This is an expanded version of a piece I wrote for Time.com.
Dr. Neel Shah, Assistant Professor of Obstetrics, Gynecology and Reproductive Biology at Harvard Medical School has written two pieces on the safety of homebirth. The first, A NICE Delivery — The Cross-Atlantic Divide over Treatment Intensity in Childbirth, appears in The New England Journal of Medicine; the second, Are hospitals the safest place for healthy women to have babies? An obstetrician thinks twice was published on The Conversation website.
Dr. Shah is also the Founder and Executive Director of nonprofit organization Costs of Care, Inc., which describes its mission as:
We believe that Americans can get their money back by trimming the fat out of medical bills – replacing or rejecting services that eat into our wallets without making us healthier.
The Problem: many medical bills are inflated with unnecessary care
So the real question being addressed in these pieces is not whether hospitals are the safest place to have a baby. There’s no question that they are. The real question that Dr. Shah appears to be asking is: Are homebirths safe enough that we can shunt pregnant women into lower cost homebirths in an effort to save money?
That’s a reasonable question to ask, but Dr. Shah’s answer is compromised by his failure to address two major issues, the existence of two different types of midwives in the US with wildly divergent perinatal deaths rates, and the growing body of literature that shows that homebirth in the US has a mortality rate anywhere from 3-9X higher than comparable risk hospital birth.
Here’s how Dr. Shah frames the issue in the NEJM piece:
For generations, both British and American mothers have assumed that the safest way to give birth is to spend many hours, if not days, in a hospital bed under the supervision of an obstetrician. Now, new guidelines are challenging these deeply held beliefs.
After completing an evidence-based review, the United Kingdom’s National Institute for Health and Care Excellence (NICE) concluded that healthy women with straightforward pregnancies are safer giving birth at home or in a midwife-led unit than in a hospital under the supervision of an obstetrician.1 Across the pond, eyebrows went up. The New York Times editorial board (and others) wondered, “Are midwives safer than doctors?”2 How can homes be safer than hospitals? And what implications will the British guidelines have for the United States?
Dr. Shah claims:
At its core, this debate is not about the superiority of midwives over doctors or hospitals over homes. It is about treatment intensity and when enough is enough.
However:
1. In contrast to the UK where there is only one type of midwife, highly educated and highly trained, in the US there are two types of midwives: certified nurse midwives (CNM), the best educated, best trained midwives in the world, and a second, inferior class of midwife, certified professional midwives (CPM), who lack the education and training of midwives in EVERY other industrialized country. Most US homebirths are attended by this second class of midwife, the bulk of whom have attained their credential by correspondence course (or no courses) and who have served an apprenticeship with another, equally poorly trained CPM. The mortality rates reflect this fact.
2. There is a large and growing body of research that demonstrates that homebirth with an American homebirth midwife has a death rate 3-9X higher than comparable risk hospital birth. Curiously Dr. Shah’s scant list of only 5 references, doesn’t include any of the many papers and datasets that demonstrate the wide gulf in outcomes between homebirth and hospital birth.
It’s not possible to review the entire scientific literature of homebirth death rates, but here are some highlights:
In March 2013, Oregon released an analysis of homebirth deaths prepared by Judith Rooks, CNM, MPH that showed that PLANNED homebirth with a LICENSED Oregon homebirth midwife had a death rate 800% higher than comparable risk hospital birth.
In June 2013, Grunebaum et al. demonstrated that homebirth increases the risk of a 5 minute Apgar score of zero by nearly 1000%.
In January of 2014, Wasden et al. demonstrated that the risk of anoxic brain injury is more than 18 times higher at homebirth than comparable risk hospital birth.
In January of 2014, the Midwives Alliance of North America published their landmark study (actually a non-representative survey of less than 30% of their members completed 5 years ago) claiming that homebirth is safe but ACTUALLY showing that homebirth increases the risk of perinatal death by 450%.
So Dr. Shah’s question, are hospitals the safest place to give birth, has been repeatedly asked and answered: In the US, hospital birth is incontrovertibly safer than homebirth.
The real question is whether homebirth is safe enough to contemplate encouraging it as a cost saving measure as they are doing in the UK.
The answer to that question is debatable, but we are lacking important information that would allow us to debate it.
Are out of hospital births really cheaper than hospital births? On the face of it, the fee for giving birth outside a hospital is much lower than the fee for giving birth inside a hospital. However, the cost of the actual birth is not the only cost. What is the cost of transport and how does that add up when more than 40% of first time mothers are transferred to the hospital and then incur hospital fees as well? The most critical component, and it is a massive component, of any cost analysis of homebirth is the cost of caring for a brain injured child who might have avoided the injury in the hospital. Each one of those children requires tens of thousands or hundreds of thousands of dollars of expenditure each year, and if the brain injury is permanent, he or she may incur millions of dollars of care over a lifetime. And don’t forget to factor in the millions of dollars that will be paid out in legal judgments for damaged or dead infants, as well as the increased cost of liability insurance to cover these claims. It is quite possible that over large populations hospital birth costs less than homebirth.
Is homebirth safe enough? That’s an individual decision that can only be made by individual mothers considering their own wants and needs. Hospital births are like seatbelts. Most of the time you won’t be in a car accident so you don’t need them; but when you need them, they save lives. Just like failing to buckle your child in on a drive to the store in unlikely to result in that child’s death, homebirth is unlikely to result in the death of a child. But over large populations riding in cars repeatedly, routinely buckling seatbelts saves thousands of lives. When it comes to homebirth, each mother must decide whether she is willing to tolerate the risk to her baby of dying at homebirth, a risk that is higher than the risk of the same baby dying in a car accident.
Dr. Shah concludes his NEJM piece:
As a U.S.-trained obstetrician, I have little doubt that the United States offers outstanding care for medically complicated pregnancies. But there are lessons to be learned from the British system. The majority of women with straightforward pregnancies may truly be better off in the United Kingdom.
That point is debatable, for a variety or reasons, but one thing is not debatable.
The majority of American women with straightforward pregnancies are far better off in hospitals and it is unfortunate that Dr. Shah did not share the scientific evidence that makes that clear.
I have no words to describe how frustrated this makes me, especially to see it from one of my favorite pages….
IFLS has gone way, way downhill. They promote a lot of bullshit. They’re as bad as any mainstream ‘science journalist’, and often worse.
As a woman who had a straightforward and uncomplicated pregnancy and who was considered low risk, I certainly agree that hospitals are the safest place to have babies! When my easy pregnancy took a sudden turn right near my due date, It was a very good thing that I had an OB looking out for me and that there was a hospital nearby. She picked up my developing preeclampsia during a routine office visit. The next day, I had developed full blown HELLP, but at the point that she discovered it, I still had no symptoms. I don’t want to think about the nightmare that would have gone down if I had followed some friends advice to deliver at home with a midwife (or even unassisted). I got so sick, so quickly, that I’m not sure my baby and I would have lived through it. I just delivered my 4th baby (via my 4th csection), with my very competent OB, and many thanks to her and her careful monitoring, all of my babies and I are healthy and in one piece. I’m beyond grateful for the ability to deliver my children in well equipped hospitals, and because I know how quickly everything can go totally wrong, I would never encourage home birth for anyone. You just never know for sure how things will go, and it’s foolish to assume that you won’t be one of a small percentage to experience a life threatening obstetrical emergency.
Why do bloggers such as this persistently tout a knowledge that homebirth is certainly unsafe when the evidence does not fully support this. In fact, most data out these is still conflicting. As we all know, this is a polarizing topic and data supports both sides. In addition, all that is discussed here are perinatal risks and concerns for pain relief. Does anyone consider maternal outcomes? It is well documented that maternal outcomes are improved in planned homebirth settings. Lower risk of death, 3rd/4th degree lacs, infection, etc.
Now, let’s discuss the perinatal risks…do we want to discuss Wax et al or Cheng? Honestly?! Its cherry picking data. Cheney et al (2014) certainly did not do justice either. Jannsen et al (2009) suggests increased safety and improved outcomes for hb over hospital among the same providers. De Jonge et al (2009) also indicate comparable maternal and perinatal outcomes among both groups of hb and hospital with an n=500,000 plus.
While international studies may not represent the US due to differences around demographics, integrated health care teams, appropriate risk-out guidelines and standardized training of midwives, it does indicate that homebirth in and of itself in not unsafe.
Instead of promulgating the anti-homebirth movement with insufficient evidence to support your cause, why not try to make a difference? Support efforts to standardize all midwifery certification….as in creating state boards of midwifery that can regulate and increase educational requirements of midwives (rater than Boards of Nursing that only regulate CNMs…thereby allowing DEMs/CMPs to fall through the cracks)…ideally moving towards a CM/CNM standard….promoting databases and benchmarking that identify risks so that solid risk out criteria may become the standard of care. Finally, integrating the providers into a system so that timely consultation and transfer occurs may also play a role in securing safe practices. The all or nothing mentality of this blog seems to have little effect on improving childbirth outcomes. It seems more like a place to perpetuate unfounded opinions and portray disproportionate risks of homebirth.
Homebirth with skilled providers is likely safe for low-risk, multiparous women who have a fetus that is cephalic with ga of 38-42 weeks. Consideration for distance to hospital may also determine safety. Risk out criteria such as pre-e, ghtn, gdm, bleeding disorders (to name a few) presence of meconium stained fluid, prolonged ROM >24 not in labor, maternal fever, non-reassuring FHT (with appropriate AWHONN IA protocol in place) should be implemented by maternity care providers. Some women desire this option and that does not mean they are they are placing their experience or devotion to the NCB Goddess over safety. It means they may have had a bad experience our outcome in a hospital or fear unnecessary intervention. Yes, the US does need to answer to the 33% C/S rate. PERIOD. No, we cannot determine if one woman’s section was necessary versus another’s…but we can implement practices that decrease the likelihood of interventions (that do indeed pose risk to both mom and baby) such as providing continuous labor support (real support, not babysitting the monitor at the nurses’ station) and offering midwifery care to low risk women.
Childbirth is a normal physiological event that may, in fact,be plagued with complications. Determining that all women must be treated like it is impending death has not yielded optimal maternal or perinatal outcome in the US, however. The very small percent of rogue homebirths cannot be blamed for these poor outcomes, but perhaps the overuse of intervention may play a part.
Why does the U.S. not need a c-section rate of 33%?
What is the optimal rate and how is that determined?
Comparing US and UK home birth, for example, is like comparing apples and oranges. I considered a home birth for my first here in the UK. I would have been risked out the second he was found to be breech and despite that being a non-repeating problem would have been risked out for my second had I wanted one then because VBACs at home are not a great idea. Had I had a home birth though, it would have been with 2 fully trained midwives integrated into the hospital system, proper prenatal care and I lived under 2 miles from hospital, a hospital capable of handling an obstetric emergency. In the US, the midwives would likely not be anywhere near equivalently trained, the midwife (generally just one) would not be integrated into the hospital system, my antenatal care would likely have differed significantly from that of my peers planning a hospital birth, and the distance to the hospital would likely be far greater. That doesn’t evne begin to discuss the lack of risking out that seems to occur in the US home birth community. None of those differences are mentioned when those on the home birth side in the US bring up UK based studies on home birth.
