Midwife-led care kills babies and mothers


Despite my misgivings about midwife-led care, I would not have predicted this.

The Dutch experience with midwife-led care kills babies (and possibly mothers). The Netherlands has one of the worst perinatal mortality rates in Western Europe, and, remarkably, Dutch midwives caring for low risk women (home or hospital) have a HIGHER perinatal mortality rate than Dutch obstetricians caring for high risk patients.

Dutch midwives have acknowledged this hideous reality [link no longer active]:

In 2011 Dutch midwifery is under a microscope. Maternity care in general in The Netherlands has come under scrutiny by governments, media, the public and care providers themselves after two consecutive European Perinatal Statistical Reports ranked The Netherlands among those with the highest rates of perinatal and neonatal mortality compared to other members of the European Union (and Norway)…

… We have learned that infants born to women of low risk whose labour started in primary care with midwives had higher rates of perinatal death associated with delivery compared to those beginning labour in secondary care…

Yesterday’s publication of the Morecambe Bay report on a Cumbrian midwife-led hospital unit shows that midwife-led care has been a deadly failure in the United Kingdom as well. The report identifies 16 perinatal deaths and 3 maternal deaths that had taken place in the unit as potentially preventable, and concluded that the deaths of 11 babies and 1 mother almost certainly could have been prevented and the other deaths might have been averted.

My objection to midwife-led care came from my belief that care should be led by the most knowledgeable, most skilled members of the team. In this case that would be obstetricians and pediatricians. But the National Health Service (NHS) made a proverbial deal with the devil in order to save money. Midwives appear to be less expensive because their salaries are lower. Dutch authorities made the same deal for the same reasons.

I would have predicted a slight decline in the quality of care. Even I’m shocked that midwives have placed their needs and desires ahead of patient care, with the inevitable deadly consequences.

Midwife-led care kills babies and mothers because in the early 21st Century, midwife-led is ideology-led care.

The ideology is the philosophy of natural childbirth and the belief that unmedicated vaginal birth is healthier, safer and better than childbirth with interventions.

That ideology is utterly, spectacularly, fatally wrong. Interventions don’t kill babies and mothers; LACK of interventions is what kills them.

Childbirth is inherently dangerous. Obstetrics is preventive medicine, and the liberal use of childbirth interventions saves lives. Neither Dutch nor British midwives believe that, but both have unwittingly proven it yet again. The Dutch and British experience with midwife-led care merely confirms the fundamental truth of these historical facts.

Why do Dutch and British midwives place ideology over the health and lives of the patients they are ethically mandated to protect? Because the ideology of natural childbirth dovetails neatly with the self-interest of midwives. “Normal birth” is the holy grail of contemporary midwifery. Normal birth is distinguished from non-normal birth by a bright line; if it is under the purview of a midwife, she calls it normal and pronounces it “good”; if only an obstetrician can do it, she derides it an unnatural, dangerous and traumatic.

Midwives have an economic incentive to keep births for themselves. Normal birth provides the ideological justification for failure to acknowledge high risk situations, failure to acknowledge when low risk changes to high risk, and failure to acknowledge that greater expertise (of obstetricians and pediatricians) is needed. Babies and mothers die because it is more important to the midwife to keep the patient for herself than to provide the care that the mother and her baby need.

I would argue, though, that at some level, both British and Dutch midwives understand that they are providing substandard care. This recognition reinforces the midwives’ antipathy to calling for assistance when it is needed. By the time they urgently need to call for help they know that they have discounted risk factors, mischaracterized high risk patients as low risk, and ignored glaring warning signs. Paradoxically, the bigger the disaster they create, the less likely they are to call for help, because a laundry list of their errors will be revealed.

Many midwives want to practice in a way that violates safety standards, hence the relentless calls for autonomy. Within The Netherlands homebirth is promoted aggressively; in the UK, midwives are relentless in their promotion of homebirth as well as midwife-led units such as that in Morecambe Bay. They want to avoid any oversight.

Consider President of the Royal College of Midwives (RCM) Cathy Warwick’s tone deaf response to the horrors that occurred in Morecambe Bay.

The Morecambe Bay report stated:

…Whilst natural childbirth is a beneficial and worthwhile objective in women at low risk of obstetric complications, we heard that midwives took over the risk assessment process without in many cases discussing intended care with obstetricians, and we found repeated instances of women inappropriately classified as being at low risk and managed incorrectly. We also heard distressing accounts of middle-grade obstetricians being strongly discouraged from intervening (or even assessing patients) when it was clear that problems had developed in labour that required obstetric care. We heard that some midwives would “keep other people away, ‘well, we don’t need to tell the doctors, we don’t need to tell our colleagues, we don’t need to tell anybody else that this woman is in the unit, because she’s normal’” …

In her response, Warwick IGNORES the central role of midwives in the deaths of babies and mothers. Warwick does not use the word “midwife” even once!

What does she claim that the report showed?

The report recommends that there should be a national review of the provision of maternity care and paediatrics in challenging circumstances, including areas that are rural, difficult to recruit to, or isolated…

The report states that the educational opportunities afforded by smaller units, particularly in delivering a broad range of care with a high personal level of responsibility, have been insufficiently recognised and exploited…

Finally, the report expresses concern about the ad hoc nature and variable quality of the numerous external reviews of services that were carried out at the University Hospitals of Morecambe Bay NHS Foundation Trust…

Warwick’s response is an affront to those who lost loved ones at the hands of RCM midwives and it is an insult to our intelligence. Not only does it fail to acknowledge the problem, it IS the problem. Warwick puts the interests of midwives ahead of patients’ health and lives.

The very first step in improving midwifery care in the UK would be to fire Cathy Warwick and reorganize the RCM; she has led the way in demonstrating utter contempt for the health and lives of British babies and mothers. It is under her watch that the reprehensible RCM “Campaign for Normal Birth” was created and promoted.

Midwife-led care kills babies and mothers. It has been in a failure in The Netherlands and it has been a failure in The UK. It’s time to call an end to this deadly practice before even more babies and mothers die on the altar of “normal birth.”

142 Responses to “Midwife-led care kills babies and mothers”

  1. anotheramy
    March 7, 2015 at 10:18 am #

    This post prompted an uncomfortable discussion with my kindergartner who can read. He saw the post title and wanted to know what a midwife is & why they kill babies & mothers. I tried to explain in simple, understandable terms without scaring him, in case I ever have another baby. Note to self: now that he can read well, be careful what blogs you click on! 🙂

  2. Young CC Prof
    March 5, 2015 at 3:14 pm #

    A subtle point of grammar: Some midwives aim to help women who ARE having normal births, some help women to HAVE normal births.

  3. March 5, 2015 at 2:06 pm #

    Reading through this, and the previous post’s comments [on Morecambe] what strikes me most is that [1] the switch to direct entry midwives in the UK drastically reduced the professionalism and education of the profession from the time when only State Registered Nurses could do a midwife’s course, and [2] the demise of the collaborative relationship with the medical staff that I remember from my time at Cambridge, and the switch to an adversarial one, where the doctors are almost vilified, are the two problems at bedrock with what has happened to a once proud service.

    Everything else follows from this. I had a high degree of autonomy, but my limits were very clearly defined, and failure to observe them was punishable by withdrawal of my license. It actually gave me a great deal of security, because the doctors responded quickly when I called, knowing that they weren’t being called unnecessarily, and I felt I had good backup at all times. Now it seems that UK midwives are trying to replace doctors, and that’s absurd.

    • Mattie
      March 5, 2015 at 3:12 pm #

      Some of what you are saying I agree with, some not. I don’t feel that direct-entry midwives are necessarily less professional or less educated although some are a lot younger. I did one year of a midwifery course before mental health, finances and bullying issues forced me to leave, aside from many of my classmates (who were great student midwives and now are qualified and I would trust them with my own care) many of the qualified midwives I worked with were young and came in to midwifery direct, they were the most professional and caring midwives I came across, the older midwives were often backward in their practice, disinclined to listen and for want of a better word…bitchy. Now, not all nurse midwives are like that, and not all direct entry midwives are good, but some are.

      However, I do feel that there is a lack of ‘fear’ maybe in practice and some midwives feel that rather than being experts in normal, and the deviations from normal, they are experts in everything and are no longer worried about the potential for catastrophe if they go outside their fear of practice. As with all healthcare providers, midwives are part of a team, and good midwives should be able to go from lead professional, to assistant, to mother’s support, without feeling threatened.

    • Joy
      March 5, 2015 at 4:59 pm #

      I gave birth at Addenbrookes in 2013. They have a snazzy new birth centre, which I didn’t get to use because I developed ICP. I thought the upstairs was ok, but when the Consultant came in saying the baby’s hr was going up the midwives tried to encourage me to keep pushing. I had been pushing for 2 1/2 hours and I said I wanted to go with what the doctor says. I guess if I had been more in the woo I might have kept going, but thankfully I knew better.

