a nursing role, and they’re already working full-time as midwives.

          • Daleth

            Whether or not they’re registered as nurses, they’re nurses if they trained as such. Much as I am a lawyer forever (in terms of my training and skills) regardless of whether I continue to be a member of the bar.

          • Cait

            Sure, but they can’t rotate throughout hospital in nursing roles unless they’re registered. I do agree that nursing skills, especially a belief that pathology exists, are very valuable for midwives.

          • Cody

            I can’t imagine that it would be any different than in Canada though. A nurse gets hired to do a specific job, it’s not as though nurses rotate through different areas of the hospital as needed. If a nurse works in labor and delivery, she/he stays there regardless of what’s happening in the rest of the hospital.

          • At least in my time in the UK, RN education [SRN actually, as the Brits think RN stands for Royal Navy] was exclusively medical/surgical nursing. All the specialties, which are covered in US nursing programs, such as pediatrics [“sick children’s nursing”] or OR [“theatre”] are additional, usually year long, programs, during which time a nurse gets an NHS salary [they were really work-study programs, with the nurses working full shifts, with lectures outside the work schedule]. What I found was that UK nurses, who did a full three years in med/surg, were extremely good, and most SRNs did at least two additional years, usually pediatrics and either midwifery or OR, often more since it was financially possible. Of course this was just before academic degrees came in [it happened later in the UK than the US] so I have no idea what the situation is now like.

        • Sarah

          Personally I think more clinical staff of any type would be a good thing. Not sure how much difference it would make if they were nurses rather than midwives. Maybe some. We just need more bodies in scrubs really.

        • Daleth

          In the UK, midwives ARE nurses. They are basically equivalent to Certified Nurse Midwives in the US.

          • Ash

            Dr K has pointed out a difference between the US and the UK. In the US, a Certified Nurse Midwife gets paid more than a RN with 2 year degree or 4 year degree. This is because in CNMs are a postgraduate program in the US. Therefore, in the US, nursing assistants, registered nurses, CNMs, and physicians typically staff the OB wards. In the UK, if I have this correct, it’s typically staffed by midwives, healthcare assistants, and physicians. No staff who are nurses but not midwives.

          • Alas, that is no longer true, and hasn’t been for a couple of decades. Midwifery training can be direct entry, but compared with US CPM training it is much longer and more comprehensive.

          • Daleth

            US CPM “training” does not exist. There are zero training requirements for becoming a CPM. A given person with CPM certification may or may not be a trained, adequately qualified midwife–but you can’t tell that from the mere fact she is a CPM.

            You may be thinking of CNM training, which is indeed rigorous.

          • I do know the difference. See my cyberpseudonym.
            There are no universal standards for CPM education. Some CPMs do have some, however; some do not [which is part of the problem as you point out.]

    • Sarah

      Yes, iirc. I don’t think there actually are nurses in delivery suites, or if there are I didn’t see any. Just doctors and midwives, many of the latter being qualified as nurses too of course.

  • Amy M

    I can see how it could save money: 1)The hospitals do not hire any more midwives, so their payroll (for midwives) remains stagnant. 2)Even though 2 midwives might go to a woman’s home, they aren’t being paid any differently than if they stayed in the hospital. But, hospital resources aren’t being used–even with a 40% transfer rate, 60% don’t transfer, so those women aren’t taking up a bed, aren’t needing meals, don’t need anything from the anesthesiologist, don’t need a surgeon, no extra supplies (chucks, towels, etc). Of course the gamble is that all goes smoothly—that the woman doesn’t need to transfer and that there are no complications.

    Meanwhile, back at the hospital, fewer midwives means minor complications might be overlooked, and fewer resources will be spent on a given woman. Of course, this could lead to increased mortality and morbidity, but I guess they aren’t counting those costs in the maternity budget.

    If this is actually how they are figuring it, its incredibly short sighted, but that’s usually the case when politicians are involved.

