What’s an ethical response to homebirth, Dr. Burcher? Start by telling the truth.

Got ethics ?

Homebirth advocates have been praising and sharing a recent piece by obstetrician Paul Burcher entitled What’s an Ethical Response to Home Birth?

Unfortunately, in offering an answer to the question, Dr. Burcher fails in his most important ethical responsibility. He hasn’t told the whole truth. Since he has held back (or, less likely, is unaware of) important facts, his answer is deeply misleading.

Who is Dr. Burcher ?He is an Associate Professor of Bioethics and Obstetrics and Gynecology at Alden March Bioethics Institute at Albany Medical College.

He previously worked as an obstetrician-gynecologist in Eugene, Oregon, where served as the back up physician for Melissa Cheyney, CPM. Cheyney, as you may recall, had some ethical challenges of her own. She was an embodiment of the ethical problem of “conflict of interest” while she held simultaneous positions as Director of Research of the Midwives Alliance of North America (MANA), the trade organization of homebirth midwives and Chair of the Oregon Board of Direct Entry Midwifery. In her first position she was privy to a large amount of data showing the disastrous outcomes of homebirth in Oregon, which she deliberately refused to share with the state of Oregon.

Burcher collaborated with Cheyney on a commentary in Birth:Issues in Perinatal Care (a journal published on behalf of Lamaze International), A Crusade Against Home Birth that encapsulating in a few words the self-pity, conspiracy theories and mendacity that are at the heart of homebirth midwifery.

Dr. Burcher bases his own piece on a nifty bit of mendacity.

An observational study from The Netherlands that evaluated more than 500,000 births in homes and in hospitals showed no increase in adverse outcomes of any kind with home birth in low-risk women.5 So home birth, in ideal conditions where midwives and physicians work together as a team and where transport to hospitals in an emergency is highly efficient, appears as safe as hospital birth…

But as Dr. Burcher knows (or ought to know if he is keeping up with the scientific literature), that’s not what the paper shows at all. Dr. Burcher neglects to mention two critical pieces of information.

1. The Netherlands, the country with the highest rate of homebirth in the industrialized world, has one of the worst perinatal mortality rates in Europe.

2. The perinatal mortality rates for Dutch midwives caring for low risk women (home or hospital) is HIGHER than that for Dutch obstetricians caring for HIGH risk women. That is a scathing indictment of midwifery in the Netherlands. The paper that Burcher cites doesn’t show that homebirth is safe; it shows that midwives are dangerous.

Dr. Burcher does acknowledge that homebirth in the US has a higher death rate than comparable risk hospital birth:

I would agree … that home birth in America probably incurs a small increase in absolute risk of poor outcomes for newborns delivered at home.

Notably, Dr. Burcher doesn’t dare cite  Outcomes of Care for 16,924 Planned Home Births in the United States: The Midwives Alliance of North America Statistics Project, 2004 to 2009 by Cheyney and MANA purporting to show the safety of American homebirth. Apparently, even he knows that it actually shows that homebirth increases the risk of perinatal death.

The heart of Burcher’s argument is this:

What, then, are our professional obligations as obstetricians working in hospital settings to women who choose to stay home with a midwife for their birth? At the risk of sounding glib by answering a question with a question, do we enhance the safety of childbirth for all women by shunning home birth or by treating midwives collegially? I believe the correct answer is the latter, and since maternal-child safety was one of the founding reasons for ACOG’s existence, I believe we have an ethical obligation at a minimum to accept transports from home with the respect and professional dialogue we afford our colleagues …

That, of course, tells us nothing. Physicians already have an ethical responsibility to care for all patients regardless of how they end up in the emergency room. Dr. Burcher’s glibness is not in answering a question with a question, but rather in the choice of the question he asks.

The real question is “What is an ethical response to a group of laypeople with inadequate education and training, masquerading as midwives behind a fake credential, who have hideous perinatal death rates?”

I would argue that physicians’ ethical obligations are exactly the same as when we are presented with patients who have been harmed by other quacks and charlatans, whether they are peddling cancer “cures,” homeopathy, or cut rate plastic surgery. First, we care for the victims of their incompetence. When patients who have end stage cancer presents after avoiding conventional treatment that might have saved them, we treat them with every ounce of compassion and skill we have at our disposal. But that doesn’t stop us from going after the cure peddlers, or refusing to serve as their regular back up. Failure to put dangerous providers out of business is an ethical lapse, not a virtue. Similarly, when patients who have horrific infections from cut rate plastic surgery present in the emergency room, we treat them with every ounce of compassion and skill we have at our disposal. But that doesn’t stop us from reporting the cut-rate unlicensed providers to the police and regulating agencies or refusing to serve as regular back up for those who prey on the hopes and fears of other human beings. Failure to put dangerous providers out of business is an ethical lapse, not a virtue.

The ethical response of physicians to homebirth ought to be exactly the same. When a patient is transferred into the emergency room from a homebirth, obstetricians are ethically obligated to treat her with every ounce of compassion and skill we have at our disposal. But that shouldn’t stop us from going after these fake “midwives”,” reporting them to the authorities, and demanding strict regulation and harsh penalties for violating those regulations. Failure to put dangerous providers like homebirth midwives out of business is an ethical lapse, not a virtue.