  4. Cobalt
    March 5, 2015 at 12:08 pm #

    This is just horrific, and terrifying. I visit medical professionals when I am sick, or hurt, or at risk of harm from my body. I put my trust in their desire to make people well and their education to know how to do so. To think these midwives are objectifying their patients to this extent, turning vulnerable women and babies into mere entertainment, allowing them to be injured or killed in the process, is sickening. Who’s “playing God” now?

  5. Amazed
    March 5, 2015 at 10:06 am #

    OT (not quite): Publisher-led care kills books.

    Of course, not all publishers are glaringly ignorant. But I’m dealing with one who is. Three of us are trying to explain that punctuation in different languages differs. Who knew – it differs?! To hell with it, I am NOT erasing dashes just because there aren’t nearly as many in the English text. And I’m trying not to tell him that he has no idea what the hell he’s talking about.

    Gods! Listening to ignorants inventing flaws in my work is maddening. How on earth can you do this? Doctors, RNs, CNMs? How can you stand those ignorants lecturing you on vaccines and evils of medicalized birth? Let alone the fact that killing babies and mothers is far more dangerous than killing books.

    • Daleth
      March 5, 2015 at 11:05 am #

      Omg how frustrating. Punctuation differs between the US and UK, much less between different languages.

      • Amazed
        March 5, 2015 at 11:50 am #

        Fortunately, it’s settled now. I just hope my explanation sinks in and we don’t have the same conversation tomorrow…

        • Joy
          March 5, 2015 at 5:03 pm #

          I was once told, after correcting someone’s powerpoint for an external presentation, that it might be vice versa in the US, but in the UK it is visa versa. Ummmmm, nooooooooo. Whatever, I left it. I hope they thought she was a fool.

  6. Margo Townsend
    March 5, 2015 at 5:14 am #

    Feb 2015 a study that finds midwifery referrals in Netherlands to obs on the rise and CS rate up. Statements such as midwife led care kills mothers and babies is inflammatory and serves no purpose what so ever, and is, frankly ridiculous.

    • The Bofa on the Sofa
      March 5, 2015 at 8:52 am #

      Thank you for your concern.

      • moto_librarian
        March 5, 2015 at 1:26 pm #

        “Then why is the floor wet, Todd?”
        “I don’t know, Margo.”

    • Neya
      March 5, 2015 at 9:32 am #

      Would you provide references to the study you mention?

    • The Computer Ate My Nym
      March 5, 2015 at 9:38 am #

      I’d also like to see the study you mentioned. It’s a good thing if true, it means that midwives in the Netherlands are considering the problem and trying to do something about it.

    • moto_librarian
      March 5, 2015 at 10:51 am #

      Perhaps that is because midwives in the Netherlands are legitimately concerned and seeking to provide safe care. Midwife-led care IS killing mothers and babies, both abroad and in the States.

    • attitude devant
      March 5, 2015 at 12:07 pm #

      Wouldn’t it be grand if NZ midwives followed suit and did the same?

    • Roadstergal
      March 5, 2015 at 12:13 pm #

      From their alarming mortality statistics, it had looked like they were under-referring and under-CSing, so if this is true, excellent news for women and babies.

      • The Bofa on the Sofa
        March 5, 2015 at 1:29 pm #

        Yeah, isn’t the fact that they are changing their practices and doing more referrals basically an admission that they weren’t doing it right before?

        Seems to me that statements “such as midwife led care kills mothers and babies is inflammatory” not only don’t “serve no purpose” but, because they are true, affect change.

    • Sue
      March 6, 2015 at 5:09 am #

      Is this the paper?
      Offerhaus et al BMC Pregnancy and BIrth Feb 2015:
      “Variation in referrals to secondary obstetrician-led care among primary midwifery care practices in the Netherlands: a nationwide cohort study”


      The wide variation between referral rates may not be explained by medical factors or client characteristics alone. A high intrapartum referral rate in a midwifery practice is associated with an increased chance of an instrumental birth for nulliparous women, which is mediated by the increased use of obstetric interventions. Midwives should critically evaluate their referral behaviour. A high referral rate may indicate that more interventions are applied than necessary. This may lead to a lower chance of a spontaneous vaginal birth and a higher risk on a PPH. However, a low referral rate should not be achieved at the cost of perinatal safety.

      If it is, their conclusions are not at all reassuring, are they? The authors appear to be ony interested in preventing “interventions”, not improving outcomes.

  7. Scandinavia
    March 5, 2015 at 3:00 am #

    I just stumbled on this blog and thought I’d post my two cents, although I’m not interested in taking part in your political debate. 🙂

    I think it’s not a problem to have a midwife led care per se since the important thing is how the system is designed. Finland and Sweden have the worlds lowest perinatal mortality rates (around 4,0-4,5 in the last years). Virtually all births are done in hospital settings (of 60.000 births, 15 were planned home deliveries). However the delivery is in low-risk cases completely led by a midwife. There is usually only 0-1 deaths of the mother/year. All mothers are also routinely followed-up pre-birth, to check for any complications.

    We live in Finland and my wife gave birth to our daughter a week and a half ago and we didn’t even see a doctor until the third day (pediatrician who discharged us), since everything was normal. The birth was our first and lasted for 9 hours.

    However there was almost continuous following of the heartbeat during delivery (had my wife taken any medical painrelief, e.g. an epidural it would have been 100 %) and an emergency C-section could have been done immediately if something had been awry. The midwifes were also very adamant about the heartbeat. Had there been any known complications there would have been a much more rigorous monitoring. My wife also lost more blood than usual (around 1,1 liters), so they gave her a liter of saline fluid, but since she was quite alright nothing further was done.

    The baby got an 8 on the one-minute Apgar and nursed on the chest within the hour. A K-vitaminshot was given immediately, but measurements were taken only at two hours. Breastfeeding was promoted and we were in almost constant cangaroo-care for the following days, but it was actually quite nice since we weren’t that exhausted. The midwife checked in on us every now and then, and they did monitor the blood sugar for the first day.

    Neither of us would want a home delivery, but it was also quite nice to not have a completely medicalized experience. Of course the world-class NICU units and operating rooms are a must, however since everything was normal and my wife didn’t find the need for medical pain relief everything was very low-key, almost like a homebirth.

    That was just an anecdote, but do look at the statistics. Midwife-led care CAN lead to very low mortality rates, if it’s done right. Although our system couldn’t be transplanted to the Anglo-countries, you shouldn’t disparage all midwifes, just the ideological ones. 😉

    • SporkParade
      March 5, 2015 at 4:07 am #

      I had a somewhat similar experience to yours in Israel, but what your wife and I experienced is not, I believe, what Dr. Amy means by midwife-led care. In the UK and the Netherlands, the midwives supervise themselves. They are also responsible for prenatal care. In the Netherlands, you actually need *permission* from the midwife to see a doctor during pregnancy. That is very different from just being the primary birth attendant so long as everything goes right and staffing the maternity ward, which is what you are describing.

      I’d also add that I’m not sure what you think a “completely medicalized experience” is because what you described sounds pretty standard to me.

    • Montserrat Blanco
      March 5, 2015 at 9:08 am #

      I live in Spain and here midwifes attend all uncomplicated deliveries on the national health system, but the system is OB-led. You would typically have at least 5-6 prenatal appointments with an OB, and in case of ANY complication the OB would be the attendant. What you describe is the norm here, but the system is OB led. OBs are the ones that decide that you are low risk, everything out of the norm must be consulted with them, they are the heads of the Department, etc. We do not have midwives-only units as it happens in UK. It is a subtle difference and you might not notice it at the birth but it is there.

      In my case when I was considered low risk I had OB appointments at 12, 16, 20 and 24 weeks. Then things went south and I got weekly appointments with an OB, blood tests, US, etc.

      When things went really wrong at 27 weeks I got admitted. The ward was attended by midwives instead of nurses, but there were OBs 24/7. When I had a problem the midwife would call the OB and the OB would evaluate me.

      If everything would have continued to be low risk I would have gone to the hospital in labor at let’s say 40 weeks, got an epidural if I wanted and have a delivery attended only by midwives.

      • Roadstergal
        March 5, 2015 at 12:14 pm #

        That’s a very good point about the difference between midwife-attended and midwife-lead…

      • Inmara
        March 5, 2015 at 1:56 pm #

        Latvian system is very similar – standard providers of prenatal care are OB/GYNs, there are several check-ups and blood tests and at least 2 USGs during the pregnancy (12/13 w screening and then 20/21 w anatomy scan). In high risk pregnancies OB assigns as much tests and USGs as necessary. Also low-risk births are attended by midwives but they are in hospital setting and OBs are always present and in general responsible for what happens (so it’s OB led care not midwife led). We don’t have such thing as CPMs too – I actually can’t wrap my head around how it’s so common practice to allow persons without medical training to assist births and especially at home. Here only very experienced midwives attend homebirths and they have equipment for treating most common complications (like stabilizing PPH or performing resuscitation). So far all assisted homebirths have been successful but probably it’s pure luck and statistics (small population and small count of homebirths).

