Homebirth advocates never analyze bad outcomes. Here’s why.

39526786_s copy

Yesterday I wrote about another in the endless parade of preventable homebirth deaths (Another unassisted birth, another brain damaged baby.).

Why are there so many deaths?

Besides the fact that homebirth advocates are ignorant and homebirth midwives are incompetent, that is.

Homebirth advocates never analyze bad outcomes. They never perform a root cause analysis as doctors are trained to do.

What is root cause analysis?

Homebirth advocates and midwives won’t analyze deaths because they are confident analysis will show they are the cause.

This explanation from MindTools is spot on:

Root Cause Analysis (RCA) is a popular and often-used technique that helps people answer the question of why the problem occurred in the first place. It seeks to identify the origin of a problem using a specific set of steps, with associated tools, to find the primary cause of the problem, so that you can:

  • Determine what happened.
  • Determine why it happened.
  • Figure out what to do to reduce the likelihood that it will happen again.

There are three main types of causes:

  • Physical causes – Tangible, material items failed in some way (for example, a car’s brakes stopped working).
  • Human causes – People did something wrong, or did not do something that was needed. Human causes typically lead to physical causes (for example, no one filled the brake fluid, which led to the brakes failing).
  • Organizational causes – A system, process, or policy that people use to make decisions or do their work is faulty (for example, no one person was responsible for vehicle maintenance, and everyone assumed someone else had filled the brake fluid).

Imagine, for example, that a new mother bleeds to death after giving birth.

Doctors don’t throw up their hands and say, “There’s nothing we could have done differently; it would have happened at any other hospital, too.”

In this setting, the physical cause may or may not be obvious. Yes, it is possible that the mother bled to death because her uterus simply wouldn’t contract after the placenta was expelled, but it is also possible that she had an underlying coagulation problem that may have contributed to the outcome. It is critical to determine what physical factors were involved, but that’s only the beginning of the analysis, not the end of it.

What about human causes?

Did the doctor fail to check the placenta after delivery to make sure that there were no pieces left behind in the uterus?
Did the nurse fail to monitor the patient adequately and therefore didn’t realize that the patient was bleeding to death?
Was the blood bank slow to preparing the units for blood transfusion leading to an unacceptable delay?

How about organizational causes?

Are nurses required to look after so many patients at once that they don’t have time to properly assess each patient?
Is the med room inappropriately stocked so that medications to stop the bleeding are unavailable when and where they are needed?
Is the hospital’s internal transportation system faulty leading to a delay in receiving blood transfusions from the blood bank?

In contrast, homebirth advocates and homebirth midwives from lay midwives on up to the Royal College of Midwives in the UK have no policy of root cause analysis. Indeed, root cause analysis is implicitly or explicitly discouraged or even forbidden.

Why?

Because homebirth advocates and homebirth midwives are well aware that the root causes of perinatal (and maternal) deaths are intrinsic to homebirth itself. Simply put, homebirth advocates and homebirth midwives don’t perform root cause analysis because they know that it is their own preferences and performances that are the root cause.

The Royal College of Midwives (RCM) in the UK has not performed and appears to have no intention of performing a root cause analysis of the multiple neonatal and maternal deaths that occurred at their hands (in the hospital) as detailed in the Morecambe Bay Report. Instead they have restricted themselves to criticizing the analysis in the Morecambe Bay report and blaming “bad actors” who are supposedly unrepresentative of midwives as a whole.

They fear a root cause analysis because, as the Morecambe Bay Report detailed, a primary root cause of the deaths was a massive organizational failure known as the “Campaign for Normal Birth” (name recently changed to “Better Birth”). Midwives officially value the process of birth as much or more than the outcome. They are so committed to maintaining control of patients that they literally refuse to call for lifesaving help from doctors even when lives are obviously in danger… and the RCM intends to keep it that way.