Dr. Burcher, however, reaches a different conclusion:

…[I]t is my assertion that our professional responsibility must include supporting all of the birth options women have and to make each as safe as possible. The Netherlands has shown that safety comparable to a hospital is achievable. We should strive to replicate their results.

Not exactly.

Maybe Dr. Burcher wants to replicate the terrible perinatal outcomes in the Netherlands, but most obstetricians, myself included, do not.

  • Maya Manship

    Wow, I live in Albany, NY. I’m glad he is not my OB/GYN! Albany is truly fortunate. We have two hospitals in Albany itself that have excellent Labor and Delivery units, Saint Peter’s Hospital and Albany Medical. I believe Albany Medical, known locally as Albany Med, is the same one mentioned about by Dr. Amy. Albany Med is where my sister had her twins in February. They specialize in high risk birth. Without them, my nieces might not be here. They are the rarest of twins, they shared the embryonic sac and the same placenta. My sister told me the doctors were very excited about the birth. She says they were showing the other doctors, the residents, and the interns the placenta, which had the babies umbilical cords still attached (they were very tangled). A third Albany hospital, Albany Memorial, does not have a Labor and Delivery unit but it is associated with Saint Peter’s. There is another option in the area, Bellevue Women’s Center in Schenectady, NY (technically might be located in Niskayuna, NY) which is where both my children were born. They specialize in women and children and are also excellent. Fortunately, with Albany Med so close by any birth that gets beyond the capabilities of Saint Peter’s or Bellevue can be quickly sent to Albany Med.

    • Anon E Mouse

      Albany Med is indeed the same thing as Albany Medical – the bioethics institute is based on the hospital, and Burcher has privileges at Albany Med. Which means that depending, he could be someone’s doctor at delivery.

      AMBI continues to be a spectacular center of fail.

      • Maya Manship

        Glad I delivered at Bellevue then! I had a medically indicated scheduled caesarean with my own OBGYN attending.

  • Dr Kitty

    http://www.bmj.com/content/349/bmj.g7346
    OT: talking about unethical Drs, this BMJ paper in the XMas edition (my favourite) basically tells people that Dr Oz is full of nonsense, but in a really sciencey way.

    • attitude devant

      Love it. Got to love the dry tone. Dr. Oz should consider himself dissed!

      • The Bofa on the Sofa

        “The Doctors” new add campaign: “Not as much bullshit as Dr Oz!”

        Although I will say, I do like the comment that the most common advice on The Doctors is “talk to your healthcare provider.”

  • Amy Tuteur, MD

    OT: from The Spudd

  • Squillo

    Yes, we should work to make homebirth safer for women who want it. The best way to do that is to insist on appropriate training and regulation for homebirth midwives. Making it easier for uneducated, unqualified and unregulated hobbyists to attend births will only ensure that U.S. homebirth continues to enjoy abysmal outcomes.

    • Unfortunately, part of the homebirth problem is that, even with the very best midwives, etc. a good many of the women who “want” homebirth are simply not candidates for it, because they aren’t low risk. Women like this will search until they find someone who will accede to their wishes, no matter how risky.

      The problem is multifactorial. Not only do midwives have to be highly educated and experienced, but strict protocols of vetting and practice have to be enforced — IMO, on a national level, or we just will see midwives moving from state to state [as we do now, in some cases]

      • fiftyfifty1

        “Women like this will search until they find someone who will accede to their wishes, no matter how risky.”

        Although women who knowingly risk their babies are a tiny minority. This sort of woman is the fringe of the fringe. The bigger problem is all the NCB lies out there that are convincing otherwise reasonable women to birth at home because they don’t realize that homebirth is NOT “as safe or safer”.

        • Roadstergal

          I think there’s a lot to that. I admit that I don’t know a lot of homebirth aficionados, and only one I’d consider I know very closely, but they point to what they believe to be medical authority (woo-ish midwives, of the US or UK flavor) to claim it’s safer than the hospital.

          • Elaine

            Yep. Among the crunchies and semi-crunchies in my area, the idea that homebirth is a totally viable alternative to hospital birth has a lot of traction. Someone once asked me if I’d had a homebirth in the same sort of tone of voice she might have used to ask me what grocery store I liked to shop at.

      • Deborah

        Yes, some of the worst homebirth transfer situations I’ve seen were clearly collaborations of poor judgement between the midwife AND the patient, with the midwife suggesting it was time for transfer, and the patient begging and/or insisting she get more time at home, and the midwife acceding.

        • Susan

          In a hospital, if the patient doesn’t want something, she can refuse. At home, sure they can refuse too. But how would an ethical midwife deal with a patient who refuses to transfer? I would imagine leaving would be abandonment. She could have her sign and date the refusal to transport. But I doubt she could say… Not doing what I suggest… Outta here… I think at that point they could not leave.

          • Ash

            Document document document. We have heard of some lay midwives transferring a patient to the hospital and falsely claiming that the MW didn’t know the baby was breech, the time the water broke was different, pt refused transport, etc.