Risks of C/S are well documented. It is major surgery that may result in infection, hemorrhage, adhesion, injury to bladder/ bowel, increase risk with subsequent pregnancies such as previa, accreta or uterine rupture, increased risk of blood clots and prolonged recovery. Further, the rate of C/S does is very costly and does not appear to improve perinatal outcomes. Risk to baby is low, but still may yield respiratory complications and some preliminary evidence suggest the whole micorbiome is affected esp as moms are treated with antibiotics perioperatively plus are not exposed to vaginal flora.Not enough evidence to argue that point, but still a consideration. While some gut bacteria is no match for brain cells, these things should be considered. C/S is a LIFE SAVING procedure that simply should not be taken lightly.
I acknowledged that the studies cited may not directly apply to the safety of homebirth in the US. What is relevant is that homebirth may be safe in a well integrated system with highly trained providers. If that is the case, than let that be stated rather than arguing that ALL homebirth poses substantial risk to the babe.
What are the risks of vaginal delivery?
You cannot just list the risks for one option while ignoring the risks for the other, then cite one option as more dangerous than the other.
Your list of risks does nothing to answer the question of ideal c-section rate and how one would determine that.
in retrospect, a particular c-section may be shown to have been “unnecessary” in that both mother and baby come through fine, but how well can it be determined before the choice is made?
I think this is the only fact that needs to be given to justify making MRCS an option: You can tear through your clitoris during vaginal delivery.
Seriously!! Ouch! But I think most anti-c-section folks miss one critical fact: the “risks” of c-section are dramatically less life-altering/life-threatening than the risks of vaginal birth. For instance:
“Omg there is a slight increased risk that CS babies will have temporary breathing problems!” Translation: a few days in the NICU and then they’re fine.
Contrast that with: “Babies born vaginally are at risk of shoulder dystocia, which can kill them or leave them permanently brain damaged due to cord compression, and/or can leave them with lifelong partial paralysis (e.g. one paralyzed arm) due to brachial plexus palsy.”
Uh… seriously?!?!?! I know which of the above risks I would rather run with my baby!
And the list goes on and on. The hip thing to fret about these days is “omg babies born thru c-section might have less optimal gut flora! They might–not that there’s any evidence of this whatsoever–but they theoretically might have different immune responses than VB babies! Which I assume would be a bad thing!”
Again… contrast that with the risks of shoulder dystocia, and WHO THE HELL CARES?!?!?
And of course, there are the risks to moms: “Omg the recovery time is longer than if you had a perfect uncomplicated vaginal birth!” To which my response is, number one, no one knows going in whether their vaginal birth is going to have complications or not, and number two (no pun intended), what rational woman would NOT prefer a week or two of additional recovery time over a FOURTH DEGREE TEAR and fecal incontinence? Or the maimed clitoris you mentioned, SporkParade?
I co-sign this. My baby had a brachial plexus injury due to shoulder dystocia, that took a year of therapy to overcome. And it could have been worse than that. She could have had nerves avulsed from her spine. She could have had hypoxia. She could have died.
Recently I had my routine pelvic with one of the ob-gyns who treated me during pregnancy, and I asked about future pregnancies. She told me that shoulder dystocia was always going to be a risk for me, due to a few unchangeable factors like my pelvis shape.
I asked about a c-section for future pregnancies, and she said, “With your history and your daughter’s history, no one here would deny you that request.” OH MY GOD, I WAS SO RELIEVED.
She does not perform c-sections herself – she’s a nurse practitioner, so that might be why. She has nothing to personally gain by agreeing I could have a c-section, because she wouldn’t be doing the surgery.
If I did have another baby, I know I’d have to deal with NCB idiots scolding me for taking “the easy way out” by getting a c-section, or telling me I’m a stupid person who was conned by her doctors. My NCB friends would almost certainly open their big mouths, and babble about how shoulder dystocia is a hospital thing, and how a c-section is an overreaction to preventing shoulder dystocia, and if only I’d just labor in a magical position it would be okay. I know they’d say all this, because they’ve ALREADY told me these things.
But they didn’t have to live with a newborn with a paralyzed arm, and with no guarantee it would improve. They didn’t take their baby to therapy almost every week, for a year. They have no damned clue what they’re talking about. Their babies were fine due to sheer luck (and also due to one of those babies being whisked immediately to the hospital, but We Don’t Talk About That). Not through any virtuous action of their own.
Honestly, surgery of any kind scares me. But I’d take a c-section every time, over what happened to my daughter. I’ve seen the bad side of that risk, and I won’t go there again.
Risks in subsequent pregnancies will, of course, be entirely irrelevant to a substantial minority of women- those who are not going to be having more children after this pregnancy. The recovery from ELCS is frequently easier and shorter than that from a complex and/or lengthy vaginal delivery. As for the microbiome business, this is, quite simply, not something we have sufficient evidence of for it to be considered a risk at this point. It should not be listed along with known risk factors.
“As for the microbiome business, this is, quite simply, not something we have sufficient evidence of for it to be considered a risk at this point.”
And even if there were evidence: swab in vagina, smear on baby, done. Large q-tip type swabs cost less than 2 cents each, and the whole thing could be accomplished in less than 5 minutes.
read an article where someone did that, they stuck some gauze up their vagina for a while then after their section wiped it all over the baby….I’d need some pretty serious research suggesting a magic microbiome to subject my baby to that.
I agree. Somehow its different, and ickier, to swap the baby with all the blood and goop than just getting him out through the primary exit.
There’s good evidence that babies’ microbiome is a moving feast, so to speak, until they are established on solids.
Actually, there was a recent study done comparing cost of C-section to cost of vaginal delivery, and it turns out that they’re about the same. The main cost of C-section is that it requires a longer hospital stay afterwards. The main cost of vaginal delivery is that the labor costs (no pun intended) are higher because it takes a lot longer. The study didn’t look at long term costs, which is a pity given how many women who deliver vaginally require physical therapy or even surgery for their pelvic floors.
For the record, there have been studies done of the risks of homebirth in the UK and the Netherlands, where they are integrated into the health system. It takes a lot of massaging of the numbers to come to the conclusion that it is as safe as hospital birth. For instance, the UK birthplace study required the women in the home birth group to meet much higher risk standards than the NHS requires in practice. And in the Netherlands, the study that showed that home was as safe as hospital for low risk women also found that the absolute safest was to be high risk with an OB (in other words, it’s not that home is safe, it’s that Dutch midwives are dangerous).
I always think the anti section brigade need to be careful what they wish for when they make the cost argument. Especially those who think women ought not to be entitled to MRCS due to cost, since logic would suggest that if sections were cheaper they would want women to give birth in this way instead.
Most countries in the developed world have a pregnant population that is getting older, fatter, iller and disproportionately primagravida. All things that make vaginal birth more likely to be complex and therefore expensive. There may well come a point where ELCS at 38 weeks for everyone becomes the cheapest option. You’d eliminate nearly all the EMCSs and complex vaginal births. That is, the most expensive ones. Sections could be done during office hours, so staffing would be easier to plan and as such cheaper. You’d still need facilities for both vaginal and emergency section delivery outside hours of course, as some women would go into labour before 38 weeks. But it would only be a small minority. So if you think women ought to be encouraged to give birth in whatever way is cheapest on average, acknowledge the potential flipside to that particular argument.
@sporkparade:disqus , do you have a list for that publication?
Here’s the study on cost: http://journals.lww.com/greenjournal/Abstract/2015/05001/A_Cost_Analysis_of_Hospitalization_for_Vaginal_and.304.aspx.
Dr. Amy has written about the other studies in various posts.
@sporkparade:disqus , thanks for the link. What’s really shocking to me is the number needed to treat for pre-labour sections to prevent pelvic surgery. IIRC, NICE estimates it’s less than 10. Dr. Kitty would know best
That would be really interesting to know. As in, “Would have a significant impact on my birth decisions if I have another kid” interesting to know.
Read the NICE intrapartum guidance.
Using the Birthplace study data it is quite clearly set out in a table that HB will lead to more adverse outcomes than hospital birth.
The ONLY justification for calling it safe is that twice a rare thing is still rare, which makes it acceptable to some women. But not all.
Someone who has two MRCS is going to cost the NHS less than someone who has three all natural deliveries.
Someone who has two MRCS is going to cost the NHS less than someone who has two natural deliveries, physio therapy, incontinece products, a TVT, a hysterectomy and an anterior repair 15 years later for Prolapse.
We don’t make people who need CABG pay for their procedures because they “should have” had less invasive stenting when their disease wasn’t so bad.
We don’t make people pay for hip and knee replacements because they opt for major surgery instead of putting up with pain and disability for another year or two.
CS have risks, VB has risks.
Let each woman decide for herself which risks she is willing to subject herself and her baby to.
Do you know what holding off on intervention in childbirth looks like?
It looks like an induction at 41w for maternal hypertension, 47hrs of induced labour, meconium and an abnormal strip, a crash GA section because there wasn’t time for an epidural and a 5kg baby with low APGARS and hypoglycaemia who spends his first days in the NICU. Mother had no risk factors for GDM.
That isn’t “safer” than an elective CS would have been.
KG – you are not well-informed about cesarean delivery. Overall outcomes are better for babies – with relatively benign and short-lived TTN balanced against a much greater risk of hypoxia, cord injuries and physical injury from vaginal delivery.
It’s true that this comes at the cost of some increas in risk for the mother, but almost always short-lived, as opposed to the risk of long-term disability for the infant. BLadder or bowel puncture, while not desirable, are not devastating complications. Bladders are intentionally punctured for suprapubic catheterisation – they heal spontaneously.
Cesarean delivery is not just for saving lives, it’s also aimed at circumventing serious injury.
Absolutely. You’d have to have just had a full bag of glue to think homebirth in the US and the UK are remotely comparable. And even in the UK, where we have a pretty well integrated and safe homebirth system, the baby is still more likely to be injured at home. As per ‘Birthplace’ stats.
Incidentally, I support the right of every woman to give birth where she chooses and in the way that she chooses. This includes homebirth, even where medically inadvisable. It also includes MRCS, whatever this leaves the section rate at. Can you confirm whether you also support a woman’s right to give birth where and in what way she chooses, and if so how you square this with your contention that the US must answer for the 33% section rate?
You know, I just read something that stated in the UK 1 out of 4 births is a C-section. So even in pro-homebirth UK, they have a c-section rate of around 25% going by that article. Having homebirths is obviously not reducing the C-section down to what we know is possible. There’s far more than just homebirthing that will make the C-Section rate drop.
According to my NCB-loving UK friend, the midwives are very opposed to induction over there? That wouldn’t help the C-section rate.
You say it is well documented that maternal risk of death is lower in a home setting. Can you please provide those links?
Also, please control for age, race, economic class, and all health related risk factors.
My problem with homebirth, in the US or anywhere, is that there is no way to guarantee that a low risk, straightforward pregnancy or labor is going to stay that way. Changes can happen in an instant.
The poster who jumps in with “why not try to make a difference? Support efforts to standardize all midwifery certification….as in creating state boards of midwifery that can regulate and increase educational requirements of midwives” clearly hasnt spent much time reading Amy’s blog. This is one of the main issues discussed here.
It’s polite, and wise, to inform yourself before you go into a boots-and-all rant.