American homebirth midwives (CPMs and LMs) are equally committed to avoiding root cause analysis because they are equally certain that they are part of the root cause. The human causes of homebirth deaths are grossly undereducated, grossly undertrained midwives. The organizational causes include an extraordinary lack of safety standards, a peer-review process that functions to support the midwife regardless of her errors and deficiencies, and a professional ethic which values maternal and midwife choice above safety.

Homebirth advocates are only too happy to collude in avoiding root cause analysis, because they are well aware that mothers are often a major root cause of deaths at homebirth. They are more concerned with avoiding responsibility than with preventing tragedies. Hence any analysis of deaths is explicitly discouraged as being “unsupportive,” is generally deleted from birth blogs and Facebook pages, anyone who attempts to analyze deaths is banned from the blogs and groups, and babies are routinely “buried twice,” first in tiny coffins in the ground and then expunged from any internet record.

Consider the brain injury that occurred at the unassisted birth I detailed yesterday.

A root cause analysis would show that the mother’s decisions to ignore her history of severe shoulder dystocia in a previous birth, to avoid obstetrician prenatal care and to give birth without medical assistance at the root cause of her baby’s brain injury. But she doesn’t want to acknowledge that, and other supporters of unassisted birth are equally committed to avoiding analysis of the injury because they are afraid that the analysis will show the obvious: unassisted childbirth is an ignorant, narcissistic and often deadly childbirth choice.

Simply put, homebirth advocates and homebirth midwives refuse to analyze homebirth deaths because they are utterly confident that analysis will show that they are the cause of the endless parade of preventable homebirth deaths.

When homebirth advocates and homebirth midwives say, “It would have happened at the hospital, too.” what they really mean is, “I can’t bear to acknowledge that it’s my fault.”

  • St

    Sara Gottfried MD the hormone guru is posting today on her FB page that it is safer to home birth because of a NEJM article showing excellent stats in Europe. I do wish you would respond

  • Daleth

    Slightly OT, but speaking of analyzing bad outcomes, can someone explain to me how this kind of accident is possible? A woman died in France in an emergency c-section because they needed general anesthesia and the idiot anesthesiologist put the breathing tube in her esophagus instead of her windpipe, so she was starved of oxygen during the surgery.

    Do they not have goddamn pulse oximeters in Europe?!?! Jesus H. Christ, I bought one myself at Walgreen’s for about $15. Would a doctor or nurse please correct me if I’m wrong—but wouldn’t having a pulse oximeter on her finger during surgery have told them almost immediately that the breathing tube wasn’t in right?

    http://www.theguardian.com/world/2014/oct/03/british-woman-dies-botched-caesarean-france

    • Azuran

      I guess it could relatively easily happen to a human.There are some doubts about the anesthesiologist sobriety during the procedure. However, such a thing could happen even to the bests of anesthesiologist.

      I’m a vet, Esophageal intubation happens as well some times in cats and dogs as well and I’ve never yet seen it shows on a pulse oxymeters since the pet keeps breathing and is breathing normal air. The Diaphragm movements are even making air coming up the tube when it’s in the oesophagus, the valves from the anesthesia machine can also appear to be working as if the animal was breathing through the tube. Usually we figure it out because the pet is not responding properly to anesthesia gaz of because of stomach content coming up the tube.
      From what I’ve heard, intubating a human is harder than a dog. If you do something enough time, eventually, you are going to miss at least once, no matter how easy the task is. Medicine is not exempt. It is a horrible story, it is very sad for the family, but yea, those things can happen even in the best of hospitals, especially in an emergency situation.

      • Daleth

        If the patient keeps breathing normal air, then why would intubating the wrong way cause hypoxia (which is what killed this woman)? Maybe pets are different–I don’t see how a person could be intubated AND still keep breathing on their own, and particularly how they could keep breathing well enough for their blood oxygen levels to remain normal.