            I think only a small percentage of these cases are true patient refusal to transport. IMHO the patient most likely to refuse all transport wouldn’t hire a midwife anyways. I have a hard time believing that a midwife that explains “I want to transport you to a higher level of care. I believe that you and your baby may be in danger because of x. X condition that you have may lead to complications of Y. It is my recommendation that in the best interest of safety, you transfer to the hospital immediately” has a high percentage of women refusing to transfer. If the woman does refuse, the midwife should document the refusal contemporaneously. There have been cases where HB MWs have heard of a MW about to do something risky and notified a hospital in advance as a “heads up”. You can also call emergency services to do a wellness check. This does not mean that EMS will legally force a woman to go to the hospital but it certainly shows due diligence.

          • Susan

            Thanks. I agree it is probably rare, but curious how they should/would handle it.

          • no longer drinking the koolaid

            I think the midwife could call an ambulance to transport the patient advising her that a higher level of care is needed. Document that this is what the midwife advised and have the parents write that they are discharging the midwife from providing further care because they don’t agree with her assessment of the situation.
            If they refuse to go to the hospital, she can’t make them go, but she doesn’t have to stay to watch the train wreck either.

          • Medwife

            If I were in that situation (although I don’t do home births), I agree with nolongerdrinkingthekoolaid, I would call an ambulance and transfer care. I bet the parents would consent to transfer, albeit furiously, once the midwife punched “9” into her phone.

      • no longer drinking the koolaid

        Had a patient more than a year ago who appeared low risk. I always tell everyone that baby gets one chance. I hear a little dip in the hear rate and I’ll be considering transfer. I hear it a second time and we are out the door. With her we had to transfer. I found out more than a year later that she is still angry with me because she thinks we shouldn’t have transferred. In her mind I should have asked her to change position to fix things.
        Never mind that baby was asynclitic, she needed Pit, had a 3rd degree tear, a large PPH, and still has pelvic repair issues. All these things are my fault because she didn’t really need to go to hospital.
        In my head I was saying, “If you wanted a midwife who was more willing to risk your or the baby’s health, you should have said so. I could have given you several names.”

  • attitude devant

    For a fine overview of the state of CPM care in Oregon, I suggest you peruse Oregonmidwifeinfo.com. It is a true rogue’s gallery.

    • attitude devant

      10centimeters.com is another excellent source of information on Oregon midwifery.

    • Samantha06

      Unbelievable..

    • Guest

      Made the mistake of reading the court documents from a case against one of the midwives. I am absolutely horrified.

    • MaineJen

      My god…that is scary reading.

    • Staceyjw

      Real life is MUCH worse than what you see on that site, because these are only those that complained, or were so bad (as in, death) someone else reported. Most of the disasters never make it to this page because they don’t post unsubstantiated claims, even if they have seen them and know they are true. and of course, the near misses, the horrible negligence, the abandonment, well, no one hears of that unless you ask the right people, at the right time, and they trust you to repeat it.

  • fiftyfifty1

    One final quote from Dr. Burcher:

    “I found it re-invigorated my own practice to sometimes share patients with home birth midwives ”

    Because nothing is quite so invigorating as getting to be The Cool Guy.

    Barf.

    • attitude devant

      Being Dr Wonderful as practice builder?

      • Who?

        Could he have a rescue/white knight thing going on? You know, all disastrous then he steps in and ‘saves’ everyone, never mind he participated in letting it happen and it wouldn’t be a disaster if the women were properly cared for in the first place?

        Some people light fires then volunteer to be the hero going in to put them out, apparently.

        • Isn’t that Munchausen’s Syndrome by Proxy?

          • Box of Salt

            Antigonos – No. As I understand it, Munchausen’s by Proxy is parents seeking medical care for their children who don’t need it in order to feed their own need for attention.

            I can’t think of the right label for “arsonist fireman who want to be seen as a hero,” but there are documented cases of this (I’ve read about specific cases, but it was a while ago).

          • Who?

            Yes they do-there’s at least one volunteer fireman in prison in Australia for lighting fires then rocking up to fight them.

          • demodocus’ spouse

            There was an arson investigator in California like that a bunch of years ago. Maybe the 90s?

          • Box of Salt

            demodocus’ spouse – that is in fact the case I’m thinking of. It was written up by true crime author Ann Rule.

          • Susan

            Remember Jenene jones a nurse who poisoned babies so she could be the hero who resuscitated them? I don’t think the label exactly fits why he thinks it’s envigorating more likely the cool guy fits. But some of the Cpms who seem to get more kicks out of the most dangerous cases? I think that’s some sort of related mental illness to Munchausens by proxy.

      • fiftyfifty1

        This says a lot. Because in most places all you need is to be a decent provider who treats people in a decent manner and you will build your practice.

  • fiftyfifty1

    Another quote from Dr. Burcher’s piece:

    “Duncan Nielson, the chief of Women’s Services for Legacy Hospitals in Portland, Oregon, described how by implementing a “home birth friendly” institutional culture, they saw a dramatic increase in transports to their hospital system from home birth midwives and that none of these transports were “train wrecks.” –

    He then goes on to say that his hospital in Oregon did the same with similar good results.