    • Neya
      March 5, 2015 at 9:39 am #

      You care system sounds fantastic. It would also not be considered midwife-led care here. I think that this blog would not exists if CPM in the US would have rigorous training and practiced under the very well-regimented standards you described. It is not the case here.

    • fiftyfifty1
      March 5, 2015 at 9:43 am #

      ” but it was also quite nice to not have a completely medicalized experience. ”

      Not sure what you mean exactly. The care you received at the birth sounds pretty standard to me. Apgars were done, baby had frequent monitoring, blood loss was measured, vitamin K given–these are all standard medical procedures at a hospital birth in the US. You also got a large IV bolus for postpartum hemorrhage and postpartum glucose monitoring. These are not standard if things have gone normally, but are common procedures if indicated.

      Do midwives there typically do a managed third stage (a dose of Pit immediately upon delivery of the baby and gentle traction when indicated to deliver the placenta in a timely manner)? A managed 3rd stage is standard OB care in the US, and greatly reduces the chance of postpartum hemorrhage. If you are not sure, it would be good to find out for your next birth, and insist on it. Although it sounds like your wife will be considered high risk in any case for her next birth, as a history of a large PPH is the best predictor of another one happening.

    • The Computer Ate My Nym
      March 5, 2015 at 9:44 am #

      I had a very similar experience in the US: CNM who collaborated closely with OBs monitoring me during labor, frankly told me that I should get an epidural (I was in the koolaid zone and was trying to claim that all I needed was a little stadol for the 10/10 pain, but was convinced by the unanimous opinions of the midwife, my partner, and my mother), and called in an OB to do the c-section as soon as the monitor showed it was time. A well educated midwife who knows her or his scope of practice and practices in an evidence based manner can be a very effective practitioner.

      Also, I’d love to transplant your system to the US. Why can’t we have it?

      • fiftyfifty1
        March 5, 2015 at 9:55 am #

        “Also, I’d love to transplant your system to the US. Why can’t we have it?”

        I’m confused. You say your US experience was very similar, yet you would love to transplant the Finnish system here. What are you referring to exactly?

        • The Computer Ate My Nym
          March 5, 2015 at 9:58 am #

          I meant the Finnish/Scandinavian system in general. My experience had a lot to do with my being a well insured patient in a major metropolitian area (actually, NYC: THE metropolitan area in the US…at least according to New Yorkers). I’d like it to be available to everyone. Not just the obstetrical piece, but the whole thing: universal health care coverage, equal access to care for everyone, better cancer outcomes, the whole thing. Plus the baby box sounds cool and I didn’t get that.

          • fiftyfifty1
            March 5, 2015 at 10:14 am #

            Yes, universal health care. So pathetic that we don’t have it.

          • Sue
            March 6, 2015 at 5:17 am #

            Finland does have great public health and education systems. They do have the advantage, though, of a very small national population (about 5.5 million) which is relatively homogeneous.

    • Sarah
      March 5, 2015 at 1:15 pm #

      A shame they felt the need to promote breastfeeding though, rather than just support all women in the way they want to feed.

    • Sue
      March 6, 2015 at 5:13 am #

      There may be a semantic argument about what midwife-LED care means.

      In Australian public hospitals, the vast majority of uncomplicated vaginal deliveries are midwife-attended, with medical referral if complications or difficulties are encountered. I would like to see this as a collaborative model – but is midwife-attended the same as midwife-led? Perhaps not.

    • Dr Jay
      March 6, 2015 at 12:11 pm #

      Continuous monitoring, active management of labor (as warranted), and an active third stage of management are all obstetric “interventions” and are not usually found in the types of births that we are talking about. I work in Australia, in a tertiary center, and even our caseload midwives (who operate semi-independently) consult with us all the time. Their patients deliver in the delivery suite with everyone else, and if there’s a problem they come find us (obstetricians). So, just quietly, by the standards you are referring to, you did have a “medicalised birth.” :). Glad to hear you enjoyed it. Contrary to popular (radical midwifery) belief, we’re not ghouls prowling the corridors looking for women to C section! I wish more people realised that just because you don’t see our face doesn’t mean we’re not involved with your care…. Sounds like your hospital had a good collaborative set up.

  8. March 4, 2015 at 8:42 pm #

    Why are they striving for Nermal birth? :/

  9. Amy Tuteur, MD
    March 4, 2015 at 8:00 pm #

    Australian midwife Hannah Dahlen, another proponent of midwife-led care, weighs in on the Morecambe Bay horror:

  10. Amy Tuteur, MD
    March 4, 2015 at 5:20 pm #

    Cathy Warwick of the RCM expands on her previous comments:


    • Anj Fabian
      March 4, 2015 at 6:51 pm #

      Wow. She walked back her original response in a big way!

      Let’s see if she if she can do something to support this new statement.

    • Daleth
      March 5, 2015 at 11:40 am #

      Yes, she did walk back and respond more appropriately. But this really gave me pause:

      “it was comforting to note Dr Kirkup’s acknowledgement that the great majority of staff in the Morecambe Bay Hospitals set out to help patients not to harm them…”

      Wait WHAT?!? It is COMFORTING that only a FEW staff members set out to harm patients?!?!?!?!?!?!

      And it is comforting that most staff members wanted to help patients?!?!? How is that COMFORTING? Isn’t that just the absolute most minimal baseline from which any kind of medical care MUST start?

  11. Amy Tuteur, MD
    March 4, 2015 at 4:19 pm #

    Some of the midwives responsible for the deaths are STILL working at the hospital:


  12. the wingless one
    March 4, 2015 at 1:24 pm #

    OT: any thoughts on this study? https://news.brown.edu/articles/2013/06/breastfeeding

    A friend posted on fb, I’m sure she didn’t mean for it to be insulting but I’m curious if it has merits of just another study attempting to shame mothers who can’t/don’t want to breastfeed. I don’t have the scientific background to analyze it myself but I know that people here do!

    • Mel
      March 4, 2015 at 2:00 pm #

      I have a few concerns.
      -The study is based on interview recollections of how long a kid was breastfed. Memory of a parent of a 3.5 year-old might be shaky on exactly how long the kid was breastfed.
      – The three groups – EBF, EFF, and a mix of both – have no statistical differences in development when the MRI was taken. Any changes in white matter in the brain between the three groups must not lead to any major changes in functioning levels.
      -Maternal SES and education level is assumed to equal maternal IQ. I find that both highly suspect and insulting.
      My conclusion is “There are brain differences b/t EBF and other feeding methods, but those differences do not show any functional differences between the groups.”

      I feel the authors overstate the link between their brain scan findings and higher/better outcomes for children. In fact, the first table on the demographics of the study sample specifically disproves that point- there is no statistically significant difference in skill development between the infants in each group.
      For fun, ask your friend if she can tell the assumptions and limitations of multinomial logistic regressions since that’s what the authors base their study on.

      • Guesteleh
        March 4, 2015 at 2:09 pm #

        I don’t have any stats background but my initial take was the same as yours–even if they document a difference in white matter, bigger studies haven’t shown any difference in IQ between EBF and formula fed babies so who cares?

      • Mishimoo
        March 4, 2015 at 6:04 pm #

        “Maternal SES and education level is assumed to equal maternal IQ. I find that both highly suspect and insulting.”

        I agree, it reeks of class discrimination and racism.

        • DiomedesV
          March 4, 2015 at 7:18 pm #

          No, it reeks of “what variables can we estimate given the limited funds we have?”

          SES and education level are reasonable — not perfect — but reasonable proxy variables for IQ. They are routinely used, and in a limited funding climate, their use is fair.

          The fact that the study sample is so small and that there were no significant differences in MRI are far more salient criticisms.

          • Mishimoo
            March 4, 2015 at 7:50 pm #

            Or even “How can we prove the point we want to make, given the limited funding?”

            I can see what you’re saying, I just think that using SES and education levels as proxy variables for IQ is flawed as it fails to take other variables that impact on all three into account. It can come across as “The poor are poor because they’re not smart enough to do better.” when there are so many complex reasons behind an individual’s personal circumstances.

          • DiomedesV
            March 4, 2015 at 10:03 pm #

            They’re not perfect proxy variables. By definition, they’re not going to capture the variance you really want. That is the bugaboo of all these kinds of studies — residual confounding variance. But they are better than nothing. Including these potential confounders actually raises the quality of this study compared to other, mostly earlier, BF studies.

            I’m not defending this study. I think that doing correlative/associate studies like this on such a subject like BF, when we already know they’re inherently flawed and that the intrinsic selection bias they include is difficult to visualize, much less control for, is bad science. Studies that have a fighting chance of truly controlling for inter-family variance (i.e., the PROBIT study and the resent inter-sibling controlled study) have demonstrated that it constitutes the lion share of differences between BF and FF infants. But science is slow to adapt, especially when there isn’t enough pressure from funding agencies and scientific journals to change.