If they are going to cut costs by refusing pain medication to women in labor, they should really just refuse pain medication to everybody for everything. Clearly you don’t have to be unconscious during that open heart surgery, either- anesthesia definitely inflates costs and produces life-threatening complications. Why do they assume that an intervention-free birth is acceptable to every mother, even if it were just as safe?
And furthermore, why do they think that any increase in risk of death or permanent brain injury to an infant is acceptable to everybody? Even if the risk is tiny, the result is catastrophic. You can’t really compare risk of serious, but treatable complications to the mother to the risk of a dead child.
It frustrates me that this therapeutic nihilism (against the hippocratic oath, no?) is so liberally applied specifically to c-sections and other life-saving interventions in childbirth. It’s ideologically-based, not evidence-based.
Yeah, but men have open heart surgery.
In related news, the January death of a newborn at a South Carolina birth center has been ruled a homicide.
http://www.thestate.com/news/state/article23156496.html
there is a good post about this on honestmidwife.com
http://www.honestmidwife.com/it-could-have-been-me/
I am an RN with 25 years experience in mother/baby, NICU and L&D and can tell you when the poop hits the fan in L&D it does so very fast with very little time to correct. I attended many births where everything was “normal” but when the baby was born it was not breathing and the mother started to hemorrhage! One person cannot handle these situations much less in the home!
That’s precisely why I would never home birth, and I think it’s something that isn’t understood by many lay people. I’ve seen so many people say “well if anything goes wrong, the midwives will recognise it in advance, and we’ll just transfer” (and it seems in many cases that perception is encouraged by the midwives themselves). But things can turn from normal to bad within seconds, and there’s very little you can do at home if that happens.
I’ve heard it said that obstetrics is 99% boredom and 1% terror, and I suspect there’s a lot of truth to that.
My sister is due with her first baby in just over a month. And the other day she informed me that she is planning a homebirth with her midwife (for the record, I’m in New Zealand, not the United States so our midwives are more like CNMs than CPM). And I was horrified. It must have shown on my face because she immediately got defensive and said it was her choice, that her midwife was confident, and the usual line about being more at risk of unwanted interventions in a hospital.
I don’t think she understands the risk correctly. While the town she lives in has a birthing unit, the nearest hospital is here where I live which is a good 40 minute car ride away (probably more like 20mins if you were in an ambulance screaming along with lights and sirens going), but once you factor in the time it takes to actually GET an ambulance to her and get her up here to the hospital, I’m guessing it’ll be at least an hour. And in an emergency, you don’t have that sort of time.
But she won’t listen to me as she believes I’m judging her and that makes her defensive. We’ve never really gotten along well (especially since she got engaged to the father of her child, but that’s a whole other issue) and our entire relationship feels like one step forward, two back.
I do love her though. And while I respect her choice, I want her to be safe, and I want her to have a happy healthy baby.
But I honestly don’t know what I can do. I’ve tried finding data on perinatal mortality here in New Zealand, but there isn’t that much available.
I did find this though:
http://aim.org.nz/did-you-know/
And it says midwives here are given bonuses for successful homebirths. If that’s true, talk about corruption.
It really sucks when loved ones make choices we feel are risky but sometimes all we can do is look on and hope for the best.
Good luck to your sister and your little niece/nephew. I think the odds are in their favor, (though not nearly as favorable as at a hospital, of course.) Here’s hoping she changes her mind.
I feel you. My sister had her second baby last week, and had been talking about home birth if she has a third. Luckily home birth seems to be more regulated in Ireland than in the U.S., and given some of the issues that cropped up during this delivery (induced for post dates, big baby at 10lb3oz, PPH requiring pitocin – luckily both her and baby are absolutely fine) there’s a good chance that she would automatically be risked out in future. I must say, I’m relieved that that is the case as it spares me from having to give my opinion against home birth. I love my sister, and she’s not unreasonable but she does tend towards the crunchy side and doesn’t always do well with people disagreeing with her.
It’s a tricky situation as attempting to change someone’s mind can just drive them further away. I guess trying to approach it from a place of love – something like “things can go wrong so quickly, and I just don’t want anything to happen to you or baby” may help. I think if my sister asked my opinion on home birth, I would have to say “Personally I wouldn’t do it. While the chances of something going wrong are low (as long as this is actually a low risk scenario), when things go wrong in childbirth it can happen in seconds, and theres not alway enough time to get to a hospital. I’d never be able to feel fully comfortable at home knowing what could go wrong, and I’d never be able to forgive myself if something happened to my baby as a result.”
Or you could anonymously send her a link to Hurt by Homebirth. But that might be the nuclear option here.
You mean the British lessons of those midwives who refuse to consult OBs and killed all those babies and moms? Are those the lessons we dumb Americans need to learn? Too late, already happening here too.
Saving lives costs money. If he really wants to analyze how to save money without factoring in safety why save babies at all? Survival of the fittest starts at birth.
The biggest whole in his logic? Under the US tort system, and ‘savings’ are going to go straight to lawyers and their clients. And well they should: there is just no excuse for treating half of the population as if their biggest medical need is….a waste of money. Every dime you spend on quality maternity care saves piles of money down the road in healthier children and healthy mothers to care for them.
I’d rather give money to doctors and hospitals for more live babies than to lawyers for more dead ones.
Word. Man, who wouldn’t!? Apart from Dr. Shah, I mean…
NICE guidelines on homebirth are not really challenging deeply held beliefs. It’s a fringe pursuit in the UK, with only a very small minority going for it. At least some of those appear to be doing so for at least partially geographic reasons too: note that the south west, relatively remote and poorly provisioned, has a higher planned homebirth rate than average. Which makes sense.
He might have done better to highlight the relative popularity of MLUs attached to hospitals, which lots of women like and see as the best of both worlds. It is not something I’d have chosen myself, and indeed having now had an EMCS I think I would be permanently excluded anyway. But if you’re straightforward and not interested in an epidural, it can be a very suitable option.
Did my epidural for pain relief “eat into our wallets without making us healthier”?
Is effective pain relief one of those pesky over-interventions that women don’t need?
In the UK, women are routinely denied epidurals because there aren’t enough anesthesiologists on staff to provide them, and there is a non-interventionist attitude on the part of midwives. That is cost-cutting and less intervention in practice.
We’ve also seen recent cases in the UK where midwives failed to
recognize serious problems in patients, with tragic results.
I know where Dr. Shah is headed. The cost-cutters would like to shift to a midwifery system, because midwives are cheaper than OBs. Plus, the services they are able to provide are limited, so money is saved. Birth centers are cheaper to run than hospitals, and home is cheapest of all (at least in the short term). That doesn’t mean better or safer outcomes for women and their babies.
While Dr. Shah doesn’t seem to think much of his profession (can’t even trust himself not to do unneccesareans), I think very highly of OBs. We are privileged in the U.S. to have that degree of expertise during pregnancy and at birth. Why should we settle for less for ourselves and our babies?
Well, you see, you’re only a woman so your pain isn’t important. If you were a man getting, say, a splinter removed, then general anesthesia would be indicated. But since you’re a woman your pain can be blown off entirely. (Yeah, I might be in a bad mood this morning.)
Nah, it’s pretty accurate regardless of your mood. I was sick through a fair chunk of my childhood/teen years, ending up with a diagnosis of HMS and fibromyalgia and a rheumatologist who basically said “I gave you a diagnosis, there is nothing more I can do for you. Since physio isn’t working for you, go and learn how to deal with it yourself.”
So, as an adult, I am absolutely amazed when I have doctors who treat me like a person and say stuff like “You’re clearly in pain, you can’t just write it off as , we need to figure this out and find out how to make life better for you.” Same with when I go in (like last night) to see if I have picked up tonsillitis from the kids, or if I just have a virus, and the doctor straight away acknowledges that I’m in a lot of pain thanks to a classic case of influenza with impressive pharyngitis, and offers suggestions other than “harden up, princess!”.
Doctors hate teenage girls with issues that leave them in pain. We must all have been hysterical after getting our periods for the first time.
Oh goodness, yes! I had odd bleeding as a teen, and my parents decided to go the faith-healing route for a bit. When that obviously didn’t work (partway though the third cycle of 3 weeks of heavy bleeding + large clots, and 1 week off) I finally got to see a gynocologist who didn’t order any blood tests, just an ultrasound, put me on the pill for a month, and informed me that I’d be infertile by 25 so “Start trying to get knocked up as soon as you get legal if you want any kids.”
I was shocked when I read about someone with the same symptoms for a shorter time ending up with blood transfusions.
What an ass that gyn was.
Way back-the late 70s, early 80s-my parents’ gp who was my doctor at the time told me, when I tried to talk to him about my menstrual and cycle issues, that I should take aspirin and learn to control my emotions.
Same guy who missed Mum’s low thyroid last year, to the point she was falling off her feet. And this was despite the test results being there for all to see. She’s one of the militant well and I suspect she talked him out of treating her if he did suggest it, but still no excuse for him as she would have taken the drugs if he’d advised it.
Luckily the locum when he was on leave was having none of her nonsense and the thryoxin (or whatever they call it) is working wonders, though she still denies she needs it.
Ha, I was going to say that parents hate teenage girls with issues that leave them in pain. Frequently I find myself in the position of advocating for a teen with painful or heavy periods (or migraines) and finding parents, especially mothers, who block treatment at every turn. I get a lot of excuses from parents along the lines of “I had heavy periods at her age too, this is something she will outgrow and in our family we don’t believe in taking a pill for every little symptom”. Really?! Your daughter barfs from pain with all her periods and I just told you she has a hemoglobin of 9—REALLY?! I had a 13 year old the other day with pica from her iron deficiency from her horrible periods, and the mother argued with me that her daughter wouldn’t have become anemic if she ate better instead of sneaking off and eating dirt. And how many times had she told her to stop doing it and stop lying about it, the little sneak! I literally spent 45 minutes with the mother and finally convinced her to let her daughter take iron supplements, but never could convince her to let me put her daughter on the birth control pill to fix the periods. Evil woman.
Yeah that too. Poor teenage girls.. Who’d be one? Doctors don’t believe you, parents don’t believe you. They’re all such attention seekers that can’t cope with life…
When my daughter (18 at the time) was sick a couple of years ago, and took about a year to be diagnosed-and then a week to be cured-some at least of the doctors thought I was part of the problem, over involved and revving her up. I knew she was really in pain and that she wasn’t making it up or malingering, but it became more difficult the longer it went on to convince doctors of that.
I’ve got a few stories along that line too. It’s a horrible attitude that many parents of kids with difficult to diagnose issues like Periodic Fever Syndromes have encountered. I don’t know what can be done to help parents in that situation. The idea that we’re attention seeking through our children is hard to take – especially because there are some parents that actually do that….
I definitely think that compounded the problems I had with doctors as a teen. Once she twigged that the faithhealing just was not working, my mother took on the whole “parent of a sick child” identity with a vengence. “Oh, it’s just so hard not knowing what’s wrong… It’s so tough on us, as a family.” while doctor-shopping and taking 2 years messing around before finally organising a referral to a paediatrician (through her work contacts), and then onto Princess Margaret for a week’s worth of specialists. They wanted me to stay for two, she refused and checked me out early.