    Does anyone with firsthand knowledge of either of these hospitals care to give their opinions of how things are going? Agree, disagree?

    • attitude devant

      One of the transports in Portland that Dr. Nielsen includes in his ‘success’ story was a set of breech/breech twins. The second baby wound up with a depressed skull fracture. This case was actually reprinted in Midwifery Today as a great triumph! If that counts as a success story then I guess war is peace, freedom is slavery, and ignorance is strength. It sure is a success for the Portland midwives because they know that Legacy will not file any complaints with their Board.

      • fiftyfifty1

        Why then it’s a win-win-win! Mommy gets the vaginal birth she had her heart set on, midwife gets her $$$ and keeps her record spotless so new potential customers won’t be scared away, and Dr. Nielsen gets to play Hero of the Downtrodden. Surely all those winners offset a baby’s skull fracture, right?

      • Amazed

        Please tell me that you’re kidding… Pretty please.

        You aren’t kidding, are you?

        Disgusting.

        • attitude devant

          Oh, I wish I were. Seriously. The story has been taken down from the web, but it was exactly as I related. And bizarrely, the midwives convinced the family that a c-section delivery would have killed that baby. The pediatric neurosurgeons who saved her must have been goggle-eyed.

          • Mel

            I know I will hate the answer, but how does a baby get a depressed skull fracture during delivery?

          • attitude devant

            Well, there’s actually a bunch of studies on that. You can find them on Google Scholar. But you will find it instructive that all of them are over 15 years old. It’s birth trauma, pure and simple, now mostly avoided by doing c-sections. In the narrative, which was written by the father, the little girl’s head was entrapped (this is a breech birth) and the midwife put her hand up in the uterus to manipulate it, and pulled really hard. So that’s how it happened.

          • fiftyfifty1

            Birth trauma causes that?

            I thought birth trauma was when you had to wear that uncomfortable monitoring belt and get a hep-lock.

          • Bombshellrisa

            I thought birth trauma happened because hospitals are “ugly” and have bright lights

          • Amazed

            Gods, now that you shared this detail, I remember the story. A terrible one.

          • Amy M

            I remember that story, it was appalling. The father somehow thought the skull fracture happened in utero or something, before labor began? I don’t remember the details, but it made no sense.

      • GuestOrPickaName

        Complaints have been filed…. I can say that for certain. What the Board of DEM in OR does with them is another matter.

    • Martha Reily

      Ahem. This is disingenuous of Paul at best. What happened was that there was a truly horrific case. This is all public record and widely reported in the press, so I can talk about it without violating any privacy laws. Anita Rojas talked a teen primipara into a breech home birth. The midwives hadn’t been doing breech homebirths but there were a couple, including Anita, who attended a presentation on breech birth, so she tried it on. The baby’s head was entrapped and the teen mom was transported with the body dangling outside of her. The ambulance arrived and two of my colleagues worked together to get the head delivered but the poor bug was long dead.

      Well, we were all pretty upset (one of the two was so freaked out that she nearly quit OB right then and there), and demanded to meet with the midwives. There was a big meeting and they even hired a mediator to run it. We foolishly thought this would be like a peer review and we would get to discuss risk criteria for home birth, but noooooo! At the start of the meeting we were told that the case would NOT be discussed because, and I quote: “Anita feels bad enough about it already.” The deal made was we would start with talking about making transport easier and more standardized and then we would meet again to discuss issues again and we would discuss safety. Well, basically we said, “Look, we are here, and if you bring your client in, we will manage her respectfully but please don’t ‘forget’ your records, and please don’t behave adversarially with us, and please call ahead so we have some warning. It was basically what we had been doing all along, but just made clear what everyone’s expectations were.

      But the follow-up meeting? Never happened, even though we kept asking for it. And there was a bunch of crazy that continued to happen, and still continues to happen. And there have been PLENTY of times when I have said to the transporting midwife (outside the room so I’m not making her look bad) “Wow, this was really not something you should have been taking on “(HBAC, for instance), or “No, you are mistaken, the uterus can still rupture in TOLAC even after she’s fully dilated.

      • Martha Reilly

        Forgot to close (long day!) by saying that most of the midwives absolutely reject ANY input we have for them about scope of practice during transport. They point out that Oregon law makes them independent practitioners. Which is true.

        • fiftyfifty1

          They refuse any review or input on scope of practice because they are “independent practitioners”. They do shit like manipulate a first-time teen mom into given birth to a breech baby at home so she can be their guinea pig for all the cool techniques they heard about at a “breech presentation”. They apparently lack even basic medical knowledge –what complete ignorance and stupidity to think that a uterine rupture couldn’t happen after 10cm. They pull stunts like hiding/destroying their records.

          And yet Dr. Paul Burcher says collaboration with them has “re-invigorated my own practice.”

          This does not speak well for him at all.

          • Amazed

            Independent practitioners when it comes to starting disasters and get paid for them. But no healthcare practitioners when it comes to owning their outcomes.