        • Azuran

          Anesthesia itself can reduce the respiratory rate and make respiration more superficial or induce transient apnea, but unless you are given muscles relaxant and put on a ventilator, you are usually still breathing on your own (Maybe that is the general procedure in humans, I dunno).
          Being intubated in itself will not make you stop breathing. Keeping normal levels of oxygen while intubated and breathing normal air is also not a problem. It’s basically just breathing through a tube.

          By itself, being intubated in the oesophagus will not make you stop breathing either, unless you are positioned in such a way that the tube in your oesophagus may obstruct the larynx, I guess.
          However, should you develop breathing problems during the procedure (generally related to the anesthesia itself) and you are not properly intubated, then yes, you can develop hypoxia because there is no way for you to be manually ventilated.

    • Montserrat Blanco

      During my CS I had a blood pressure cuff, an artery taken in order to monitor my blood pressure, two IVs, one of them with IV fluids going, one urinary catheter, one spinal catheter, one epidural catheter, oxygen and yes, one pulsioximeter. Standard procedure for preeclampsia moms at my hospital. So yes, they monitor blood oxygen. Always.

      It might happen though, it is surgery and surgery carries a risk albeit small. The anesthesist is being processed for manslaughter, which is something that I understand is not a solution for her family as they would have preferred her to be alive, obviously, but it speaks volumes about accountability.

      • Daleth

        You’re not in England, though, right? Regardless of the exact mechanism that caused her not to be able to
        breathe, what I don’t understand is how the doctors and nurses failed to NOTICE that she was becoming hypoxic, in time to save her.

        • Rosalind Dalefield

          Indeed, why didn’t they notice from the colour of her blood?!

  • Anonymous

    “It would have happened at the hospital, too.”

    Yeah, but there are people there that can help. All the patchouli and essential oils in the world aren’t going to stop a hemorrhage.

    • Daleth

      Exactly. The PROBLEM would have happened at the hospital too, but the BAD OUTCOME would not have happened.

  • ChristopherSSandberg

    Your first choice skepticalob Find Here

  • dimux

    Your first choice skepticalob Find Here

  • pinky

    Looks to me that the RCM is taking things pretty seriously in this document https://www.rcm.org.uk/sites/default/files/Kirkup_Response_FINAL_FINAL_11June2015%20v2.pdf The RCM is a union, not a regulatory body & is not responsible for midwifery standards. That’s the NMC which is not fit for purpose

  • Amy M
  • Gatita

    A reason why homebirth midwives never do RCAs: because RCAs necessarily focus on systemic problems and midwives fetishize the individual provider. Quality improvement tries to idiot-proof the system–for example, color-coding different doses of drugs (adult vs. pediatric) to avoid overdosing or having barcodes on patients and meds to ensure you’re giving the right drug to the right person. And when something does go wrong the presumption is that the entire system needs to be looked at, not just one person being scapegoated.

    But midwifery goes out of its way to repudiate a system of care in favor of mysticism and midwife-as-guru. Once you start looking at systems of care it necessarily demotes the importance of the midwife’s knowledge as subordinate to the bigger picture. And they can’t tolerate that. Of course, they can’t tolerate personal responsibility either. So no incentive either way for them to do something concrete to improve care.

  • KeeperOfTheBooks

    Making an honest mistake, I can understand. Everyone does, much though we might not like to think about it within a medical context. It’s what you do after the mistake’s been made that determines what kind of provider you are. Look at it honestly, and put safeguards in place to prevent reoccurrence? You’re the kind of provider I want taking care of me. Ignore it? Yeah, *no.* Get me out of here!
    A friend ran into this kind of thing while in high school. She was driving a go-kart at an amusement place. The cart flipped due to shoddy maintenance, caught fire, and left her with a nasty burn that resulted in fairly major scarring. Her parents told the owners that they weren’t going to sue; all they wanted was a) an apology and b) assurance in the form of a written copy of new maintenance standards/requirements that this couldn’t happen to another kid. The owners, insanely enough, refused either, despite their having been found clearly in the wrong by oversight authorities. This got the parents mad enough that they did sue for time/damages/costs/a court order to get these idiots to fix their equipment properly. Naturally, they won. Had the owners been willing to say “yep, we screwed up, and here’s how we’ll avoid doing so again,” they wouldn’t have lost their shirts in court.