I’ve stuck with the one GP clinic and my local hospital (for antenatal and emergency care), and have received absolutely amazing care. It is so much easier and better accessing medical help as an adult.
We were so lucky our lovely gp supported her so well-mystified as they all were. Daugher refused the week in hospital to go over with fine tooth comb when it was offered about 3 months in. I was unhappy with that choice but had to respect her wishes; can’t help feeling we may have sorted it then had she taken that route.
Most of the doctors were great with me, a few were clearly of the view I was contributing to the trouble: I don’t think they realised that I was at hospital all the time and in appointments because she wanted me there, not because I had nothing else to be doing. And saying that to them would only have made it worse.
By the way-faith healing omg-I hope you don’t think I’m rude or patronising when I say you should be so proud of how sane and normal you have turned out.
You’re an awesome mum! I’m glad you were so supportive even though it sounds like it was frustrating.
Hahaha no, I’m not offended because it seems so ridiculous now. I do tend to speak up about it, simply because there are so many ‘success’ stories out there and I don’t want other people to suffer and think that it’s their own fault for not being ‘Christian’ enough.
Thanks for saying that. It was compounded because she was (legally) an adult, but particularly when she was sick, quite emotionally dependent. She really struggled with advocating for herself when she was unwell, and advocating for me on top of that would have been just too much.
Thank you for advocating for teenage girls, it really does mean a lot.
If my girls inherit my period pain/issues, I’m taking them straight in for the pill (and blood tests) because they shouldn’t have to put up with it.
Thanks goodness most parents don’t let their kids suffer. I just can’t wrap my head around the ones who do, especially when they have experienced it themselves. It really can ruin your teen years to be incapacitated from pain.
I’d like to think now there are things that can be done about period pain etc most parents are more keen to follow up than they used to be. Though I have a friend who is a hospital midwife, whose daughter used to have terrible periods, and she didn’t want the girl on the pill because of future side-effects. I shared my experience as a teen, and asked her what about the side effects of horrible bleeding, aching from belly button to knees for days on end, feeling sick etc. She hadn’t seen it that way before and took her daughter along for some help, which was great.
Sad that a real midwife believes these myths about the birth control pill. I’m glad you convinced her.
Or if she has endometriosis that the pill can help mitigate some of the damage so she can actually conceive later? Kind of sucks to be fifteen and while everyone around you is worried about accidentally getting pregnant you wonder if you even can.
I’m not a medico so just focussed on the ‘quality of life’ issues. I think my friend hadn’t seen her daughter’s symptoms for what they were-debilitating, miserable and entirely avoidable. The side-effects now of doing nothing were my topic, which my friend hadn’t conceptualised that way. The symptoms were ‘normal’ for Emma-as my horrible symptoms were for me-but so what? If they could be improved, why wouldn’t you? She wouldn’t hesitate to support treatment for knee pain or back pain, why hesitate for this?
My mother refused to believe I needed anything other than Tylenol for my periods. I was passing out at school and bled so badly i wore real diapers. The second I went to college I went straight to the health center and got 4 dollar packs of birth control pills. My needs just plain never existed in her head, and she made up the craziest explanations for things. Like gastroenteritis meant I was pregnant.
I had the same trajectory, those pills changed my life!
Does “a hemoglobin of 9” mean anemia? What’s a normal reading? (Random curiosity and my google-foo failed me)
Yes, anemia. Normal would be about 12 or above (give or take depending on lab).
Interesting. Thank you.
I had hemoglobin of 9 after my daughter was born and I felt *awful* Dizzy, weak, tired, nauseous, despite it being an easier delivery than my other 2 kids. In pictures I looked awful too. I can’t imagine a teenager feeling like that on an on-going basis.
Wow my daughter had similar issues with her periods I expected it as it seems to run in my family so it was off to the doc to get her on birth control pills and painkillers when needed. No anemia she was lucky in that respect. Had to convince my spouse about putting her on the Pill but I can be pushy
I was “lucky” (if that’s truely the word to use here!) to be in a similar situation to you. Heavy bleeding with clots, horrific pain, and endometriosis run in my family so my mom was ready to jump on the issue as soon as I stopped being pig headed about it. Mom actually preferred labor contractions to period cramps because she got actual pain relief and instead of a bloody mess, she got a bloody mess AND a baby at the end!
Those videos they show you in school that tell you your period might be heavy and abnormal at first are true but need a caviet of “still be evaluated by a doctor” instead of “being a woman is wonderful and this you blooming into your femininity and it will pass!” So I was in denial about how bad my periods actually were and thought it would “normalize.” I bleed on average about seven days with four to five requiring ultra tampons. I didn’t know this jwasnt normal until I was about fifteen and heard the majority of girls complaining about their 3-5 day periods and not being able to use their light and regular pads if i needed to borrow one because they’d be soaked through in minutes. I’m pale naturally but I look back at my yearbook pictures and I was so sickly pale from blood loss all the time.
I prefered my mom’s analysis, “Welcome to your reproductive years. I’m sorry for my terrible genes. Don’t listen to the film strip, this is gonna suck. Let’s go to the doc so we can make this livable for you.” She tried to intervene sooner but I’m kind of a stubborn little shit. So she had to wait for me to admit I needed help.
I’ve always preferred straight up honesty when it comes to health issues. Don’t sugar coat it, just tell me what I need to do to make it livable.
This poor girl… It’s just disgusting what overly prudish parents will do when a girl has dysfunctional bleeding or problems “down there.” No, we cannot use the pill! That’s for sinners and harlots! My daughter is neither! She is pure pureness and that will cure her womanly issues! Look at her, she’s fine! They say as they have to lift her pale, limp body off the floor while she’s moaning “kill me.” She doesn’t need pain killers either! We don’t believe in taking pain medicine when we don’t need it! Don’t you dare give her a pelvic exam to see if she has issues like adhesions or cysts! She is to remain untouched and virginal and your hands will devirgin her!
Why don’t you go stick her in a tent and declare her “Unclean!” for a week while you’re at it?
“never could convince her to let me put her daughter on the birth control pill to fix the periods.”
What… the… effing…
How old does a woman have to be before she can be prescribed BC without parental consent?
Well in the UK a minor child (under 16) is allowed to make their own medical decisions once they reach an age at which they understand the decisions they are making, and the consequences of those decisions. In practice it’s usually around 12 years old but there isn’t a set age. It’s called Gillick Competence and there’s a handy wiki article about it 🙂 http://en.wikipedia.org/wiki/Gillick_competence
If a teen comes in seeking reproductive care, I legally can prescribe her birthcontrol and keep it confidential if the teen requests. Practically, however, this is difficult when the mother has come along to the visit and won’t let me talk to the child alone and is the one who controls the insurance card which is needed to buy the birth control (unless the child has her own money).
Check for von Willebrand’s? A hemoglobin of 9 from just heavy menses is impressive and makes me wonder about bleeding disorders, vWD being the most likely. Also, I tend to jump straight to IV iron when the hemoglobin’s that low, but by the time I see people they’ve usually already tried oral iron and found it intolerable.
I guess pain relief doesn’t even factor into it? My impression was that the vast majority of American women are not interested in NCB and want epidurals. In Dr. Shah’s model, would these women get to choose hospital birth so they could have timely access to pain relief?
My OB says 80-90%of his patients opt for an epidural, and I live in crunchy-granola land. I can’t believe how many people ask me if i’m having a home birth — even reading thsi blog all the time, it seems so fringe to me.
“My OB says 80-90%of his patients opt for an epidural”
Yes, this seems to be the number. Wherever epidurals are freely available, about 85% of women, give or take, choose to use them.
I always have to laugh about my mother in law’s birth experience with my husband. In a “ha ha omg I’m so sorry!” kind of way. She had him all natural while on base in Guam. Not by choice but because she didn’t know epidurals existed.
When they got back stateside and heard about epidurals for pain relief she was piiiiiiiissed. You mean there was a way not to be in total agony that’s safe?! She couldn’t say yes to an epiderual fast enough for when my brother in law came along!
The way you handle this in a midwifery model of care is to have an official policy that women have many choices in pregnancy and birth (including epidural) – but don’t adequately fund choices that are considered non-essential (epidural). Don’t have enough anesthetists/anesthesiologists (they’ll be in surgery or just not available). It helps to back up this policy with a lot of natural birth mumbo-jumbo (interventions are bad, the safest birth is a natural birth). Some women will be traumatized in such a system; midwives will reassure them that birth is a beautiful process.
Update on the woman whose episiotomy video IB was sharing.
https://www.yahoo.com/parenting/woman-forced-into-episiotomy-fights-back-with-120714679647.html?soc_src=unv-sh&soc_trk=tw
I hope she gets relief and that doctor gets justice. I also hope IB doesn’t screw her around anymore. She’s been through quite enough.
Interesting that they filed an assault and battery suit instead of a civil malpractice case. Do any of the lawyerly folks want to weigh in on that? This is unusual, yes?
Edited,
My guess is that it’s an attempt to get around either rules for when you need an expert, damage calculations, or both.
I am a physician committed to achieving universal care in the US. I have devoted the greater part of my career to serving the underserved and uninsured. I understand the complicated financial concepts in play. I understand that we have to make hard financial choices.
But we can’t make these hard choices without honest conversations. And a conversation that neglects to present all the facts about increased perinatal morbidity and mortality is no conversation at all, it’s dangerous and deceptive ideology. Dr. Shah should be ashamed.
I would support a universal health care system with a private option like Australia’s, but after seeing how hard it can be to get an induction or C-section in Canada and the UK, I would never want a system with no private options.
I don’t know where you went to get treated in canada. But our C-section rates are well over 20% as well. Induction and c-section are pretty routine, all my pregnant friends where given a clear deadline for their labor to start naturally and if it didn’t, they were induced.
I don’t think you can just walk in a hospital and ask for one without any medical reason, but if you need one, it is clearly going to happen.
I am not from Canada. Women from Canada have posted here about difficulty with getting elective CS, and it’s legally impossible to pay to have one there since there is no private option if denied in the public system. These women wanted one for mental health reasons. I live in the US and easily scheduled one for mental health reasons. In the end, I ironically needed one for physical health reasons anyway, but I would never support a system that would refuse to allow women a CS for mental health reasons. In a system like Australia’s, if your reason for wanting a CS isn’t considered valid in the public system, you can choose to have one in a private hospital, which is not an option in a system like Canada’s.
I’m Canadian. Sounds to me like she had a doctor who wasn’t listening to her mental health concerns. Let’s face it there are bad dr’s everywhere. I believe she should have gotten a second opinion.
You are talking about ELECTIVE C-sections. I think that some women forget the CS is major surgery, has risks, and has a longer recovery time. That can also have an effect on the mothers mental health. IMO dr’s shouldn’t be scheduling CS because a woman wants one. CS should only be done if it’s a medical necessity. That’s great that in the US I can walk into a private hospital and pay for an elective CS. I mean the dr wants my $$ right? I wouldn’t want a dr who would put making money over my best interests. For the most part I believe that dr’s refuse to do CS upon request because they are wanted not needed. Canadian system isn’t perfect but every system has it’s pro and cons.
What do you mean “some women forget”? If they’re getting informed consent from their providers, surely you have more faith in women’s intellectual abilities than that?