            Dr Paul Burcher sounds as bad as they are, just like Dr Wonderful is worse than any of them. Because midwives might be mostly clueless but those two have the knowledge that should have let them know better.

        • Young CC Prof

          Independent practitioners with no review board, insurance company, malpractice court or anyone else to answer to. What fun it must be!

        • birthbuddy

          This same excuse was used in New Zealand.

      • Trixie

        That is horrifying.

      • Squillo

        Poor little delicate flowers are too sensitive for actual peer review. Because it’s all about their feelings, and patient outcomes are a (distant) second. Or maybe third after making sure the midwives continue to enjoy total independence (read: immunity from any accountability whatsoever.)

        Tells you all you need to know about these midwives.

        • Samantha06

          I’m thinking they’re sociopaths. Take someone like Lisa Barrett. If you look at pictures of her during she always has a smirking grin on her face.. pretty disgusting considering she’s killed at least five babies. Sick people..

      • Who?

        How bad is bad enough to feel about something so appalling and avoidable?

        • DaisyGrrl

          I would expect “bad enough” to look something like this:
          1) give up license and agree never to practice again;
          2) apologize sincerely to the family, attempt to provide some sort of meaningful restitution, knowing it will never be enough;
          3) participate in a meaningful review process with the hospital, learn what went wrong and help everyone improve for the future; and
          4) volunteer your time to educate others about your experience, emphasizing how easily it could have been avoided by following a few simple protocols

          I realize it’s a lot to expect of anyone, but that’s about what it would take to convince me that someone felt “bad enough” following such a disaster.

          • Samantha06

            But that would involve actually have a conscience. These folks clearly missed that boat..

          • DaisyGrrl

            And that’s the heart of the problem.

          • Samantha06

            Yep.

          • Anj Fabian

            I think it’s more than conscience.

            This is built into the culture of lay midwifery.
            Lay midwives have set precedents in that they have successfully avoided any meaningful consequences when they have contributed to the death of a baby.

            Why should any midwife be held accountable or punished when so many before her have done similar things and walked away?

            Some midwives have stopped practicing voluntarily but few have ever been forced to stop practicing.

          • Samantha06

            Yep. And what is so sad is that the culture is accepted and even applauded by the NCB crowd.

      • Amazed

        I remember the case you’re talking about. The “Anita feels bad enough about it already” part had me collecting my jaw from the floor the very first time I read it.

        You know what? Even if it was about poor Anita and not minor details like mothers and babies, poor Anita SHOULD have felt bad. The crazy bitch basically killed a baby and the rest of them crazy bitches all brushed it away. And someone who teaches ethics hails that kind of “cooperation”?

        Kudos to you, Dr Reily, for participating and showing that Dr Burcher is just one OB and not the face of American obstetrics rallying behind the crazy.

      • PrimaryCareDoc

        Holy. Shit.

        Anita feels bad enough already?

        I wish I could post a picture of the expression on my face.

      • PrimaryCareDoc

        I just read the “disciplinary action”. She got a ONE MONTH suspension of her license and had to take 2 (non-specific) midwifery classes????

        I am stunned. Blown away. That’s discipline?

        http://www.oregon.gov/OHLA/DEM/docs/Final%20Orders/Rojas_A_749869_07-5100_11-25-08.pdf

        • fiftyfifty1

          One month!? A doctor who manipulated a teen nullip into delivering a breech baby at home could never work again.

          • PrimaryCareDoc

            Rightfully so.

          • fiftyfifty1

            Yes. This is unethical at so many levels. I cannot believe that a homebirth was something that this young mother was insisting on all on her own. And even if it were, the ONLY ethical response to the situation would be to absolutely refuse to attend her at home and do everything in your power to convince her to deliver in the hospital.

          • Ash

            Wasn’t she 21? I found the news article online. Her name began with a K.

            Not like that really changes anything.

        • Amazed

          One month? ONE MONTH? And that’s the kind of collaboration Dr Burcher is extolling? The kind of practitioners that invigorates his practice?

          Why the hell does HE have his license? That’s patient endangerment that he’s endorsing.

      • PrimaryCareDoc

        I’m still stunned over this. I’m just picturing how it would go if someone stood up at an M&M conference and said that we weren’t going to talk about a doctor’s mismanagement of a case because he felt bad enough about it already. They would be laughed out of the room.

        • Squillo

          Would be a great “House” episode, though.

          • Cobalt

            Why is there not a House episode with a homebirth? Too many great lines for House, not enough time?

          • Dr Kitty

            House needed a medical mystery to solve.

            Imagine:

            Patient: “Dr House, I’m having breech/cephalic MoMo twins, and I want a Homebirth, because my CPM And doula tell me it is safer than hospital. My evil OB insists I have a prelabour CS before 37 weeks. I’m here for your opinion”.

            House: “Well, this is a train wreck waiting to happen, and you’re a moron if you believe the cackling witch in the corner who tells you differently. Are you that desperate to ruin your own bedlinen that you want to kill your children to do it? I’m high on Vicodin right now, and I still think it’s crazy and stupid”.

            The End.