          • DiomedesV
            March 4, 2015 at 10:14 pm #

            “I just think that using SES and education levels as proxy variables for
            IQ is flawed as it fails to take other variables that impact on all
            three into account. It can come across as “The poor are poor because
            they’re not smart enough to do better.” when there are so many complex
            reasons behind an individual’s personal circumstances.”

            It is not, nor should it be, the goal of any individual study to address the complex reasons behind an individual’s personal circumstances. The whole point of aggregating data into larger sample sizes is to detect an effect that comes through *despite* the individual’s complex personal circumstances.

            Using SES and education levels is STANDARD for virtually all social science/educational/psychological studies. It is not intended to be a statement of anything. Moreover, given that IQ is affected by early environment, and that it is not a static variable over the course of development, it is not at all clear that always using IQ instead of these proxy variables would represent such an improvement that it justifies the expense/hassle.

            The problem is the underlying methodology of the study. Unless the authors are willing to categorize their data as entirely preliminary and not worth much mention, they should have done an inter-sibling comparison study. Anything less at this point is nearly useless.

    • Twilight
      March 4, 2015 at 2:05 pm #

      Well they only looked at 133 babies. Other studies on breastfeeding have looked at literally thousands of babies. Maybe formula fed babies are left in creches more and not getting much attention as their parents have to work?

    • The Computer Ate My Nym
      March 4, 2015 at 2:43 pm #

      I have the following initial concerns about the validity of the study:
      1. They claim that the children came from comprable backgrounds but I notice that the p-value for SES between exclusivly breast fed and exclusively formula fed is 0.12. In other words, there’s about an 88% chance that the difference between the two groups is NOT chance.
      2. The children’s scores on the Mullen tests are pretty similar. Is any observed difference in structure on MRI really that significant in the face of these scores being similar?
      3.OTOH in table 5 they do claim that they see a difference in receptive language…in older children, based on a sample size of about 20 in each group. Subset analysis should always be taken skeptically.
      4. The R2 on the duration of breastfeeding versus VF(M) is not impressive. Anything less than 0.5 I’m inclined to disregard. In other words, there doesn’t seem to be a strong dose/response pattern.

      My conclusion is that they MIGHT be on to something, but I’m dubious. I’m suspicious that this may be a good example of correlation not equaling causation.

      • the wingless one
        March 4, 2015 at 6:52 pm #

        Just wondering, for your point 1) can you clarify what you mean about the 88%? Is it that there’s an 88% chance that the difference between the two groups is likely related to their mother’s SES/education level and therefore not related to the factor of EBF vs EFF? Sorry if that’s a dumb question, just want to make sure I understand what you’re saying before I use it in part of my response to the article! Thanks for the super informative post 🙂

        • Mel
          March 4, 2015 at 7:50 pm #

          The authors ran a statistical test to determine if two groups were statistically different from each other.
          One of the outputs of the test is the p value. The p value tells the chances of the test finding that the two groups are NOT different when they are actually different in reality. For example, researchers in plant sciences (and many others) accept that a p value of less than 0.05 is the cut-off to say that the groups are statistically different from each other. Another way of saying it is that a p value of 0.05 means there is a 5% chance of misidentifying two statistically similar groups as different due to random chance while a p value of 0.45 means there is a 45% chance of making the same mistake.

          Since the researchers want the two groups to be nearly identical to start with, a high p value is good.

          For SES, a p value of 0.12 means that there is a 12% chance of misidentifying two identical groups as different groups. That doesn’t sound like a problem, but if the groups are truly identical, you’d want a much higher chance of misidentifying the two groups like 0.45 or .94.

          IOW – there is a good chance that the EBF and EFF groups are in different socioeconomic status groups as well as different feeding styles. If that is the case, the authors need to control for the effects of poverty on brain development – which is another whole can of worms.

          • the wingless one
            March 4, 2015 at 8:48 pm #

            This makes sense, thanks for the explanation!

    • Amy Tuteur, MD
      March 4, 2015 at 4:16 pm #

      I wrote about the study when it came out. The author participated in the comments.


    • the wingless one
      March 4, 2015 at 6:49 pm #

      Thanks everyone! I knew I could count on you guys for the real information. Now I’m just trying to craft a comment that is informative and not taken the wrong way….

  13. March 4, 2015 at 12:16 pm #

    This – ideology driven care results in bad outcomes. This is particularly true for those who do not agree with the ideology to begin with. In the UK and in Canada there are women who are ascribed their care providers – if you are low risk, you are assigned into a model of care. There are women – such as cesarean by choice mothers, who may well be “low risk” but are not sharing the ideology of these care providers. These women suffer harm, because instead of having their voices heard by a sympathetic provider, they encounter significant resistance. “Just try to have a vaginal birth” – “See how well you handle the pain before asking for the epidural.” “You don’t really need x, y, z – get by on fentanyl and gas.” “Just a little longer.” All of which is a violation of that woman’s right to determine what she does with her body after being provided the information she needs to make an informed choice. These women might well end up with “normal births” but they come at a tremendous psychological cost.

    • Young CC Prof
      March 4, 2015 at 12:17 pm #

      Exactly. There are a substantial number of women who have no interest in natural birth at all. And even among women who want a natural birth, the number who would take a significant risk to get it is very small.

    • Young CC Prof
      March 4, 2015 at 12:00 pm #

      On page 4, ” The lowest perinatal mortality rates occur for second born babies and those born to women younger than 35 years of age.”

      Second-born babies of women who had unremarkable first births are at the lowest risk of COMPLICATIONS. It is only in settings without adequate care that second-born babies are at lowest risk of death. For example, in the USA, there is no such pattern of decreased mortality in the second birth. (There is a pattern of increased mortality with higher-order pregnancies after the first few.)

      • Anj Fabian
        March 4, 2015 at 1:36 pm #

        If you want the lowest risk pool – multipara women who:

        have never had a complicated pregnancy or birth
        are not grand multipara
        do not have advanced maternal age

        That’s the lowest risk pool. It’s also a relatively small group because you have to jump through a number of hoops to get into it.

        I’ve never tried to quantify this. The average study is either looking at a specific high risk group, or looking at the standard group of prima para women who don’t have risk factors X, Y, Z – so those studies aren’t much help.

      • Anj Fabian
        March 4, 2015 at 1:38 pm #

        I’d also like to add that anecodotally I have seen the NHS classify at least one woman as low risk (Ehlers-Danlos) that I would have expected to be high risk.

        • The Computer Ate My Nym
          March 4, 2015 at 2:46 pm #

          Huh? They classified an Ehlers-Danlos as LOW RISK? That’s…not right. OB’s, correct me if I’m wrong, but I thought there was a very high risk of aortic dissection during second stage with at least some forms of EDS.

          • Daleth
            March 4, 2015 at 4:09 pm #

            Yep. Ehlers-Danlos type 4 has the really glaring risk of cardiac/blood vessel problems, and AFAIK all E-D patients are at higher risk of healing complications from any wounds they may incur (c-section incisions or perineal lacerations… but really… is there anyone here who, if forced to experience a wound that’s not healing properly, would rather it be a jagged wound in their genitals betwixt the vag and the anus, instead of a clean incision on their belly??).

          • Mishimoo
            March 4, 2015 at 5:49 pm #

            I was more concerned about the caesarean incision not healing properly because it’s bigger. I was also concerned about losing my core strength because it makes a huge difference to my back pain, and about adhesions causing more pain. I also didn’t want to have one with not enough anaesthetic due to my resistance. Having said that, I didn’t know at the time that having persistent OP babies increased my risk of 3rd and 4th degree tears, and that I simply lucked out.

            My sister was advised by my midwife to inform her medical staff if/when she is pregnant that there is a family history of persistent occiput posterior babies, and to strongly consider a caesarean delivery.

          • Dr Kitty
            March 5, 2015 at 7:08 am #

            My OB was altogether less happy about me attempting a VB when I told him that my mother had me at 42 weeks, after 24hrs PROM without contractions, that my head never engaged in her pelvis, that she never dilated more than 3cm even with 8 hours of pit and that she ended up with a crash section when my heart rate tanked.

            There I was at 38 weeks with a completely non-engaged baby at the upper limit of the size we though I could safely deliver, still happily swinging between OP and OA, a very unfavourable cervix and a known pelvic abnormality.I think we were both aware that
            the odds of history repeating were very, very high…

          • Mishimoo
            March 5, 2015 at 5:22 pm #

            I ended up in the room closest to the OR for my first, just in case, because I’d been a complicated caesarean. It made me feel so much safer. Since my bub was small, low and engaged, and everything looked fine for a spontaneous vaginal birth, they were happy for me to give it a try and it (luckily) worked out for both of us. I did have a small labial tear thanks to her trying to highfive the CNM on the way out. 😉

          • Daleth
            March 5, 2015 at 10:46 am #

            I’m really glad you lucked out!! Those kinds of injuries seem horrific to me.