As someone who suffers from chronic mental illness I can say that at my worst I don’t always think clearly. I become so focused on one thing that I can’t see anything else. If I asked my doctor for a CS in the middle of one of my episodes, I don’t think I’d hear anything other than the “no”. I wouldn’t be able to consider the reason why, even if it was a valid one. Perhaps my dr thought that waiting another 5 days to my due date would be better than having a CS because I was at a high risk for infection. I will say that some dr’s do not take mental health issues as seriously as they should. I’m talking about elective CS’s. IMO requesting a CS so you can go to your sister’s b-day party with the baby in 10 days, isn’t a good reason. Dr’s do get those types of requests, from time to time. Greedy dr’s do exist. As long as the patient is paying they will go ahead. I believe in women’s decision making but sometimes we don’t want to/can’t consider other facts that might be relevant. And sometimes dr’s are just not listening (as I said above) which isn’t ok either.
The practice I went to, did not try to talk anyone into having an elective CS. My primary doctor was the mother of twins who had needed a CS for medical reasons and had a difficult recovery where she was on narcotic pain medications for over a month. They offer elective CS if the patient asks about it or has certain concerns about vaginal delivery. I have an anxiety disorder so I was terrified of labor to begin with, and my body was not doing well with the pregnancy near the end and I was very weak from frequent vomiting. I was concerned about even having the strength to go through labor, particularly if I ended up going overdue since I was getting sicker every day. We decided upon a scheduled CS after 39 weeks. In the end, it turned out I was so sick because I had been developing preeclampsia and I ended up with an emergency CS at 39 weeks exactly.
Just a nitpick: Any CS that can be planned ahead, even if it is medically indicated, is considered elective (e.g. breech presentation, twins). Any CS that is planned for any reason not specifically relating to the pregnancy, such as anxiety disorders and history of traumatic vaginal birth, is considered maternal request.
I belong to a Facebook group for women who have had/are planning/are considering maternal request C-sections, and literally no one has ever said “I want one so I can be sure to make it to a party.” There are, however, women who request CS or induction because their husbands are in the military and about to be deployed overseas and they want their husbands to meet the baby just in case hubby ends up coming home in a box, but I think you’ll agree that that’s a different situation.
SporkParade gives a good explanation of the difference between elective and maternal request below. I had an elective CS after a biophysical profile at just over 38 weeks showed significant calcification of the placenta. It was a matter of “I think we need to do this today” but not running down the hall to the OR. I was offered induction, but my OB told me that with my low Bishop score it was likely to end in c-section. I know several people who’ve had inductions due to deployments as well. It’s anecdotal, of course, but I’ve never known of
anyone who wanted a c-section just for the hell of it. My recovery was easy, and by 1.5 or 2 weeks postpartum I was back to my usual activities
(though I had been warned how long and awful recovery would be).
The decision about c-section belongs between the mother and her doctor, not being crowd-sourced on the internet, a la Jan Tritten.
** requesting a CS so you can go to your sister’s b-day party with the baby in 10 days, isn’t a good reason.**
It’s also not a real reason. If you want the baby out by a certain date, you can just request induction. Timing alone is not a motivator for a CS.
What if you have other kids or are a single parent and the only time someone can come stay with you is a specific week or two.what if your spouse is going to be deployed for six months and is due to leave a week before your due date? What if your mother is dying and probably won’t make it more than a few days and your baby is due in two weeks?
For a woman who has extreme anxiety about labor and vaginal birth due to an anxiety disorder, or who had a previous vaginal birth that was emotionally traumatic, a longer recovery may be worth it for her. The person whose body it is should get to make the decision. My doctor offered an elective CS because of my anxiety, but cautioned I would likely have a harder recovery so I would need to consider which was more important to me. I chose the CS. I’m happy I did because I was prepared for it and didn’t have any disappointment or anxiety when I ended up needing an emergency CS before my scheduled date.
Point taken. You had a great dr and it was your choice due to your medical condition and trauma. What I’m saying is in a situation like this ” IMO requesting a CS so you can go to your sister’s b-day party with the baby in 10 days, isn’t a good reason”. From time to time,.those requests happen and dr’s say it’s not a valid reason and they don’t want to do the surgery. I do think dr’s have a right to refuse in this type of situation. That’s all I’m trying to say. Maybe I didn’t communicate my point clearly.
It would think it’s kind of weird for a mom to request a CS for something like that. I had probably one of the easiest recoveries I’ve heard about, I still don’t think I’d have wanted to stand around at a party showing off the baby a few days after getting home from the hospital.
Doctors can legally refuse to do a maternal request CS in the US, it’s not like they are forced to if they aren’t comfortable with it, but there aren’t any guidelines stopping doctors from doing maternal request CS – national guidelines (ACOG) pretty much leaves it up to individual doctor’s judgment as long as the mom is at least 39 weeks. My insurance covered CS and didn’t care what the reason was. If doctor approved the CS, they’d cover it with no further information needed.
A couple of points…other people have told you some of the very valid reasons women would have for requesting a c-section that isn’t strictly medically indicated. Some of these reasons are very private and not the type of thing most people would feel comfortable sharing with casual friends or acquaintances. It wouldn’t surprise me at all if some of those women made up reasons that appear to be not very good. A coworker asking why a c-section was performed might get waved off with “Oh, I was too posh to push,” rather than being told that the mother was sexually abused and suffered panic attacks at strangers seeing her genitals.
Another point is that some women might not have a “good” reason but that doesn’t mean a maternal request CS is unreasonable. I’m over 35, overweight, and haven’t had children. Should I have a child now, I would be at a much higher risk for an emergency c-section than a woman 10 years younger and healthier. I would also have a higher likelihood of morbidity or mortality than younger, healthier women – with or without a c-section. Also, since emergency CS is more expensive than elective CS (for a multitude of reasons), it might be fiscally prudent to encourage maternal request CS in certain patient populations.
I’m not saying we should start going around telling everyone to get a c-section, just that factors leading women to choose maternal request CS are varied and nuanced and deserve proper consideration from their doctors. The current popular debate doesn’t reflect this reality.
You said it!
I think the way I wrote my comment didn’t come across the way I wanted it to. Sorry if I offended anyone, that was not my intention. I also need to re-think my definition of, elective C-section. In my mind all the reasons people have stated here are valid reasons to request or for a dr to suggest a CS. To me that ‘s not an “elective” CS. I don’t know any other way to explain it. I’ve deleted my previous comment because it wasn’t reflective of what I was wanted to say. Thanks for the comments. They have given me a lot to think about.
It’s a difficult topic to get one’s mind around. Women are bombarded with the message that natural is best and the c-section rate is too high (the “ideal” rate is highly variable). When I started visiting this site, my views were similar to yours. It took me many months to truly feel that c-sections are entirely between a woman and her doctor and that there doesn’t need to be *any* medical indication. The more I learn about the subject the more comfortable I am with this view.
I think it’s a pretty common misconception. At my antenatal class the other week, we were divided into groups and asked to brainstorm reasons for planned and unplanned c sections. And the only things my group was coming up with were “anxiety about birth”, “wanting to avoid pain” and “wanting to plan when baby arrives”. I was trying to prompt them into giving medical reasons (it’s a weird situation to be in as a doctor where you know the answers but don’t want to just blurt them out) but I think I ended up suggesting breech, twins and placenta praevia myself because we had nothing else to work with.
Studies show that cesareans, compared to vaginal delivery, are a bit safer for the baby and a bit riskier for the mother. A maternal request cesarean transfers risk from the baby to the mother. If a woman wants one, for whatever reason, there is no reason to deny it unless there is a medical contraindication for it.
Elective pre-labor CS are apparently, according to a gigantic UK study, actually safer for the mom. You’re less likely to die, as a mother, from having an elective pre-labor CS than you are from attempting vaginal birth–primarly because so many attempts at VB go haywire and result in an emergency CS, which is more dangerous for the mom than a pre-labor elective CS.
Here’s a link to an article describing the study (which covered all births in the UK over a three-year period, so more than 2 million births):
http://www.telegraph.co.uk/news/uknews/1584671/Women-choosing-caesarean-have-low-death-rate.html
I wonder how this would translate to the US? I’m starting to have serious doubts about the relative safety of vaginal birth in the Uk vs the US. Too much NCB ideology going on over there.
One way I can think of to check how comparable the data is would be to dig into the underlying data and see why the women who died after attempting vaginal birth died. If most of them died because they ended up with an emergency c-section, it might be fairly comparable since they would have been under the care of OBs at that point if not earlier, whereas if most of them died after delivering vaginally maybe it’s not as comparable because many or most of them would have delivered under the care of midwives, which would not be the case for most women birthing vaginally in the US.
Thank you for posting this link. Women need all of the information available in making decisions about birth. It’s relevant to decisions about VBAC, too.
I just love that there is a Birth Trauma Association. It looks like they are doing very important work.
In my opinion women requesting a CS to be available for a party (btw you should make up your mind about that: is a c-section a major surgery that requires a long recovery or is it a procedure that allows to attend a party just days after ?) are exactly the same thing that “women who get abortions because they can’t be bothered to take birth control” (a common trope here in France from the anti-choice) : a very small, if existing, minority which is thrown in the debate as if it were a significant proportion of women, for sophistical purposes.
Jennie Elliott
Try reviewing the websites http://www.choosingcesarean.com or
http://www.thechaosandtheclutter.com/archives/and-then-my-uterus-fell-out
It is amazing how any method of birth includes risks and recovery time. Imagine what an informed consent form for planned vaginal delivery would look like.
Vaginal birth has major risks also. And why shouldn’t I get to choose how the baby comes out of my body?
Exactly. My body, my damn choice!
So why is it that it’s perfectly acceptable to ask for a tummy tuck for aesthetic reasons, but not for a c-section ? Does that mean that the risks exceed the benefits when the mother’s mental wellbeing is at stake, but not when it’s her silhouette ?
I think a better comparison is breast reconstruction after breast surgery for cancer.
This is considered so important that in the US, private insurers are required to cover this procedure, although one could argue that the appearance of the breast is a cosmetic procedure. We consider this important despite that you could make some of the same arguments as a c-section; it lines the pocketbooks of the medical system, it is an unnecessary procedure, etc.
In France a tummy tuck is reimbursed, or partially reimbursed by the social security in certain cases (if the pregnancy has been very damaging to your abdominal belt for instance). France has many flaws (conservatism, chauvinism, an unexplicable taste for red tape), but we are very lucky regarding the health system.
CS only has a “longer recovery time” if the other option is a vaginal birth with no complications. But none of us knows, going in, whether OUR attempt at vaginal birth will end that way. It’s not like we can choose “uncomplicated vaginal birth” in advance.
Apart from possibly ending in an emergency CS, labor can also end with a third or fourth-degree tear, a massive postpartum hemorrhage, or any number of other things that make recovery long and difficult.
I don’t know. My C-section recovery time just wasn’t that bad. I mean, I was tired, and I needed Vicodin for the first 4 days and a decent amount of ibuprofen for the next three or so, but after that I was fine. (Well, still tired, but that’s what happens when you have a newborn.) I have friends who gave birth vaginally. Some recoveries sound a lot like mine–sore (albeit in different places) and tired for the first few days, but afterwards okay. Others sound like hell: lots of tearing, not able to sit in comfort for weeks, etc.