          • Samantha06

            Love it! The cackling witch description is great!

          • Dr Kitty

            Let’s just say I expend a considerable amount of time and effort suppressing my inner House.

            Channelling him for that post was quite cathartic!

          • Dr Kitty

            By which, to be absolutely clear, I mean I bite my tongue and try to be nice to my patients, not that I have an addiction that I’m barely in control of.
            🙂

          • Samantha06

            I think all of us in health care bite our tongues at times. I know I do! For me, it’s not so much with patients as most of them are pretty decent. It’s the midwives and doulas I have to “grit my teeth and smile” for! Next time I get really pissed at one, I’ll think of her as a cackling witch, then I’ll have to keep from laughing in her face!

          • Dr Kitty

            I’m a GP, which means people come in, tell me their symptoms, and, when I suggest a safe and effective treatment say “I’m not really a tablet person”.

            Which leads to me NOT saying “oh, sorry, I’ll just wave my magic wand ” or “why did you come and see me then?” and instead we have a nice chat about the totally ineffective “natural” things they’d like to try instead, and why I think my original suggestion is better.

            Here is the deal. I’m a Dr.
            I am likely to suggest an examination, tablets, blood tests, scans or scopes for things that bother you enough to come and see me about if they haven’t settled with first aid and over the counter remedies.
            That’s my shtick.

            Do not come and see me with serious symptoms if you want me to recommend ignoring them as a sensible course of action.
            I am not here to be co-dependent in your denial.

            Oh…once you let House out, he’s quite hard to put back in his box…

          • Samantha06

            I do hear similar things from the GP’s I work with, but it doesn’t seem to be as prevalent here. It’s frustrating for sure. I get irritated when I have a patient in labor who gets angry when we simply ask if they want an epidural. They assume we are “pushing” it on them.But the thing that really gets my goat is when they’ve declined, and declined, and then all of a sudden, they are overwhelmed, start screaming and *demand* the epidural *right now*!

          • Anj Fabian

            Because that’s how hospitals work, right?

          • Samantha06

            Oh absolutely! You can’t win with patients like that. They get pissed off because they had to wait 5 or 10 minutes for the epidural, of course after they made a big production of refusing it when it was the optimum time to get it and the anesthesiologist was readily available.

          • fiftyfifty1

            “I’m not really a tablet person”

            Ah, English English….
            What they say here is “I’m not a big pill person.”

            I practice near the headquarters of a large international company, so get a few patients from the UK. The concerns they bring are no different, but it’s always refreshing to hear them expressed in new language,

          • Roadstergal

            I remember, early on in the series (I fell off as I felt impending shark-jumping), they had an aside where a crunchy type told him smilingly, during clinic, that they weren’t going to vaccinate their pretty little baby, and he had a rant that involved ‘tiny little coffins’, IIRC.

            Also, “Are you that desperate to ruin your own bedlinen that you want to kill your children to do it?” You need to write House fanfic. 😀

          • Dr Kitty

            The medicine in House was horrible.
            There was an episode where the patient had a liver biopsy before they had an LFT blood test…
            Which is like putting in a skylight before you’ve laid the foundation.
            But it was engaging to watch nonetheless.

            There are two shows that have got the medicine right more often than not. Nurse Jackie and Scrubs.
            Honestly, those are the shows where I wasn’t tempted to throw things at the TV and shout “fire your consultants”.

          • Haelmoon

            Scrubs was the best – I just recently got acces to US netflixs, and am super excited to watch scrubs!! I loved it, it was more realistic than anything else (although nurse Jackie is a close second I agree). Grey’s and ER just total are bad when it comes to obstetrics (not that it stops me from watching). Secret joys on call at two in the morning!!

          • araikwao

            Ah, the perfect place to admit I’ve been catching up on very old episodes of Grey’s while on holidays from med school! I was annoyed to see Bailey declining an epidural because it would “increase my chances of a C-section” (obviously she can decline an epidural if she wants, just a shame it was on false information).

          • Haelmoon

            Grey’s is VERY bad when it comes to obstetrics in general. For a while they had an MFM fellow on (about the time I was in fellowhip myself). My goodness, the things the fellow was doing would not normally be seen by MFM anyways, but she was just being used as a glorified resident. At the time of Callie’s car accident, there was a whole bit on age of viability and the fellow was in trouble for not giving steroids at 23 weeks. ACK – so unrealistic to present the case this way, most babaies at 23 weeks die, those who do survive mostly have long term diabilities, not the perfect little girl they ended up with. But then, it is just TV, but I love to vent. My husband can’t figure out why i watch it, only to yell at the tv. I remind him her does the same with hockey games and he lets me watch in peace. Netflix has been great, because now I catch up on call, while waiting up for babies in the middle of the night.

          • Ash

            Wait, the people in Grey’s Anatomy practice medicine? I thought they just had romantic affairs in hospital closets.

          • araikwao

            Addison is still in the series I’m watching atm, and she mot only delivers the babies, but does the surgery to correct the jejunal atresia and looks after them in NICU too!