            Why would a c-section impact your core strength? I had always thought c-sections involved cutting stomach muscles, but apparently that’s only if they do a vertical incision, which they only do in a life-threatening emergency these days. With the horizontal bikini line incision that they do in most c-sections, they don’t cut the muscles; they just spread them apart enough to get the babies out.

            I’m guessing if people notice less core strength after having a baby via c-section, it’s because of what the pregnancy did to their stomach muscles… not the mode of delivery.

          • Young CC Prof
            March 5, 2015 at 11:16 am #

            Let me say again that I went for some PT due to back pain a couple months after my c-section, and it was the best idea ever. I had no idea how much core strength I’d lost (I was also on no-exercise for a lot of the pregnancy) and building it back up made such a difference.

          • Cobalt
            March 5, 2015 at 11:59 am #

            I’ve had shocking core strength loss with each pregnancy, and I’ve never had a cesarean. Pregnancy is just hard on the body.

          • Daleth
            March 5, 2015 at 1:24 pm #

            I hear you. It boggles my mind when I hear women (NCB types) saying… and I swear I’ve heard this; clearly there is no shortage of irrationality in the world… that they “still have lower back pain years later from the epidural” that they were somehow talked into/tricked into.

            I’m like… really? What caused your lower back pain was that little needle, and not PREGNANCY ITSELF or carrying babies or wrangling toddlers and their gear?

          • Mishimoo
            March 5, 2015 at 5:10 pm #

            It’s because I grew up only knowing women that had emergency caesareans (which they believed were unnecessary), the only vaginal birther being pro-homebirth, and so it was one of those things that I had to unlearn.

          • araikwao
            March 4, 2015 at 4:45 pm #

            Ha, I was just asking my (ob) supervisor about this very thing. Type IV is absolutely high risk, and they will tend to do an early CS (I.e. in later prematurity) because of the risks during second stage, including (but probably not limited to) uterine rupture, haemorrhage (from pretty much anywhere, given that it is a vascular condition), and cardiac stuff, e.g. aortic dissection etc.

          • Medwife
            March 4, 2015 at 5:00 pm #

            I live in an area which has a surprisingly high rate of Ehlers-Danlos Type 3 (perfect example of founder’s syndrome). It manifests as hypermobility. They tend to have very painful pregnancies (they are always co managed with a rheumatologist) and we have to be very careful with positioning during labor and delivery, but they are basically low risk patients in an obstetric sense.

          • Mishimoo
            March 4, 2015 at 5:38 pm #

            I have Joint Hypermobility Syndrome (there’s some discussion on whether JHS and EDS 3 are the same thing) and was low-risk for all of my pregnancies. My CNMs made sure I was comfortable and helped me to be in stable/safe positions for my joints. For example – I tried all fours for a brief moment to see if it helped (OP babies), it felt like my back was about to fall apart so they helped me out of that really quick. I ended up sitting on the bed like a queen on her throne because it’s one of those really cool adjustable ones.

          • Daleth
            March 5, 2015 at 10:49 am #

            Yeah, hypermobility is the least problematic type of ED. I’m glad you know enough to be “very careful with positioning during labor and delivery”–I’m sure a lot of midwives, and for that matter some OB’s, don’t.

          • Medwife
            March 5, 2015 at 12:51 pm #

            Well, a few years ago there was a journal article about joint injuries to women with no hypermobility problems but who were positioned incorrectly during second stage, so I think about it anyway. Just logical that with EDS the risk for that injury goes way up.

          • Medwife
            March 4, 2015 at 5:10 pm #

            Yeah, I wouldn’t touch a Type IV lady with a ten foot pole. They get a nice big MD ONLY on their problem list 🙂

          • Anj Fabian
            March 4, 2015 at 6:48 pm #

            She was going to have a midwife attended birth with OB oversight, as opposed to the midwifery led unit, but all prenatal care was to be midwives.

            I’m not sure how severe her EDS was, but her mother and maternal grandmother both had two births and a hysterectomy at the second birth. The attitude I got from her interaction with the NHS was that her case was not considered particularly special. What I read about EDS made me think that EDS does indeed make pregnancy and birth particularly risky in very specific ways.

          • Dr Kitty
            March 5, 2015 at 5:14 am #

            What that probably indicates, if my experience of UK midwifery is any judge, is that because EDS is rare, and NOT SPECIFICALLY LISTED on the risk out criteria, it wasn’t felt to be a problem by the midwives and so no OB opinion was sought.

            Believe me, I have had patients with some rare medical conditions, which I have listed on antenatal referrals, only to have them assigned shared or MW led care because the MWs didn’t appreciate that their condition was a risk factor, didn’t have the intellectual curiosity to find out if it was, and certainly didn’t ask an OB what they thought.

            I’ve learnt that unless I put “has condition X- increased risks associated with this condition in pregnancy- NOT A LOW RISK PATIENT- CONSULTANT LED CARE” it isn’t guaranteed that the MW will know enough medicine to pick up the risks.

            The glaringly obvious case I can think of involved someone with a history of ulcerative colitis, colectomy and J-pouch, which was apparently NBD to the midwife, because everything had been “fixed”.
            Uh, no.

            There seems to be this idea that if a condition would cause problems in pregnancy MWs would automatically have been taught about it, or know about it, so if they don’t know about it, ipso facto, it can’t be a problem…

  14. Young CC Prof
    March 4, 2015 at 11:15 am #

    Rural areas with insufficient educational opportunities? Ignorance wasn’t the problem there, it was a deliberate decision NOT to learn from mistakes, and more importantly, it was incorrect priorities.

    • Mel
      March 4, 2015 at 12:22 pm #

      I found it terrifying that the midwives didn’t know that low body temperature in a newborn is a sign of sepsis. (That sign is plastered on newborn calf care manuals everywhere.)
      Let’s see how the “limited educational opportunities” clause plays out:
      – Apparently, no one on the unit had access to the internet. If they had, there are many websites created to help train midwives in remote developing nations.
      -Apparently, no one had a DVD, BlueRay or VHS player either. You can buy cheap copies of the information covered in neonatal care and play them for the entire unit.
      -Apparently, no one could ask the pediatricians to give an staff meeting talk about warning signs in newborns

      Yeah, that’s not problems caused by rural areas. That’s the problems caused by hubris.

      • Guesteleh
        March 4, 2015 at 12:50 pm #

        My son was born with low body temperature and he was whisked away after some skin to skin to spend time under a warmer and now I know why. Wasn’t thrilled at the time but much better to be cautious.

      • araikwao
        March 4, 2015 at 4:47 pm #

        Yeah, how is hypothermia not one of the “page the paediatrician” criteria??

        • Dr Kitty
          March 5, 2015 at 8:28 am #

          The coroner wasn’t entirely convinced that the midwives didn’t know hypothermia was a problem.
          There was a suggestion that there was a decision made to close ranks and report that none of the midwives on the unit knew that it was a symptom which suggests sepsis, when that might not have been the case.

          It still doesn’t actually matter though- the legal precedent is whether a representative body of your peers would have acted in a similar fashion given the same situation. Even if YOU don’t appreciate that hypothermia is a risk, if most midwives would, then it is still negligent care.

          Hypothetically, if I don’t know about a drug interaction and kill a patient as a result, if most doctors in my position would know about that interaction and wouldn’t make that error, it is on ME.
          I don’t get to say “sorry, didn’t know that, mustn’t have paid attention that day in pharmacology, my bad”.

          • Young CC Prof
            March 5, 2015 at 11:12 am #

            “I didn’t know that could kill someone” just means you didn’t do it on purpose, ie, aren’t a murderer. If you SHOULD have known, you’re still negligent.

          • araikwao
            March 6, 2015 at 6:00 am #

            That is jaw-droppingly awful, and makes their priorities very, very clear..Spoiler – it’s not the families.

    • Anj Fabian
      March 4, 2015 at 1:42 pm #

      That excuse is bullshit. Yes, remote areas do have issues that are very difficult to overcome – but using that as an excuse is also a good reason for a personnel overhaul (Perhaps we need to bring in a new team that can do the job properly?) or to shift services to a more distant hospital that doesn’t have such an appalling track record.

      • Sarah
        March 4, 2015 at 2:46 pm #

        Remember as well that it’s only remote in UK terms. Cumbria is rural and there’s not a lot up there, but they’re also only a couple of hours away from some of Western Europe’s larger conurbations. England isn’t very big and there are a lot of people here. It’s a totally different ball game to, I dunno, a little cottage hospital in the middle of Montana.

        • Daleth
          March 4, 2015 at 4:11 pm #

          “Remote,” my ass.