I find the statement “I think that some women forget the CS is major surgery, has risks, and has a longer recovery time” alarmist and inaccurate. My experience was the opposite as what that statement implies. CS were presented as a very risky option and the risks and recovery time of vaginal birth were downplayed.
The bit that I find irritating in that statement is ‘some women forget’. How patronising to assume that in making a significant health decision for themselves and their children women-silly creatures-forget critical information.
My doctor was paid the same amount regardless of delivery method. Virginal or C-section the Insurance paid her the same thing. Now the hospital charged more, but then there’s all the extra people and medical equipment needed for that too. Also, I didn’t find my C-sections all that difficult to recover from.
I know it’s autocorrect, but “virginal” birth cracked me up. I would definitely charge more for that.
I’ve turned mine off-why would Bill Gates know better than me what I want to say?
Oh, I just love auto correct. How it entertains!! Sorry, it’s hard to edit with kids running around.
I’m glad the kids were running around–I love it!
Just out of curiosity, not mocking or anything, what are mental health reason to want a C-section?
I don’t know here situation but being a childhood sexual abuse survivor could be an indication for maternal request CS.
Being a sexual abuse victim, in childhood or not, is a very good reason to request a c section. Many sexual abuse victims are terrified even by a pelvic exam, so a the perspective of vaginal delivery with several people in the room can indeed by traumatizing.
tokophobia (very specific fear of labor and birth), more generalized anxiety disorders (I have general anxiety and for me the thought of attempting a vaginal birth was causing me severe anxiety because it is less predictable while a CS was more predictable and controlled by the doctor, I felt it would be very hard for me, emotionally, to handle going through labor and being terrified like that), previous traumatic vaginal birth – one mom I knew of wanted CS because her only previous birth was a vaginal delivery of a baby stillborn due to a fatal genetic disorder, when she thought of going through labor again all she could think about was that the last time she did that, she had a dead baby
I knew one woman who had three quite straightforward vaginal births, followed by one stillbirth (knot in the cord) and then a baby who died at a couple of weeks old from SIDS. She requested (and received) C-sections from then on.
Sexual abuse survivors sometimes prefer them because it cuts way back on the number of vaginal exams you have to have. In labor, from what I hear from friends, you can be checked a dozen times, each one potentially very stressful and traumatizing even though the caregivers are kind/understanding/mean well/etc, and then the actual delivery involves a fair number of people seeing (and your OB/midwife touching) your genital area. A lot of women don’t care about that once they’re in labor and whatnot, but it can be very triggering for sex abuse survivors.
Some people who have have been sexualky assaulted or molested in the past do not want to have to deal with vaginal exams. Some people have anxiety disorders exacerbated by pain. There can be lots of reasons. A very traumatic painful vaginal birth might result in PTSD. If having a scheduled pretty labor C-section is prefer ed and possible in that hospital then why force a person to have a vaginal birth?
I don’t know about an elective CS for the first one in Canada, but once you’ve had one, you can certainly get subsequent CS’s with no questions asked. My SIL had an emergency CS the first time and wanted no part of an attempted VBAC for the second. That was presented as a choice, but discouraged. For the first one, I’m pretty sure if you were of a mind to you could shop around and find a doctor who would find a medical reason for you to have it.
The UK has private options.
Well. Private option in the singular. There’s a private maternity hospital in London. Not in the rest of the country as far as I know. Those of us who don’t live within driving distance would be shit out of luck if we weren’t planning either ELCS or an induction (and possibly even then if baby came earlier). Not that I had the money to go private, but I had no clinical need for induction for either of mine and wasn’t interested in ELCS. So it simply wouldn’t have been an option even if I had a spare 10k.
Also, I may be wrong, but I think the Portland doesn’t actually deal with certain obstetric emergencies anyway? You get bounced back to the NHS if enough shit hits enough fans. Private healthcare in the UK isn’t really set up to provide for emergencies. The focus is more on elective procedures.
There are some private ‘wings’ of NHS hospitals, but again in London. The Portland is probably the best known private maternity care provider…and you can (if you’re rich enough) book there, and stay in London for the end of your pregnancy to ensure you can deliver there. They do have emergency facilities, NICU, SCBU, transitional care and adult high dependency unit, but I’d imagine that if something came up then families would be given the option to transfer back to NHS for cost reasons.
I’m not sure it’s so much a choice as the Portland and any private wings (do you know where?) simply not having the facilities that are necessary when mother and/or baby are quite ill.
Well, the Portland has NICU, SCBU and transitional care for baby, and HDU for mum, preemies are not delivered there before 30 weeks so women in premature labour are probably sent to NHS facilities.
Other private wings include the Lindo (St Mary’s) where Princess Katherine had her babies, there’s a few others listed here http://www.privatepregnancy.co.uk/private-clinics-and-hospitals/private-maternity-hospitals-for-childbirth/ not sure of their emergency provisions, they will obviously have some.
Oh yes, I’d heard of the Lindo. I don’t think there’s anything outside London though, is there? Nothing in the north west, certainly, which is interesting given that there are pockets of great affluence in the region. The footballers wives all end up having their babies in NHS hospitals here.
As for the facilities at the Portland, I know they can do a certain amount, but if you need more than that it’s going to be NHS. If you have anything reasonably rare, the Portland just isn’t going to handle enough of your particular complication to give them the necessary expertise. Perhaps part of the reason they don’t do pre 30 weeks?
Probably, I think they work with other local specialist hospitals to manage more complex needs. I think they can handle pretty much anything if it’s an unplanned emergency, so bleeding, poorly baby, pre-e, GD management but perhaps not complex pre-existing conditions.
Yeh I think all the private hospitals/maternity units are in London, despite other parts of the UK having affluent communities. I know there’s independent midwives all over, which some wealthy people choose.
Like Mattie pointed out, there are a few other options but mostly in London. NHS hospitals appear to vary on how easily a maternal request c-section can be arranged, as they vary with most things.
I do agree that the NHS is generally much better set up to handle emergencies than the private system.
As far as I know they’re all in London? In terms of MRCS, yes you’re correct they vary between trusts.
I think most places (NHS) are fine with MRCS if it’s a repeat section, but very few that will do a section first time for anything other than breech or multiples.
Private options are quite common in Australia and the government encourages people to have private health insurance too. More than half the people I know delivered in a private hospital.
Canada also has some private options in general. Maybe not for c-sections since you still need a pediatric NCIU in case something goes wrong.
I do agree that mental health problems do not yet get all the understanding and care that they deserve. That is sad and hopefully things will get better in the future.
However, I would never consider even for a moment to switch to the American health system. All put together,my family have gotten through: 4 induced vaginal delivery, with one neonatal resuscitation, A wrist fracture, an open radius/ulna fracture, multiple fractures in a foot that refractured 2 aditionnal time during recovery. Multiple IRMs/contrast CT, sleep apnea testing, surgery for cancer and an intra-vascular cerebral aneurism embolisation.
After all of this, we have a medical bill of 0$, we don’t even have a co-pay. There was never any question of what is and is not covered by our insurance.
No system is perfect, but yea, if the price to pay nothing for my health is not being able to walk in a hospital and request what I want, I can live with it.
I’m American. Signing up my children for health insurance after they were born was a month-long nightmare.
The UK varies.
Northern Ireland, weird as it is, is a good place to have a baby.
Being seriously about 25 years behind the rest of the UK means that NCB and Homebirth haven’t caught on, and getting a CS and epidural are very possible.
It is also possible to see a consultant privately for antenatal care and deliver in an NHS hospital.
I know NI very well, and despite all the problems there, I think there are several ways in which it’s better than the rest of the UK. Interesting to hear about another one.
Dr. Shah responds on Twitter:
But they don’t explode 1 in 3 times for low-risk nullips..
Maybe it’s not actually a bad analogy. Airbags explode in your face mostly when things are going really bad. And they leave you with a few bruises and some icky powdery residue instead of dead dead dead.
It is from HIS point of view. He clearly prefers cars with no airbags at all. It’s a matter of time before he disses seatbelts altogether.
No airbag, no seatbelt, no pecky restrictions. Sure, you may die but you’ll die a free woman!
With the side implication: you’re only a woman. It’s ok if you die.
The more I think about it the more think it’s a good analogy but not in the way he intended. The risk of an accident for any one car trip is quite low, so you can argue that putting an airbag–which has risks of its own and can potentially kill you if you’re unlucky–in every car is overkill. But when you get into a bad accident, the airbag dramatically increases your odds of surviving. So he’s saying let’s have low risk women birth at home because the odds they’ll need a CS are very low and they can avoid “airbag” injuries–but the “airbag” won’t be there for the babies who need it.
Your characterization of C-sections is offensive Dr. Shah. My c-section was not an explosion. It was my vaginal birth that was an explosion.
Same. And I had an EMCS.
No, hospitals are airbags in extremely unreliable cars which crash about 1 time in 3. It is hardly the fault of the airbag if it goes off in a crash.
The seatbelt analogy works better. C-sections are like seatbelts that lock up when you come to a sudden stop. Most times the seatbelt didn’t prevent violent injury. We put up with seatbelts that lock up like this because they have a low threshold for engagement in order to save the most people from the worst injuries.
I think the point he’s trying to make is that airbags cause injuries but when you look at the big picture, airbags prevent more deaths than they cause so using airbags is safer on a population level. He’s not logicking well, which is kind of shocking for a doctor.
That’s a pretty shocking analogy, particularly with the completely unnuanced stat of 1/3. I had a hospital birth with a midwife with zero interventions — up until my emergency c section after hours of pushing and my baby went into distress. It wasn’t the hospitals fault I had a c section, and there were no costly interventions to blame. My midwife actually told me that if I had attempted a home birth (which I never would have done!) we would have had to transfer early on in labor due to my sons heart Decels. Why is an OB who’s likely seen lots of true emergencies disparaging life saving c sections?? There might be some that are unnecessary, but certainly not all are, not even close. If that’s the way dr. Shah uses scientific findings and statistics then I’m not sure why anyone is interested in what he thinks. Absolutely ridiculous.
I guess it’s the old “all emergency interventions happen in hospitals, so hospital care must cause emergency interventions” argument. I expect that kind of thinking from NCBers, but not a medical doctor.
So, I remember looking at the Birthplace study and seeing that the risks of serious outcomes to the baby for first-time low-risk mums were almost doubled at home, but the risks of serious outcomes to the baby for multiparous low-risk mums were comparable at home and hospital.
Then I remember that whole brouhaha with Morecambe Bay and the other horrible things that happened with midwives at hospitals. And that lead me to wonder – does homebirth look better in the UK partially because the midwives lead the care in the hospital? That is, are we looking at a Netherlands situation?
UK homebirth isn’t just relatively safer than in the US, but UK hospital birth is relatively more dangerous than US hospital birth? That’s a great insight, with a lot of implications.
One thing driving the UK’s poorer numbers is its high term stillbirth rate. The UK pressures providers to wait for natural labor. They say it’s because it’s more natural and thus better, but in reality it’s because it’s more expensive to induce rather than wait. In Dr. Shah’s words, women may “spend many hours, if not days, in a hospital bed under the supervision of an obstetrician” if they induce.