    • Amy Tuteur, MD

      But you have to maintain all those hospital resources anyway. The biggest costs are capital costs and staff costs and those wouldn’t change.

      • Amy M

        Yes, I guess that’s true. Oh well, it really wouldn’t save money then. Has anyone over there pointed this out to the ones making the budget?

        • Sarah

          They don’t appear to have counted the costs of disability resulting from birth, which is higher at homebirth.

      • theadequatemother

        Agree. In an economic analysis of the cost of homebirth vs hospital birth those fixed costs (capital and staff) for the unit should be ascribed in some fashion to both birthplaces. Also, if all of the women who qualified for homebirth gave homebirth a go there would be additional costs. Transfer/ transportation costs for example. Not every transfer would occur in an ambulance but a proportion certainly would and ems capacity may have to be increased or costs ascribed to transfer delays for other ems patients who may have worse outcomes.

        • guestS

          The midwives who do homebirths are the community midwives, so they’re working the same shift patterns as the hospital midwives and carrying out midwifery duties (i.e., anti-natal clinics, post-natal home visits), as well as being on call. That’s the same as the midwives working in the hospital, who will also have a shift pattern and on-call times.

          You’re not paying a midwife to do her Christmas shopping and pop to a birth if one happens. If that’s what you were implying?

          • moto_librarian

            I believe that theadequatemother was referring to a case in the UK where a midwife did not show up in time for the delivery because she was out Christmas shopping (yes, she admitted to it).

          • guestS

            That’s bad!

          • theadequatemother

            Yes I was.

          • sdsures

            Holy ****!

      • Dr Kitty

        As you still have to have ORs staffed and ready to go at all times, but potentially less busy, it becomes less efficient and cost per use rises.
        The cheapest way to run a surgical department is to operate 24/7.
        If you’ve got expensive machines and ORs lying empty and staff twiddling their thumbs, you’ll lose money.

    • Mel

      I mentioned this above, but I suspect that a homebirth gone wrong wipes out the savings of many, many uncomplicated births….

  • I understand the thinking, although I think it is based on absurd ignorance of the way the world works.

    I’m sure the estimates are not based on the number of midwives. It’s based on how much it costs to keep hospital facilities open — in a home birth, there isn’t any need for a labor suite, with all its equipment, or a nursery, or an NICU, or cleaning and dietary staff, etc. hospitals are very expensive to run and maintain, and one of the budgetary difficulties is that its impossible to predict when it might be possible to NOT have all of the facility working at full capacity. An NICU has to continually be fully staffed and equipped, whether it is being used or not. There have been shifts that I’ve worked without a single woman in labor and I got a lot of knitting done, and at times myself and a second midwife delivered as many as 14 babies in 8 hours. It is an illusion that home birth is cheaper since so many “hospital costs” are passed on to the “health consumer”, but it’s a very attractive illusion for the bean counters.

    • The Bofa on the Sofa

      Isn’t that the argument? With more home births, we need fewer hospital facilities, like rooms and beds? We can cut the birthing centers out of some hospitals and centralize the hospital births in a couple of places…

    • Box of Salt

      Penny wise and pound foolish.

  • EM

    OT: Can anyone provide info on the risks of waterbirth?

    • moto_librarian
      • EM

        That story triggered a debate on one of my Facebook pages. Some people were very dismissive quoting from the article that it was the 1st death, as if it’s no big deal from the disease under those circumstances in US history. Is that factually accurate? I want to be armed with information before I carry on because these people are exhausting.