          Morecambe Bay is SIXTY TWO MILES, yes 62 miles, from Manchester, the third largest city in the UK (population 3 million+, and home to one of the country’s largest medical schools).

          • Anj Fabian
            March 4, 2015 at 6:54 pm #

            If I were in charge, I would definitely use the threat of moving services to Manchester to convince people to comply.

            I’m evil that way.

          • Who?
            March 4, 2015 at 8:26 pm #

            What kind of monster are you?

          • Anj Fabian
            March 5, 2015 at 5:47 am #

            The monster that knows how hard it is to change an entrenched culture.

            The obvious move would be to remove the ringleaders – either by striking them off altogether or having them work with as little contact with each other as possible. If they aren’t struck off, it’s likely their union would fight any changes to their employment.

            The other strategy would be to enforce every rule on the books, especially any rules regarding documentation of care and review of that documentation. It’s a lot easier to do things the right way the first time than to spend time and energy explaining why you didn’t.

          • Sarah
            March 5, 2015 at 6:23 am #

            Cumbrian women needing more complex care sometimes come to Manchester for it anyway. St Mary’s hospital deals with a lot of more difficult cases from the whole of the north west and North Wales too.

          • Daleth
            March 5, 2015 at 10:50 am #

            That’s not evil, Anj. That’s smart.

          • Hannah
            March 7, 2015 at 7:55 am #

            The thing is the problem wasn’t “Morecambe Bay” as such, although the quality of management certainly left a lot to be desired, the problem was specifically with Furness General Hospital. The geography of Morecambe Bay is that to the east you have the mainland with the motorway running through it and
            relatively well connected to the rest of the north, a hospital in Lancaster (just under 60 miles from Manchester). Lancaster is relatively small, I’ve only
            been there once (for a university open day) and it rained in sheets, but nevertheless not the back of beyond. To the north you have the Lake District
            national park, which is what most people associate with Cumbria, and a sort of mini hospital and midwife led unit at Westmorland General Hospital, in Kendal.
            Then, to the west, you have the Furness Peninsula, bounded by the Lake District to the north and water on all other sides. FGH is located just outside
            Barrow-in-Furness, which suffers from a degree of post industrial decline (see wiki), closer to 100 miles from Manchester, and connected to the mainland only
            by one winding A-road. 

            Now this has to be seen in the context of the adage that in America 100 years is a long time and in Britain 100 miles is a long way, but the fundamental
            problem for FGH is that very few people choose to live and work in Barrow, in the long term, who don’t already live in Barrow, which makes It easy for things
            to become… stale.


The Kirkup Report states (para 3.85):


”We heard consistently that recruitment and retention have been particular issues for the 
maternity unit in FGH. During the period covered by the review, the
            service has been dependent
 upon locum doctors and bank and agency midwives and neonatal nurses. Recruitment of good-
quality medical staff has been difficult and there have been disciplinary issues, with conditions of
 clinical practice being placed on senior clinicians by the GMC. There is also evidence of failure to 
retain senior clinicians.”

 and (para 3.87):

            “At interview, several senior managers from the
            Trust and commissioning groups explained that there was no difficulty in recruiting to RLI [Royal Lancaster Infirmary], but FGH was a problem. As a consequence, services in RLI, including maternity and neonatal services, have been very well staffed compared with those in FGH. Moreover, the vast majority of the clinical leads are based in RLI, although interestingly the long-standing obstetric lead
            is based in FGH.”

            Paras 3.33 onwards detail the differential outcomes between the two hospitals. The middle grade doctors at the unit (these were the ones being shoo-ed away by midwives) tended to be there on rotation and at the junior end of the spectrum (para 3.42), this didn’t seem to be taken into consideration in terms of service delivery and consultants were rarely present until the brown stuff hit the fan.

            One Guardian comment reads:

            “FredHughes outoftcrookedtimber

            4d ago

            Small hospitals in areas of the country where people don’t want to work. Groups of nurses/midwives working in the same posts for years, over confidence in their limited abilities, reluctant to change and a refusal to accept criticism, weak Consultants unwilling to challenge nurses/midwives, weak management unable to do their job. It’s a similar pattern, and having worked in hospitals like this in the past, reports like this aren’t surprising.”


            The “musketeers,” who I’m willing to guess were born and brought up locally, or at least their leaders, were most likely the longest-standing clinicians there,
            which is why they were able to rule the roost, and the dominant personalities were able to apply their half-digested philosophy to the point of unreason,
            where elsewhere those tendencies, while present, might have been tempered by some degree of insight or at least kept in check by other groups of clinicians
            and clinical governance. The trust managers were sitting 32 miles away in Kendal, looking at high level data that didn’t pick up the problem, and unable to join the dots between a series of seemingly disparate incidents, and other groups of clinicians were also
            massively dysfunctional at every level (see the whole section 3.48 to 3.90) and franky most of them wouldn’t have got there by being best in class.

            Further Guardian comments under the same article read:


            4d ago

            UHMBT has been misconceived from day one. Putting together two hospitals which are 90 minutes driving time apart was never going to make a workable Trust, it was like joining a hospital in London with one in Birmingham. On top of that it has been beset by poor/incompetent management throughout its existence. As well as failing to manage two hospitals and staggering from budget crisis to budget crisis, the Trust has maintained an expensive but very small third hospital, which does little more than a well equipped Health Centre, but does find room to accomodate some spacious and convenient offices for the Trust and its executive well away from the messy business of seriously ill patients. UHMBT should be disbanded without delay.”



            4d ago

            It wasn’t just the maternity unit at Furness General that was needlessly losing patients during this period. I was working in Barrow at the time and people were terrified to have any operation done there however minor. Personally I know of one death and 2 near misses through routine surgery- and I didn’t know
            that many people in the town. It was common knowledge you were safer staying on the list longer and going to Lancaster!


illeist saladcrazy 4d


            There have been problems in every department and it has a bad reputation in the local community partly because when things go wrong staff close ranks. The community has been saying for a long time that the whole hospital needs reorganisation and staff an entirely new attitude, or it needs to be closed.”

        • Who?
          March 4, 2015 at 8:32 pm #

          Or Australia.

          I’ve been glued to Outback ER, which every week covers the story of some events in the emergency ward at Broken Hill, which is in New South Wales but whose nearest major city is (ahem) Adelaide, SA. This is interesting because health is a state responsibility in Australia, so the nearest hospital isn’t even in the same state health budget as they are. Hours by plane, assuming one can be rustled up.

          You do not want your baby coming out crooked out there.

          That’s remote.

          • Sarah
            March 5, 2015 at 6:20 am #

            Well, yes. Or rural Canada, or lots of other big countries with sparsely populated regions.

      • Medwife
        March 5, 2015 at 12:52 pm #

        Or, I don’t know, install the internet and a phone line, since apparently they were so very isolated.

  15. DoulaGuest
    March 4, 2015 at 10:29 am #

    I am curious on your thoughts on CNM lead care in the states…

    • The Bofa on the Sofa
      March 4, 2015 at 10:48 am #

      US CNMs actually add to the case. For example, indications are that CNMs that do homebirths (although rare) are no better than CPMs in terms of their outcomes. Why? Because it is the ideology of those who are willing to do homebirths in the first place that prevent them from doing them properly, not their lack of medical training.

      In fact, I’ve suggested that their additional training when coupled with ideology makes them MORE dangerous, because they are over-confident on the things that they think they can do. Whereas a CPM might realize they need to transfer (with all the complications that come with it), the CNM will hold out because “she thinks she can handle it.”

      • DoulaGuest
        March 4, 2015 at 10:55 am #

        I was referring to hospital based CNMs, and those outcomes. I was under the impression that CNM outcomes for low-risk women, were better than OB outcomes for low-risk women in the US. I agree though with your comment above.

        • Young CC Prof
          March 4, 2015 at 11:11 am #

          According to CDC data, about 1/3 of attended home births in the USA are attended by CNMs, the rest by “other midwives.”

          Neonatal death rates for CNMs and “other midwives” are basically identical, as are the rates of high-risk conditions such as twin birth, first-time mother and post-dates pregnancy. I don’t know exactly why this is the case, but it’s right there in black and white. I suspect it’s a matter of ideology.

          Now, only a small percentage of CNMs attend home
          births in the USA. Most CNMs are delivering babies in hospitals, providing prenatal care, and doing stuff like STD tests and birth control scripts.

          If you look at hospital births only, CNM outcomes are better than OB outcomes, with a neonatal death rate about half as high for 37+ week, 2500+ gram, singleton babies. (0.3 per 1000 versus 0.6 per 1000, if I remember correctly.) Of course, that’s low-risk versus all-risk, so outcomes should be better!

          It’s really hard to compare apples to apples and make a fair comparison, but that does at least indicate that CNM hospital care isn’t causing major problems.