  • fiftyfifty1

    From Dr. Burcher’s opinion piece:

    “if obstetricians want a seat at the table to make recommendations regarding when women should travel to a hospital or birth center because of their remote home location, they are going to need to take a position that acknowledges home birth as a reasonable option that some women will choose ”

    I don’t see why this would be the case. You can acknowledge that some women will choose homebirth without having to endorse it as a “reasonable option”. You can be part of a team that drafts travel recommendations for rural pregnant women without recommending that they just stay at home instead.

    • MLE

      Which table would that be, the gross incompetence table? Nice how he frames it as though OBs are on the outside looking in, when most women choose OBs to begin with.

      • fiftyfifty1

        no, the You’re Not the Boss of Me table.

      • Siri

        OBs are a humble and inferior species, tolerated at best, untouchable at worst. Their proper stance is cap-in-hand, forelock-tugging, base prostration before the midwife goddesses and their acolytes. Have you heard the story of the little matchstick girl? That’s an allegory. The girl represents the OB.

    • Sue

      Agreed – this is illogical nonsense.

      Can specialist clinicians only make best-practice recommendations if they acknowledge that nowhere-near-best-practice is acceptable?

      This guy’s thinking is a study in cognitive error and logical fallacies. Is he even a particularly good OB?

  • NatashaO

    If we are striving to replicate the Dutch model, the first thing we should do would be to eliminate the CPM/DEM. Right?

    • Sue

      Exactly – which would automatically exclude Collaborator Cheyney, no?

  • LADowns

    OT: Have you seen this article from The Guardian, Dr Amy? It has been circulating quite a bit here in Canada, and I’m more than a little annoyed that while it states several times that the risk of homebirth is very low, no links to studies, or even citations to studies/data are included. It is a waste of time to point this out to the women posting this article like it is an absolute truth — even though the Midwife education program in Ontario at least (I cannot say for other provinces) IS an intense 4-year university program, and is highly competitive (or so states the information page of most universities that offer it). I don’t aim to deny women the option of a home birth that is attended by a well-educated, competent, and strictly regulated midwife (we have those regulations here), and I do know that midwives here can and do order the regular rounds of prenatal testing (US, bloodwork, optional genetic disorder testing, etc.) However, I feel strongly that this sort of article dismisses the very real risks that even a competent midwife may not be able to deal with — and if you live, like HUNDREDS of upper Ontario women, more than 20 minutes from a hospital with an OB ward, those dangers are very, very real.
    Are there any studies that speak more to Canadian standards or Canadian risks? Too many of my female friends dismiss the dangers because, “Oh that only happens in the States. We’re better here.”
    Thanks.
    http://www.theguardian.com/lifeandstyle/2014/dec/03/low-risk-pregnant-women-urged-avoid-hospital-births

    • Who?

      I saw that one yesterday, it is odd. Not sure whose barrow is being pushed, perhaps the second shoe will drop at some point.

      Cliches out.

      • LAdowns

        It is sufficiently vague, and entirely irrelevant to Canadian statistics and Canadian standards of care that it makes it frustrating that there is no way to point out where the ‘information’ comes from. 😛

  • Young CC Prof

    An ethical response to home birth as it currently exists in the USA is to:

    1) Be honest about the risks, how to reduce them through testing risk-out and transfer, and the fact that they cannot be completely eliminated.

    2) Legislate basic responsibility for home birth midwives (a malpractice insurance mandate is probably the easiest way) and oppose legal recognition of any midwife who does not hold a CNM, CM, or equivalent degree.

    3) For doctors, continue to support a pregnant woman’s right to bodily autonomy even when making choices you disagree with, and treat home birth transfers compassionately.

    Backing up a fake midwife and allowing her to continue practicing is not on the list.

  • Martha Reilly

    I have worked with Paul, at the same hospital, at the same time. He continues to commute from New York to Oregon to attend Homebirth Summits and the like. He and Missy Cheyney collaborate frequently.

    When the MANA data was released, I asked him, a professor of ethics, how it was ethical for Missy (then the Chair of the Oregon DEM board, a professor at an Oregon state university, a MANA official) to actively hide such terrible statistics from the state (she actively refused to release the data to the state, even though the state funded its collection), from the midwives, and from the public. His reply was that to point out Missy’s glaring lapses in ethics was to needlessly vilify other practitioners.

    Paul admitted several terrible trainwrecks to our hospital after transport from home. The details would shock you, but I would violate HIPPA if I recounted them because they are so jaw-droppingly bizarre that the women would be identifiable. In other words, he is not unaware that even (and especially!) on Missy’s home turf, midwives are doing incredibly stupid things. I cannot begin to explain his stunning lapse of ethical intent toward the women under their care.

    I wish I could not rattle off the names of twenty women I know, right off the top of my head, hurt by homebirth in Oregon, but I can. And apologists like Paul help make it all possible.

    I should say that before the advent of the CPM we had some really amazing midwives in our area. These were women who had studied long and hard, did careful risking out, were very clear about what was in their purview and what was not. The current crop? Not too bright, poorly trained, confident where they should be scared. True believers. Thanks, Missy and Paul. That one is on you. Both of you have the clout to make things better and yet you do nothing but defend the indefensible.