        • moto_librarian

          This is not the first death associated wtih water birth. From the ACOG Opinion:

          “Among this list of complications, given its potential seriousness, the possibility of a neonate aspirating water during birth while immersed has been the focus of understandable concern. Alerdice et al (26) summarized case reports of adverse neonatal outcomes, including drownings and near drownings. The case reports included immersion births in hospitals and at home. Subsequently, a study by Byard and Zuccollo reported four cases of severe respiratory distress in neonates after water birth, one of whom died of overwhelming sepsis from Pseudomonas aeruginosa (19). Although it has been claimed that neonates delivered into the water do not breathe, gasp, or swallow water because of the protective “diving reflex,” studies in experimental animals and a vast body of literature from meconium aspiration syndrome demonstrate that, in compromised fetuses and neonates, the diving reflex is overridden (27, 28), which leads potentially to gasping and aspiration of the surrounding fluid.”

          It may be the first death from Legionnaire’s, but definitely not the first one associated with water birth. The NICU admissions for aspiration-pneumonia are also very troubling.

        • Samantha06

          I’ll look for that link to the woman pooping in the water during her delivery. Show them that and ask them if they would put their faces in it.

      • EM

        Inserted at the wrong point in the comment… sorry

      • Sara Lucy

        I just saw that. Awful.

    • Samantha06

      To put it bluntly, it’s like delivering your baby into the toilet.. the water is contaminated with fecal bacteria and more..

      • Cobalt

        Not just any toilet. A warm toilet. And if you rent the tub or use the one at the birth center, a public toilet.

        Yes, the staff do or are supposed to clean the tubs. Just like public toilets.

        • Samantha06

          Sooooo gross!!!!! I guess women having water births don’t even think about this. Someone on here posted a link to that pic of the water birth that was taken down on FB and the woman was defecating in the water while the head was delivering. I wanted to vomit. I bet these women wouldn’t dream of putting their faces in that water, but it’s OK for their baby to be born in it. Disgusting.

      • Roadstergal

        Aren’t there also some risks around the baby aspirating water, or issues with the cord when they try to yank the baby above water before it starts breathing?

        And why, oh why, do water-birth babies always look some horrific shade between grey and blue?

        • Samantha06

          Yes, aspiration.. and poop water too! So gross!! Lots of babies are somewhat blue right at delivery, not all, but if they are vigorous and cry right away, they pink up relatively quickly. They’re probably gray because they’re much more stressed at delivery (maybe from pushing for 4 or 5 hours!)

      • sdsures

        Yep, that’s about it.

  • fiftyfifty1

    I have no trouble understanding why NCB advocates continue to promote it. But what I can’t understand is why the government continues to promote it.
    On second thought, I suppose it is because when government give their endorsement to homebirth, they know that few women will actually choose it. But by holding it up as an ideal, they can use this NCB ideal to justify why epidurals and other expensive things won’t be easily available.

    • Cobalt

      I’m putting my money on this one.

    • Mel

      That makes a lot of sense – especially since the governmental officials aren’t on the front line of watching homebirth diasters and NCB tragedies play out.

      Connected question – how quickly does the cost savings vanish when these disasters are counted in? The costs mount very, very quickly when something goes wrong. A friend of a friend is a labor and delivery nurse at a good hospital in the US. A while back, she begged and pleaded with a laboring mom to get a CS when the baby started showing signs of distress. The parents were adamant. The OB, RN’s, social workers…everyone was frantic. The parents refused a CS. They got a vaginal delivery of a stillborn baby.

      Perhaps the hospital saved some money in terms of avoiding a CS. I doubt it, though, once you count the extra costs in terms of counseling for the affected staff, additional support for the family, and a potential lawsuit…..

      And this was (and I don’t know how to say this…) medically uncomplicated. Mom was fine after the delivery physically. There was attempts to revive the baby, but no extensive stay in a NICU – the baby was born dead. If this had been closer to some of the homebirth stories gone horribly wrong, the medical expenses on mom alone would be over a million dollars.

      • Amy M

        That’s awful. Do you know if the parents reversed their feelings about Csections after that?

        • Mel

          I have no idea. I doubt it came up in the immediate aftermath.