Yep, inductions can take a lot of time and are often a pain for all involved: the provider, the patient and the pocketbook. But they save lives. It’s the difference between a mother first seeing her baby’s face as a living crying baby vs. a dead baby.
But hey! It saves $.
Those are very expensive dollars saved.
My induction saved my baby’s life. I am deeply grateful for it.
And when you consider all the money they now don’t have to pay for healthcare and school for that dead baby, it all makes sense. It’s all a conspiracy of Big-UK to control it’s population!!!
kind of ironic, when you look at how much of the NHS maternity budget goes towards paying for birth injury claims…
I’m still shocked that the NHS can’t be bothered to pay for the varicella vaccine. Is it really that much cheaper to administer the MMR than the MMRV?
I suppose it must be. Chicken pox also tends to be something dealt with at home without the need for medical input, except serious cases of course, so it doesn’t actually cost the NHS that much for most of the population to get it.
Alternatively, I wonder if the NHS just doesn’t want to add anything else to the MMR given the shitstorms over the vaccine already. We already have a big problem with too few children receiving it. I suspect adding another immunisation at the same time would. however unjustifiably, further reduce uptake. Although I’m glad you mentioned this, I keep meaning to get the vaccine privately for my eldest but haven’t got round to it yet.
Well, could the country’s economy (not the NHS specifically) suffer from lost wages and productivity, no? Or if parents stay home for a few weeks for a sick child, is that paid leave? (I don’t know the answer, I’m just thinking of reasons sometimes mentioned in the US.)
There was a study done in France and Germany – http://www.ncbi.nlm.nih.gov/pubmed/15877593 which supported varicella vaccination for economic reasons.
It could be paid or unpaid leave, assuming a parent takes time off work. Depends on the generosity of the employer! There’s no legal right to take paid time off to look after a sick child, lots of places will try and let you take annual leave to do it if possible.
Obviously there are families with a SAHP, or relatives neaby who’ll help too. The majority of households with an under 5 have one parent who is either at home full time or only working part time, so it may not have as much of an impact as one might think. But yes, I imagine it’s possible that it costs more in productivity than the vaccine would to roll out. I’ve never seen it costed, tbh. Meanwhile, I shall be dropping £97 for it in the near future…
Mere minutes after I wrote this post, my husband arrived back from nursery with our eldest, and it turns out there’s chicken pox going round there and she’s been lethargic and hot this afternoon. Oh shit…
Oh no, good luck!
Good luck
Oh my goodness, I’m so sorry!
I hope she’s fine, whether with or without chicken pox. Give us an update when you can! Have you and your DH had it?
Yes, both. She seems alright so far and as luck would have it, there’s a vaccine clinic tomorrow and they had a slot. So she’s booked in for that. The main worry is the baby really, I could cope with a toddler having it but it’s really not ideal for a four month old. Thanks all for your concern, keep your fingers crossed please!
I’m glad you’ve both had it, at least, but…ugh! A four-month-old? I will cross my fingers for you, and I’ve said a prayer or two as well.
That’s very kind of you, and I really appreciate it.
Additionally, I’m grateful to be financially secure enough to be able to pay £97 at short notice. There are many people for whom this wouldn’t be an option. If I were one of them, even in our socialised system I could be looking at dealing with a poorly baby in the near future.
My pleasure. I had chicken pox twice, once at 7 (very mild case) and once at 13 (utterly horrible). I wouldn’t wish that on anyone, especially a baby. (Well, I might make a case for obnoxiously anti-vax parents, but I digress. 😉 )
That’s really rough. 🙁 I’m kind of surprised a) that it’s not a standard offering and b) that you’d have to pay for it. I mean, wouldn’t just a few adult (or infant) hospitalizations cost the NHS a hell of a lot more than a *lot* of varicella vaccinations? Strictly as a cost-saving measure, I should think it would balance out, or come very close indeed.
Hey I had it twice too! Once when I was two (mild) and again when I was nine (full blown illness).
So much for the wild type virus conferring life long immunity like anti-vaxxer claim, huh?
Indeed. From what I understand, it’s not uncommon for people who get only a mild case of certain viral diseases to not develop an immunity to them. When I was pregnant, I did titer immune to varicella when they ran blood tests, so I’m delighted to say that those several weeks of hell when I was 13 at least gave me that. :p (I’m also delighted to say that unlike me, DD will be vaxxed against it, thankyouverymuch.)
Crossing fingers and good luck!
Oh no!! Hope they’re both okay!
And don’t forget the Shingles you can get later in life from having chicken pox. Certainly that contributes to missed work, etc. (Not sure about in the UK but I’ve been seeing younger and you get patients with Shingles, like in their 30’s and 40’s).
I heard that chickenpox vaccine actually increases the likelihood of getting shingles later in life, or it’s more likely than if you have ‘regular’ chickenpox as a child. Not entirely sure why varicella is not a routine immunisation, guess NICE doesn’t feel it needs to be at this time.
If you have had the varicella vaccine you can still get shingles later in life (because it is a weakened live vaccine not a killed one) but it is rare compared to the rate for people who had true chickenpox.
There’s a theory, and I don’t know where the evidence stands currently, that the increase in shingles rates occurs when a population is transitioning to varicella vaccination, and is temporary.
The thought is that wild pox in the population both creates new pox infections and also presents a low level immune challenge to those previously infected. This “natural booster” effect of these low level challenges reduces shingles rates by keeping immune response high, and removing wild pox from the population through vaccination reduces the availability of this effect. Of course, if varicella can be eliminated through vaccination, future generations won’t be at risk for shingles in the first place.
Also, in the US there is a shingles vaccine.
Absolutely. The data is very clear that in the UK, induction at 41 weeks reduces the stillbirth rate. However most trusts do not routinely offer it until 41+4. This must, therefore, lead to more stillbirths.
“The data is very clear that in the UK, induction at 41 weeks reduces the stillbirth rate. ”
And actually the data are making it clearer and clearer that routine induction at *39 weeks* reduces stillbirth without raising CS rates. But it for sure costs more money, and women will “spend many hours, if not days, in a hospital bed under the supervision of an obstetrician.”
Wouldn’t they recommend a C-section if you’ve been induced and laboring for 48+ hours?
Yes. But those women are likely the same ones who wouldn’t have progressed well through spontaneous labor either.
I thought so. His comment of laboring for days seems a bit disengenious (sp?) to me.
Even if you were just going on cost, isn’t there a resourcing advantage to induction, though? Women in spontaneous labor can show up any time. Women being induced, you can plan and resource for.
And, of course, term induction lowers unwanted CS rates, as I feel I always need to signal-boost on…
But, factor in that inductions take longer, at least where I work pitocin is 1:1 nurse patient ratio as well. Also, they aren’t that easy to plan in terms of when the patient will deliver unless it’s a super easy induction.
“Even if you were just going on cost, isn’t there a resourcing advantage to induction, though?”
No, because inductions take up more hospital bed time because you are hospitalized from your first contraction to the end. In contrast, if you wait for spontaneous labor, a woman may do half her labor at home. Inductions on first time mothers, in particular, can take a looooooooooong time.
Interestingly I often wonder if there’s a correlation between our low number of scans in pregnancy and the rate of stillbirth. Standard scans are one ‘dating’ at around 12 weeks and one ‘anomaly’ at around 20 weeks (this is what normal, singleton, low risk pregnancies get). It means that often any possible problems late in pregnancy are not picked up, which is awful.
Are you in the UK? I think that’s fairly standard in the US, though if any complications arise, or if the pregnancy is going past 40wk, more ultrasounds will be done. I may be wrong on this—I had a complicated pregnancy (MZ twins) so I had way more u/s than the average American woman.
really? I was under the impression that in the US women got a scan at almost every visit…not entirely sure why I thought that haha I do remember a documentary where a neonatologist blamed lack of sufficient USS for stillbirth rates being high. Unfortunately I don’t remember the documentary for link purposes.
I just looked at the standard of care for a clinic in my area (USA)
8 weeks dating ultrasound
a combination of lab tests and a 12-week ultrasound for estimation of Down Syndrome 12 week ultrasound for evaluation of possible downs syndrome and Trisomy 13/18 risk
20 week ultrasound
3rd trimester ultrasound if there is medical indication to do so
Standard for my Dr. office is generally 2 scans. One at 8-9 weeks and then the 20 week scan. When I had my last baby in ’12 you could get some kind of ultra-sound to look for Downs, etc at 12 weeks, but it was optional. I had more scans because I needed ART to get pregnant (lots of early scans) and my first was breech so I had a scan around 37-38 weeks to determine the babies position.
Maybe a lack of ultra-sounds for postdate babies is what that doctor was referring to.
I don’t think it is the scans. 2 scans are the norm here too, unless there is some deviation from normal. I think the main driver is less induction. Or lower threshold to call somebody high risk rather than low risk.
I appreciate that Dr. Shah’s piece didn’t go too deep into the woo, but I’m unclear on how he can come to the conclusions he came to based on the evidence he presented. He himself said, “For first-time mothers in particular, the risk of delivering a baby with serious medical problems is two to three times as high at home as it is in a hospital.” How does he then arrive at the conclusion that home birth is safer than hospital birth? It’s a mystery to me.
Since you brought up the 2 categories of midwives, let me ask you a question: Suppose for a moment that hell froze over and only CNMs were allowed to practice midwifery in the US, and homebirths with a CNM become common practice. Wouldn’t that still be a terrible risk to take? Does it really matter that CNMs are more qualified than CPMs, when they still don’t have blood products, cooling caps, or an OR available to them at home?
I think whether it is a “terrible risk” really is down to the woman making the choice, even now. The risk should be made clear, which is not generally the case now, but whether a risk is too high should be up to the individual.
The CDC data shows that CNMs have better homebirth outcomes than non-CNMs: the risk of perinatal death is merely doubled at homebirth with a CNM.
Why? What part of the process of becoming a homebirth CNM improves outcomes? Since there’s such a limited range of treatments available at home, it doesn’t seem like they could really do anything to help a troubled birth other than transfer. Are they just better at identifying problems and getting care transferred appropriately, and avoiding ridiculous or dangerous therapies like cinnamon breath and magic diets? Are their transfer rates higher than CPMs?
Yes, the improvement in safety involves recognizing problems earlier, transferring earlier, and (hopefully) refusing to take on high risk patients.
Yep all of this, and also the ability to cope in an emergency, I know all UK midwives (including independent midwives who only do homebirths) do regular ‘drills and skills’ training to deal with emergency situations, so that ideally they are ‘prepared’ enough to not freeze in an emergency. Also neonatal resuscitation is taught as standard, and refreshed I think annually, with some midwives doing more advanced training so they can teach.
Midwives at home carry vitamin k, uterotonics, oxygen (possibly, for mum, most newborn resus is started with air) and gas & air, they have suture kits to suture 1st and 2nd degree tears (3rd degree tears are transferred). Also obviously they have the same sterile birth kit that hospital midwives have. For pain relief all midwives carry gas & air, and if women want pethidine then they get it prescribed by their GP and store it at home themselves, but the midwife would administer it.