          • guest
            March 4, 2015 at 11:57 am #

            Purely anecdotally, but there is 1 CNM practice where I live. A friend and I both used them. They were prepared to send me home at 2 days before full term, baby had late decels on the monitor, and the residents at the hospital strongly recommended induction. All in the name of avoiding unnecessary interventions. (I declined the CNMs recommendation).

            My friend PPROM’d at almost 42 weeks, didn’t go into labor, and they were going to let her wait until past 24 hours before even starting pitocin – all in the name of avoiding unnecessary inductions. (Family talked her into inducing 12 hours in, baby born 4 hours later, no complications.)

            On the flip side, we were both healthy, young women, with very low risk pregnancies (up until that point). So, I wonder if the hospital-based CNMs in the US serve such a low percentage of the population – and they’re appropriately risking out – that when they decide to go loosey goosey with risk, it tends to just work out.

            Or maybe they’re not the typical CNM group? I know they’re VERY friendly with the home birthing coop in town.

          • The Computer Ate My Nym
            March 4, 2015 at 2:54 pm #

            If it’s any help, my CNM anecdote is quite different: the CNM who had been following me called OB back up quite quickly when it was clear that I wasn’t progressing properly and she also bluntly recommended an epidural when it was clear that I was having more pain than I should have for early labor (I wonder if she suspected obstructed labor already and wanted to be ready in case it was or just thought I was a wimp? Either way, it worked out well when the need for a c-section did develop.) So I’d say that there are good, fact based CNM practices out there, but you have to be careful about which one you go with.

          • guest
            March 4, 2015 at 4:38 pm #

            Unfortunately, that is literally the only CNM-based practice in a large metropolitan area, so it’s them or OBs. I wasn’t terribly impressed with the OB for #1, switched to the CNMs for #2, and now with #3 I’m back with an OB (and I think I’m much more realistic about what maternity care entails, and quite happy with the OB).

            I prefer a mostly hands-off approach that seemed to align better with the CNMs, but it turns out I’m way too risk-averse for them. I also felt their approach to be pretty paternalistic (no inductions till 42 weeks, if you ask at 39-41 weeks, we WILL talk you out of it, we never offer epidurals, you have to ask first, I got a talking to for feeding my daughter a hot dog etc.)

            That being said, I’m sure you’re right. I know some great NPs and CNMs that work directly under OBs, and I think they do awesome jobs. As many people have commented since my last comment, it’s the ideology that’s getting in the way. Even these CNMs could be great providers (I thought their care during labor was excellent and they didn’t hesitate to call back-up staff when, for instance, my baby had mec in the fluid), if they weren’t so married to the “low intervention, cascade of intervention” mind-set.

          • Medwife
            March 4, 2015 at 5:08 pm #

            They wouldn’t have to deal with so much mec if they’d induce at or by 41 wks like the rest of the country.

          • CrownedMedwife
            March 4, 2015 at 7:08 pm #

            Again, it all goes back to holistic care and viewing woemn as partners in their care…something midwives proclaim, yet fail to adhere to is demonstrated by unwillingness to comply with a request for delivery at 39-41weeks. Whose ideal does that meet if it onvolves ‘talking’ a woman out of it?

          • Young CC Prof
            March 4, 2015 at 7:28 pm #

            Indeed. A care provider should never attempt to override a patient’s lower risk tolerance with her higher risk tolerance!

          • SporkParade
            March 5, 2015 at 5:31 am #

            I want to embroider this on a pillow.

          • Daleth
            March 5, 2015 at 11:00 am #

            “A care provider should never attempt to override a patient’s lower risk tolerance with her higher risk tolerance!”

            Brilliant. That’s exactly what was happening with my MFM team when they repeatedly tried to talk me out of scheduling a pre-labor c-section with my mono-di twins (identicals who share a placenta), one of whom (twin B) was breech or transverse at all but one of the many many ultrasounds I had.

            They were waving the vaginal birth pom poms and yet casually mentioning that as a mono-di twin mom I would have to labor **in the OR**, which told me all I needed to know about how high they thought my risk of needing an emergency CS was. And then I went on PubMed to find out more and every single study basically said, “Rah rah, vaginal birth–totally reasonable to try it if twin A is vertex, and although vaginal delivery of mono-di twins seriously endangers twin B, if things go south we’ll just do an emergency CS and usually that saves twin B!”

            To which my response was, fuck that, schedule me a CS now. I had to talk to three different members of my team before I found one willing to schedule the CS, and I truly believe it’s because I was at an excellent university hospital that delivers more than 10,000 babies a year and handles all the high-risk cases in the area, so the doctors had a lot of experience with mono-di twins, breech birth, yada yada and had developed a high risk tolerance for that.

            And even after I had scheduled it, when my last ultrasound showed Twin B happened to be vertex that day, the head of MFM once again tried to talk me into a vaginal birth! If I could have found a t-shirt that fit in late pregnancy I would have worn one that said, “NO MEANS NO.”

          • Somewhereinthemiddle
            March 4, 2015 at 7:58 pm #

            Huh, that’s interesting. I saw a hospital based midwife group for one of my pregnancies and they started mentioning induction once I passed 40 weeks and they recommended induction after 41 weeks. They also required a NST for anyone wishing to go past that point.

          • Mishimoo
            March 4, 2015 at 8:36 pm #

            Mine were happy to do a stretch & sweep to get things going at 39+6 if his head was engaged simply because I was miserable and there was no good reason to keep him in any longer. We also talked induction and stuff at the 40 week check up with all of my pregnancies.

          • Somewhereinthemiddle
            March 4, 2015 at 9:41 pm #

            Evidence that not all midwives are sucked in by the vortex of stupidity. 😉

          • moto_librarian
            March 5, 2015 at 10:58 am #

            I had prodromal labor with my second for nearly two weeks. After another long day of contractions that did not cause additional dilation, the CNM on call stripped my membranes (she could feel me contracting during the exam). I was 38 + 5, and I went into labor about two hours later. I will always appreciate that she was willing to give me a “soft” induction.

          • The Computer Ate My Nym
            March 5, 2015 at 9:53 am #

            I got to 40 weeks 3 days and said something like “I’ll probably go 43 weeks like my mother did” and my midwife snapped, “Not on my watch you won’t!” She then said that she’d do a NST and probably induce on Monday if I didn’t go into labor before then (this was a Thursday, I think). I went into labor on Saturday night and delivered Sunday, just scooting in ahead of the deadline. We joked that baby really didn’t want another ultrasound…

          • Poogles
            March 4, 2015 at 12:13 pm #

            I know that “The American College of Nurse-Midwives Healthy Birth Initiative” has me nervous and has made me lose a bit of confidence in CNMs as a group.


          • Amy M
            March 4, 2015 at 12:20 pm #

            When I was pregnant, there was a program through my insurance called “Healthy Birthday” for women at risk of pre-term labor. It had nothing to do with reducing interventions though, and everything to do with trying to reduce prematurity, though there wasn’t a hell of a lot they could do—mostly make the pregnant women aware of the signs of preterm labor.

            I looked at the link you provided, and its pretty NCB heavy. They even mention that 15% “ideal” Csection rate. They should take a look at the UK and Netherlands—see all the babies that SHOULD have had Csections and back calculate.

          • Roadstergal
            March 4, 2015 at 12:51 pm #

            How can you be in favor of lowering the C-section rate and against ‘interventions’ like induction? If you want to lower the C-section rate, induction is the proven way to go…

            They mention reducing elective deliveries at 39 weeks, but I thought the research showed that 37+ week induction improves outcomes and reduces C-sections? Am I misremembering that one?

          • The Bofa on the Sofa
            March 4, 2015 at 1:19 pm #

            How can you be in favor of lowering the C-section rate and against ‘interventions’ like induction? If you want to lower the C-section rate, induction is the proven way to go…

            Well, if you want to reduce abortions, expanding contraceptive use is the way to go, but that doesn’t stop the Catholic Church from opposing both.

            IOW, it’s a religious issue for them.

          • Roadstergal
            March 4, 2015 at 1:22 pm #

            Excellent parallel.

          • CrownedMedwife
            March 4, 2015 at 7:13 pm #

            It should have you nervous. It has me nervous and appalled. ACNM pairing with MANA and demonizing interventions as NonPhysiologic, dangerous combination driven by ideology.

          • Laura
            March 4, 2015 at 9:32 pm #

            As I finish nursing school and eventually head into my CNM training program at my nearby university, I don’t want to be at odds with my “woo-ish” CNM colleagues, especially ones that I am interviewing with for a job! My ideal situation would be to work with a midwife/ob/gyn practice and stick to safe medical protocols but give my patients the unique care that nurses provide. We shall see….one step at a time I guess…

          • Who?
            March 4, 2015 at 10:57 pm #

            Congratulations on working towards your career.

            Thing is, you do want to be at odds with those people. It might be uncomfortable, and it may cost you jobs which seem really important at the time but which ultimately you don’t want.