          I was more focused on helping my friend’s friend grieve. I was trying to help the friend’s friend have a place that the person could feel safe admitting that their job can make them feel helpless, furious and hurt.

          We all agreed: the helplessness is the worst. Watching a situation spiral out of control and being unable to stop it is horrific.

      • This is going to sound awful, really, really awful. The costs of an infant death are small relative to an infant brain injured and in need of care the rest of their life. If homebirth means more babies die, but fewer are left brain injured, then there might be cost savings. However, if it means more babies die and more babies are left brain injured, then it is unlikely that there would be any cost savings accruing from homebirth. That is the bit that seems missing, how many kids go on to lifelong struggles?

        • Mel

          Yeah, that’s what I was dancing around in the first part. My twin and I have relatively minor brain damage from a premature birth – severe hearing loss and very minor hyptonic CP for her; minor hypertonic CP for me.

          But even those mild disability have cost million of dollars to the health care system in terms of newborn hospitalization, hearing aids and tests, and years of physical therapy for me.

          If we had had more severe disabilities, the costs skyrocket.

  • Ellen Mary

    Oh snap! Turning away women in labor is not in any way acceptable.

    • Amy M

      Do they turn them away in labor? Or just refuse to take them on as patients at the beginning of their pregnancies? And if the latter, how do these women get pre-natal care? And what about women who are not actual patients of the staff at a given hospital, who show up in labor? Is there some kind of EMTALA rule over there? (these are general questions, not just for Ellen Mary)

      • Amy

        Not sure about EMTALA, because that was specifically written in response to hospitals refusing to accept patients who couldn’t pay. Even in the US, EMTALA allows hospitals to redirect some patients to other nearby ERs if their own ER is overbooked.

    • guestS

      They will turn you away during labour if you’re not in established labour. You’ll never be refused as a patient because you don’t choose your care provider or have specific midwives or OBs or anything here.

      If the facility that you had planned to attend is full at the time you need it you’ll be redirected to the nearest hospital. Sometimes that’s actually equidistant from your home, just a different trust (e.g., if you’re Midlothian NHS you’ll go to the West Lothian hospital but you might live inbetween both of those plases but your postcode puts you in Midlothian).

      • Sarah

        I’m actually not sure what happens if you rock up in very established labour, though.

        • guestS

          You normally phone first so it probably wouldn’t happen…but I suppose if you rock up crowning they’ll have to deliver you in the corridor if needs be!

      • Dr Kitty

        If there are “literally” no beds, not on labour ward, not in the postnatal ward, and no staff available to care for you, with a very real chance of you delivering your baby unattended on a chair in a hallway OR you can travel 30-60 minutes to a unit with an empty bed and free staff, is it more unethical to turn you away or to accept you?

        • guestS

          I’ve never had a problem with that system. I think you accept that you don’t always get what you want with labour, it’s not like you can plan for it and they can even it out with every other pregnant woman in your postcode.

          As I understand it they will tell you which hospital you should head to when you phone up to say that you are, or you think you are, ready to come in. I think they will also arrange ambulance transfer from home if it’s going to be too much to make your own way in.

          • guestS

            Oh! And you can choose to give birth in a different NHS trust, or different hospital to the one you would automatically be assigned to if you like. But it’s the same thing, there are no guarantees that there will be a bed available on the big day.

        • Roadstergal

          It seems like a greater acceptance of induction would be something the bean-counters should get on board with, then? Since it’s safer for both mom and babe than expectant management, and you can mitigate a little bit the issues of the randomness of birth leading to swings between a fully staffed and dead ward vs an overcrowded and understaffed ward…

    • Joy

      I had a friend who was turned away from two local hospitals and had to go to one 46 minutes away with no traffic. I asked at one of my midwife appointments how I would get there, since my husband doesn’t drive, I was told I would need to get there on my own. Good thing my hospital had beds. I called five times and when I finally went in against the advice, because they didn’t think I was in labour, I was 7 cm.