    • moto_librarian

      Is there any way for Paul to be held accountable for his role in this? If he actually admitted some of these home birth transfers as the backup physician, is he not culpable in some way?

      • attitude devant

        No, not really. Most of his backup was in ways that didn’t put him at risk—DEM Board stuff (supposedly he told the board that twins were within the scope of practice of midwives), articles like this, etc. As for transports, we all took turns with those. He got as many as the rest of us, but no more.

        • moto_librarian

          I simply cannot believe that a guy like this is teaching ethics or obstetrics. How jaw-droppingly awful.

    • Dr Kitty

      If you say “jaw droppingly bizarre” I’m going to assume things like a woman with a transverse lie who has been pushing for more than 6 hours, undiagnosed triplets, unrecognised complete uterine inversion from cord traction and seizures from blue cohosh overdose.

      Am I in the zone?
      Are they that level of incompetence and crazy?

      No details necessary, but if we’re talking about complications that haven’t happened in hospitals in the last 50 years, Dr Burch should be ashamed of himself.

      • attitude devant

        How about pushing for 6 hours at 6 cm? That was one. Some of the midwives don’t believe in cervical exams. Others don’t know how to do them properly.

        BTW, Dr. Kitty, one of the women who lost a baby here in Oregon was allowed by her midwives to push for 22 hours. I wish I were lying or joking. How insane is that?

        • moto_librarian

          22 hours?! Holy shit.

        • Who?

          How is 22 hours even possible? I pushed for a grand total of less than 2 hours in 2 deliveries and the physical effort and pain would have killed me had it gone on and on, even after shortish first stages. And the poor baby.

          • attitude devant

            Well, keep in mind too that one of the consequences of obstructed labor is uterine atony, leading to post-partum hemorrhage. So, mom suffered quite a bit. And of course she lost her child.

          • Amy M

            My entire labor including pushing was 22hrs….yeah, its amazing the woman in question did not die herself. Though I see below she hemorrhaged, which must not have shocked any real medical professional involved.

        • Haelmoon

          Having come from Bangladesh recently, I sadly heard many stories of women pushing for 22+ hours. They were all patients at the fistula hospital. They had all lost their babies and had C-sections for subsequent babies. There is a reason we don’t need access to fistula hospitals in the developed world – it is because we have timely access to C-section.

        • Bombshellrisa

          I can believe it though-I have had friends attempt homebirths and their midwives let them push for 6-8 hours and then transfer to the hospital when the midwives told them “I think you need a forceps delivery”. I doubt they were fully dilated while they pushed at home. But their midwives told them to push when they felt like it and that is what they did.

        • Dr Kitty

          So…yep…in the zone.

          If you want to be an independent healthcare Practictioner you need to have some mechanisms in place to ensure competence and to weed out unethical, dangerous people.

          “Independent” assumes you have the knowledge and skills not to require supervision. It shouldn’t mean a complete lack of standards, oversight and accountability.

  • moto_librarian

    I am in a particularly grumpy mood today. An acquaintance is expecting her third child. Her other two were delivered by the same hospital-based CNM practice that delivered my own children, yet she has decided to have a home birth this time. Now, she is at least low-risk and has a proven pelvis, but the area of town that we live in is at best 30 minutes from the closest hospital with a labor and delivery ward (there is a hospital around 15 minutes away, but it closed its L&D several years ago). During rush hour, it could easily take 45 minutes to an hour to transport, yet she had no problem finding a midwife willing to deliver her at home. Should things go awry, it is extremely likely that there will be a poor outcome. The absolute risk may be low, but it exists.

    • Young CC Prof

      If someone other than her and the midwife will be at the birth, it might help to make that person aware of the WHO partograms and of the fact that a third labor should take LESS time than the previous two, since the midwife can’t be trusted to know (or believe) it.

      • moto_librarian

        Her husband will be there (and probably their two children). I just didn’t know what to say when she told me she was birthing at home. Her kids are friends with mine, and I worry about them witnessing something bad as much as anything else.

        • Bombshellrisa

          Even if it’s a straight forward birth, children can still be afraid of the sounds and sights they will be faced with. My husband was present for the birth of his siblings and he was terrified (both births were uncomplicated). I guess it depends on the child.

          • anotheramy

            Heck, i’m 33, delivered 3 kids and I don’t like the sights and sounds of delivery. I’ve tried to watch birth videos on YouTube and I can’t click “close” fast enough. I can see why a kid would be scared.

    • Who?

      I have nothing useful but everything crossed that it goes okay. Then of course there will be another ‘home birth is so awesome, what do all those worry-warts know’ story, but I guess that’s the most minor cost of these decisions.

      Also thinking of all those women all over the world who will deliver at home at the same time as your friend who would love to be in a setting where they could be cared for properly.

    • mostlyclueless

      Since the odds are in her favor, chances are everything will go fine, and she will then have “proof” in her mind that home birth is safe.

    • Elaine

      I know a lot of people who have had home births in similar situations. Drives me nuts. And then when the birth does go well, they’re on Facebook recommending home birth to everyone else. ARGH.