            Early in your career can be a hard time to stick with your values but it is so important that you do. Finding colleagues who support you and your values is critical to your professional development: be choosy about who you work with.

          • Laura
            March 5, 2015 at 12:42 am #

            I do agree with you, but it can be hard when starting out to sort through which hills to live and die on, so to speak. Because I am older, I bring a maturity and perspective to my work that I find very helpful. I also work very well with others and am quite diplomatic, but direct and uncompromising about what I feel is important. I believe I’ll find my way, but at least I am aware of difficult dynamics that might be at work from the git go.

          • manabanana
            March 5, 2015 at 8:55 am #

            I am a SNM. Here’s the other problem with being “at odds” with these people. The “woo” people. The “woo” nurse-midwives.

            (And I wouldn’t call it “at odds” but employing critical thinking…. but midwives can wilt in the face of being intellectually challenged.)

            THESE PEOPLE ARE GRADING MY HOMEWORK. And all they want to hear is ingratiating bullshit about how magical, perfect and wonderful midwifery is. Any inkling of criticism is returned with retaliatory poor grading.

            I feel like I am in a no-win situation. They want to believe myth – they do not want to critically analyze. They are threatened by information that runs counter to their own ideologic beliefs – and they want to indoctrinate me into the profession.

            This is not my idea of higher education. My Bachelor’s degree is NOT in nursing, but another science – and I was trained quite well in the scientific method and research and the ability to critically examine information. And to not take personal offense when this information challenges my beliefs!

            So here I am in a graduate nursing program that …. ugh … just seems to be promoting indoctrination. This is truly frightening and disheartening. And I hope some ACNM/ACME/ACMB figures of authority happen upon this – because as far as I can tell – standards for CNM education have slipped at the same time more schools are only offering DOCTORATE degrees for nurse-midwife graduates. It’s freaking sad. And wrong.

            I don’t know if it’s woo or intellectual incompetence – NO I take that back – it’s not incompetence – it’s IGNORANCE. Because these are intelligent people. They could be competent. But not when the programs are driven by ideology. Adherence to ideology requires ignorance, blind devotion, and deference to authority.

            I’m stuck in this place where I have to spit out the BS, and parrot the sacred tenets of midwifery, and not question certain practices – because I have to pass these courses.

          • CrownedMedwife
            March 5, 2015 at 9:07 am #

            I wish I had more time to respond. I’ve been there and know just what frustration you’re going through. How much better served our profession could be if our education could be provided without the ignorance. You’ve accomplished the first step in navigating the woo by realizing you’re regurgitating the bullshit as a means to an end, while surrounded by the majority who willingly accept and indoctrinate themselves into these beliefs.

          • manabanana
            March 5, 2015 at 9:22 am #

            Thanks CrownedMedwife. I think today I just needed to vent a little bit. I appreciate your perspective and encouragement.

            I realize that I’d made two almost contradictory posts – but the reality is – the way I see CNMs practicing is often not ideologic. Not at all.

            And the way it’s taught (by midwives and APRNs who have a compulsive hobby of collecting degrees and certifications) is much different. Much more steeped in myth and woo. You’d think with their obscenely long string of letters behind their names they wouldn’t get their egos hurt so easily.

          • Laura
            March 5, 2015 at 9:12 am #

            Yep! Thanks for the heads up. As diplomatic as I am, I refuse to be false to my own beliefs. I will have to be very careful and skirt the edge of b.s. and choosing topics that are less offensive and more in line with how they want me to think. I am several years away from that point. Maybe then the backlash against woo-foolishness will be more revealing of what’s wrong with ideology over hard science. I can only hope.

          • Medwife
            March 5, 2015 at 12:58 pm #

            Bah. Don’t get me started on the “doctorate”. Doctorate implies PhD and the DNP ain’t that. It’s a bullshit way to be called “doctor”, that’s all. It adds some coursework in “health systems” and nothing in the way of more clinical expertise.

          • manabanana
            March 5, 2015 at 8:41 am #

            That “partnership” – between ACNM and MANA – is truly appalling.
            I maintain that most CNMs do not espouse this kind of flippant adherence to “normal, physiologic” birth, but it appears the current ACNM leadership is ideologically motivated.

          • CrownedMedwife
            March 5, 2015 at 9:01 am #

            It is my hope most CNMs do not adhere to what is espoused in the ACNM Health Birth Initiative or promoted by the demonization of care that includes AOL, epidural pain management or assisted deliveries (to list just a few). It is difficult to accept that ACNM represents CNMs as our professional organization, yet repeatedly we’re called to proclaim “we’re not all like that” in response to what ACNM promotes as best practice. If the majority of CNMs don’t subscribe to those tenets, it sickeningly demonstrates how NCB has infected the leadership of CNMs. That leaves the majority of CNMs without a professional organization to represent actual CNM practice.

          • fiftyfifty1
            March 4, 2015 at 7:42 pm #

            I lose more than a bit of confidence. I lose all confidence. They’ve laid it out plain to see. It’s about ideology and their own interests, not moms and not babies.

            ACNM here’s a message for you: I don’t give a shit about your whether you judge my birth to be a “healthy birth” by your bogus standards. My goals are a healthy baby and a healthy me.

          • Amy M
            March 4, 2015 at 12:15 pm #

            If the CNMs in the hospital are consulting with OBs appropriately and turning over high risk cases to them as the need arises, then they should have the lowest perinatal mortality rates. I guess if we looked at individual hospitals, and compared the CNM perinatal mortality/morbidity rate to the OB’s, and DIDN’T see that pattern, we could suspect that the NCB ideology was taking hold.

    • Alannah
      March 4, 2015 at 11:54 am #

      CNMs are not entirely comparable to Dutch and UK midwives because they are also nurses. They have a general understanding of how the human body works, pathophysiology of all organ systems (as opposed to only the genitourinary tract), and of medicine in general as it is practiced outside the L&D ward (which is a little world on its own, isolated from the rest of the hospital).

      Midwives who lack nursing training and experience don’t have all that so they are much more prone to errors in judgement where medical issues in pregnancy and childbirth are concerned. Also, nursing schools lack the ideological bias that pervades midwifery training so their alumni tend to be far less… extreme and more patient-centered in their thinking than midwifery-only trainees.

      • DoulaGuest
        March 4, 2015 at 12:46 pm #

        There is a study coming out on CM outcomes, and I am interested to see what it shows in terms of outcomes. However, in the UK (while not a prereq) there is a track for midwives who are nurses, so I am not sure that is true.

    • staceyjw
      March 4, 2015 at 1:02 pm #

      I think it really depends on how ideologically driven they are, which is the same for OBs, who also fall for the woo (although it isn’t their identifying philosophy). All CNMs have the skills and knowledge to do a good job, it just depends on whether or not they buy the NCB line or not.
      I have no idea what the CNM community looks like from the inside. It seems, from then outside, that there are a very vocal group of NCB zealots, as well as a large contingent of evidence based birth CNMs who are not heard publicly. Whether they speak out amongst their peers is what I would love to find out. They could be very vocal and still not get anywhere, or they could be silent, who knows?

      • CrownedMedwife
        March 4, 2015 at 9:47 pm #

        I’ve already shared quite a bit of my background, experiences and professional standards on SOB, so forgive me for being redundant in the content of my response. I’m a Medwife and I don’t make apologies for assuming that title. I practice in a collaborative setting with an OB, provide well-women care and perinatal care. In reality, the NCB ideology and proclamation for autonomous practice didn’t sit well for me in graduate school, but gave classmates benefit of inexperience and naievete as justification for their attitudes. I joined ACNM as my professional organization. Needless to say, my classmates moved into NCB upon graduation and after several years ACNM no longer demonstrated values consistent with my practice, nor provided effective guidelines for practice. Had no need to stay connected to classmates and ACNM didnt represent my practice. My peers were physicians, Green and Grey journals provided research applicable to practice and my practice was based on ACOGs guidelines as ACNM fell short in its utility. Lost touch with classmates, dropped ACNM . I work with a few other Medwives and we are similar in practice. I don’t belong to Midwifery groups and decline to partake in the communities of HB CNMs and NCB communities. I’ve witnessed the harms of NCB ideology too many times and have seen the value of Obstetric management with collaborative care far too often.

        So, I suppose it makes me one of the silent ones. In my silence, I’m accessible to women seeking midwifery care and use my time to help them navigate the hubris of NCB and the realities of best practices. In my silence, I receive the transfers from my Obstetric peers, lest they risk allowing their patients desiring Midwifery care to fall into the HB or NCB around us. In my silence, I do not provide referral, backup or transfer for local HB CNMs. In my silence, I accept that I am a member of a profession with such extremes of practice and choose to define Midwifery by setting an expectation for practice consistent with ACOG guidelines and in a setting supported by collaborative practice. In my silence, my peers are Medwives and Physicians. I’m silent as I have nowhere to speak out, but use my actions to speak volumes of what the public and health care system should expect of Midwifery.

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