You can see how terribly deficient CPM education from be from the very official sounding National College of Midwifery.
http://www.midwiferycollege.org/AcademicProgram/Pages/ASMacademics.html
If I learned how to be a healthcare provider from a series of PDFs like this, I would surely kill or seriously injure someone out of ignorance.
The education CNMs receive is undoubtedly far superior to what passes for education for CPMs. But if you’re in an environment without resources, what practical application of that education is actually beneficial, aside from better problem recognition and transfer protocols? A CNM is going to (hopefully) identify a problem sooner and also transfer instead of whatever goofy alt-med is currently trending, so that will save lives for sure. But is all of the difference just reliably calling for transfer before it’s too late, or is the actual in-home care better?
Are there any problems a CNM can address in-home that a CPM can’t, considering the technology limits of the setting?
I suspect CNMs would be more likely to work in pairs, enabling at least one caregiver per patient in the event of an emergency. They’d also be able to legally carry more stuff (pitocin, proper oxygen masks, suturing kit, etc).
But you’re right, the superior training is what they bring to the table. No neonatal cpr on a bed, no ignoring signs of pph, proper recognition of an emergency and better ability to document what happened and convey it to emergency personnel. Of course they’d also call 911 earlier which is also huge.
Better technical skills in IV placement could help, and I suspect (although I’m not sure) that a CNM would have a higher likelihood of current certification in neonatal resuscitation and adult resuscitation. Some states license lay midwives to carry certain medications, others do not, but a CNM would be able to carry anti-hemorrhagics, Vitamin K, etc.
Honestly, though, I suspect a lot of it is having the good sense to transfer care before disaster. Look at inclusion criteria for this USA CNM practice
http://www.mountainmidwifery.com/care/
How many CPMs would consider Declining or refusing Gestational Diabetes Screen or Rhogam to be exclusionary? Or TOLAC?
Wow, actual appropriate risk-out criteria!
found out about this practice from Honest Midwife facebook. There is also a CNM practice in Minnesota with similar criteria.
Wow ok, so they exclude women who declined gestational diabetes screening? Do they mean the urinalysis or the glucose tolerance test? I know now that I won’t be having GTT unless there’s clinical indication of GDM (so glycosuria on more than 2 occasions, measuring large for dates etc…) even though my father has type 2 diabetes, but that doesn’t make me any ‘riskier’ than someone who has no family history of GDM and has the potential to develop it during pregnancy.
If you decline screening and wait for symptoms to become apparent you might miss the opportunity to avoid some of the negative outcomes or increased risks. Not knowing (and therefore not treating) is riskier than knowing and responding accordingly. GD increases risks at delivery, untreated GD more so.
That’s fair, but that only works if you screen everyone, in the UK GTT is only offered if symptoms present or if there’s a risk factor. With only one risk factor for it, and no family history of GD at all, I would be accepting the risk that I would be more likely to develop it, but not wanting a diagnostic test (GTT) unless I actually presented with symptoms. The same way a woman with no risk factors would be treated.
What risks does GD present at delivery, and would there not be other indications of GD that would show up before delivery, even without a GTT?
“What risks does GD present at delivery, and would there not be other indications of GD that would show up before delivery, even without a GTT?”
Most GD is silent. Mother feels no symptoms and shows no signs. The glucose level has to be fairly high for it to “spill” into the urine.
The risks of undetected, untreated GD include:
-higher rates of stillbirth
-larger babies (which may go undetected until it is too late because external measurements are estimates)
-more shoulder dystocia and damage to mom
-higher chance of undeveloped lungs
-higher chance of severe hypoglycemia in baby after it is born.
That’s interesting, so do you feel that GTT should be a routine test? Or just offered to women with risk factors?
also, if the treatment for GD is generally just diet, wouldn’t you be fine just being careful with your diet ‘in case’ of GD with or without a GTT?
I just had dietary management, and was very careful in subsequent pregnancies even after ‘passing’ the screening.
But it’s easier to just get the screening than to spend months unnecessarily limiting your diet, and the diet limitations don’t necessarily work the same for everyone (you don’t know unless you’re testing your sugars at home- I was surprised how different foods with the same amount of sugar would impact me differently), so you don’t know if your dietary changes are effective in maintaining target blood glucose or not. You cannot just completely eliminate carbohydrates, your baby needs the glucose to grow properly.
In the US, the one hour screening is recommended for everyone, if you have risk factors or fail the one hour you get more extensive testing.
I had GD in two out of four pregnancies and didn’t have any external symptoms or anything that felt different. We knew early though, so I had good monitoring and could do early dietary management. My GD babies were both normal size at birth, but the younger was only normal size because she came early (7 lbs at 36 weeks, first scan at 9 weeks so definitely not missed dates).
Wow, yeh, I was pretty big I think…5 lb 2oz at 33 weeks, but AFAIK my mum didn’t have any problems, other than me being prem. Did you require insulin or just diet management?
It is a routine test here in the US, and I think that’s good. Then again, our population has a higher rate of GDM than many other places due to a variety of factors including older mothers, heavier mothers and a large percentage of ethnic groups with high backgroud rates (latina, Native American, certain asian groups and African Americans). So different countries make make different choices to save money if their background rates are low. That said, yes I would be personally worried if I had a family history of DM2 in a father, and they didn’t screen me. The genes that cause DM2 are the same genes that put a woman at risk for GDM. If your dad had been a woman, he likely would have had GDM.
Interesting, and thank you 🙂 yeh my dad having DM2 means I get a GTT at 20 weeks, or at least they get to try, currently lucozade makes me throw up (I am weirdly sensitive to certain flavours) so can only imagine that would be heightened while pregnant.
*snarl*
Sorry, this just hit a raw spot for me. A friend posted on FB recently about how she declines Rhogam even though she’s RH- and her DH is RH+ because that way she avoids Teh Evil Toxins. So far, she’s been lucky: first baby was fine, second tested RH-. It’s freaking Russian roulette. At least the comment section of the article she posted on was, shockingly, filled with people saying “I’m anti-vax, but this is effing stupid, get the damn shot. I lost siblings/babies/etc because my mom/I didn’t get it.”
Yep, CNM are more likely to transfer. While I personally wouldn’t make the choice, a mom in an online group I am in decided to have a HB with a CNM for her third after two uncomplicated hospital births. CNM required an ultrasound for all her patients. US showed marginal previa. CNM said she couldn’t deliver her if it didn’t move and she would be required to keep having US with the OB. OB rechecked it a couple times and it finally moved so she did get the HB in the end. Otherwise, she would have had to deliver in hospital.
I’d say it’s a mix of everything. If a CNM does something stupid, she can probably be held more accountable than a CPM. So A CNM is probably way less likely to do ridiculous stuff like HBA4C.
Given their medical training, they most likely do more prenatal work up of their mother and will be more likely to exclude risky women. Therefore, their number of complication will be lower.
They are also more likely to monitor more, realize someone is wrong sooner and more likely to transfer earlier.
If something still do get wrong, they have access to better emergency treatment (although in case of full cardiac arrest, it probably doesn’t make much of a difference), they are also more likely to pick up that something is wrong with the baby after it’s birth and recommend you take it to a hospital.
Yes. These poorly trained CPN’s often don’t have enough education & training recognize when one of their mothers needs a transfer to hospital. They don’t know how to monitor a birthing mother properly and don’t know what signs to look for that indicate mother and/or baby need a doctor. When a complication happens time is of the essence. What’s happening is that poorly trained midwives don’t realize there’s a problem (often when signs been present for hours) until it’s too late. By the time mom and/or baby get to hospital there has been a death and/or serious injury has occurred. Also, these midwives don’t have the medical education to screen potential clients the right questions to see if their medical history indicates a high risk pregnancy. These mothers think that the midwife has done an assessment based on their training and believe that they’re not “high risk”. The mothers trust their midwife when the fact is they don’t have the knowledge to make a proper assessment. These midwives often think they know more than they do, overestimate their abilities, and find themselves in medical emergencies that they can’t handle. One case I read about where the mother had a serious complication, the mother needed an IV until the ambulance was able to get her to the hospital. The midwife didn’t insert the IV because she wasn’t “comfortable” with the technique. She waited until the paramedics arrived so they could do it. That was too little to late and the woman died at hospital. Someone who can’t even insert an IV into an arm has no business delivering a baby.
IMO, it wouldn’t help a lot. The problems with homebirth are not exclusively due to the type of midwife. Home is NOT the place to be when something suddenly goes south, and it occasionally does, even in the lowest of low-risk situations. From the moment a call to transfer is made, until the baby is out in hospital, 40 or more minutes can easily pass; all it takes for brain damage is 4 minutes of hypoxia.
Quite simply, it is impossible to turn a home into a hospital, but a hospital can become more homey.
“Quite simply, it is impossible to turn a home into a hospital, but a hospital can become more homey.”
Exactly my line of thought. Although, if we are going to make hospitals more homey, I would rather focus on the postpartum ward. Many hospitals have ridiculously accommodating L&D rooms, but once the baby is born and all are stable you get thrown to the wolves, so to speak. You’re likely spending several days there, a comfy room and the option of sleep would be nice.
Not too likely in the US with the proliferation of “Baby Friendly” hospitals.
There is an alternative, however. In parts of the UK a program known as the Domino System is used. Much of the antenatal care is done in the home, and when a woman thinks she is in labor she summons the community midwife who transports the woman to hospital for the labor and delivery. The mother and baby [assuming there aren’t any complications] are transferred back home 6 hours after birth, for recovery.
There are criteria that must be met before a woman can go home. In my time, that meant [1] the home must meet certain basic standards, [2] a family member must be able to be in the house with the new mother for 10 days round the clock, and [3] there is a community midwife available to make daily home visits for the first 10 days to ensure that everything is OK with mother and baby.
In many ways, this seems the best of both worlds, to me.
I don’t know of anywhere that still does daily PN visits sadly, it would be so good especially for primips but there just aren’t enough community midwives =/ also never heard of a midwife driving a woman to the hospital, or requiring someone to be at home with the mother for 10 days…was this a while ago?
Probably long before you were born :-))
I was in Cambridge in the mid -70s, and I know the Domino System was still in use in the 80s. It seemed a highly intelligent approach.
It does seem better, although 10 days when everything is ok seems excessive, better to have resources on an ‘as needed’ basis, although currently there isn’t the money for that either.
I’m guessing that homebirth CNMs are better able to recognize a looming emergency and transfer the woman earlier than a CPM/LDM would. And also, unlike CPMs/LDMs, they probably know how to use the potentially life-saving equipment and meds that they carry, because they actually did so multiple times during their training.
Seems to me that part of the problem is that homebirth midwives, especially in the U.S., practice in a vacuum. Not only is there little official, organizational accountability, but there’s no immediate accountability. Aside from an apprentice midwife, there’s usually no other practitioner at the birth (or during antepartum care) to question even the most egregious lapses. This problem is magnified by the fact that many homebirth midwives (and I’d argue all non-CNM midwives) are motivated by ideology about birth.
It’s compounded by the way non-CNM midwives in this country are trained: more than 50% are PEP-trained, having learned everything they know (or think they know) from a single preceptor. At least CNMs get exposed to a variety of instructors during training, so they may actually be required to critically assess differences in approach. Once they’re on their own, or with a small group of like-minded colleagues, ideas, good and bad, get reinforced and questions don’t get asked.