  • Dr Kitty

    Question for the MWs and OBs.

    I’m planning for a ERCS at 39w.
    Currently at 31w and having frequent, painful (no, not mild discomfort- painful) Braxton Hicks, often 2 or 3 in an hour for several hours at a time, lasting 60-90 seconds at a time, mostly in the evening.
    While painful they don’t turn into anything more regular or frequent.
    This has been the situation for the last 3 weeks.
    I didn’t have any pain with BH at all in my previous pregnancy. I’m attributing the pain this time to adhesions from previous surgeries and endometriosis, and the fact that this baby seems to want to hang out transverse most of the time (previous baby was cephalic from 24w). I don’t have any scar pain. Otherwise I feel fantastic- no other issues, active baby, going to the gym, fine at work.

    Seeing my NHS midwife next week, and going to check with her, but I don’t need to be concerned unless contractions become frequent, right?

    I do tend to minimise things with my own health, and I really don’t want to be ignoring something, but this doesn’t seem like something to be concerned about.

    • Cobalt

      I would go in for an exam at earliest convenience, but I know I can dilate to 4 cm without feeling more than a few irregular contractions in a few hours.

      If you’re worried (especially if you’re a non-worrier!), get checked. You’ll either get reassurance of health or needed treatment, as appropriate.

      That said, I had regular, painful BH contractions every night for weeks and weeks and it was just BH contractions. Totally normal.

      • Dr Kitty

        Thanks.
        If things ramp up at all I’ll get checked out sooner, but I’m happy to wait to see my MW next week as it is only a few days away.

        The chances of my scarred, stenosed cervix dilating don’t seem particularly high.

        • Karen in SC

          Keep us posted please

    • Mattie

      I’d give delivery suite a call, explain that you’re booked for a section but that you’re a little concerned and would like to come in for an assessment as 31 weeks is pretty early and you don’t want to be dilating at home without realising. They should see you without problems, but if they fuss…insist. Always better to be safe than sorry, and no good HCP will have a problem reassuring you 🙂

    • fiftyfifty1

      Call and get it checked out.

    • yentavegan

      I never ignore pain. I would have called my ob’s office and tell them I need to be seen .

    • dbistola

      I was high risk for prematurity, especially in my second pregnancy. I was on bedrest due to a shortened cervix for 3.5 months.

      Those Braxton Hicks contractions that you describe happened to me a lot, the same way you describe. It might be scarring and all those things you mention, but for me those were tied into my weakened cervix. It might be shortening or weakening.

      I would also vote for a cervical check. If you pass any blood, even a little spotting, staining, or light smear, I would definitely call then.

    • Kelly

      I had those in my second pregnancy and I did not have a c-section the first time. I had them from 34 weeks until I gave birth at 39 weeks without complications but that is my story. I would still talk to your health care provider and see what they think about it. I feel for you. It is like you are having labor for months.

  • Homebirth advocacy is simply an attempt to defend the indefensible, and therefore, since it is doomed to fail, better not even to try. Denial that anything untoward occurred is so much simpler.

  • Gatita

    OT but such good news about the Supreme Court’s Obamacare ruling! I felt like doing cartwheels when I got the news.

    • I think celebration is a bit premature. The intent is excellent, but the law as written is not a good one. I think, however, it will take at least another 5 years to see just how bad it is. The ACA, a single piece of legislation, tried to be all things to all people, and that never works. The various areas that needed reform should have been broken down into several sets of laws.

      From the standpoint of being “in the business”, I see things from another angle entirely. The ACA does not address how an expanded population of insured will be cared for without radically increasing access to facilities [even now currently inadequate!] and medical, nursing, and paramedical staff. Hospitals are closing ERs because of financial problems that will only get worse; doctors are retiring and not being replaced by newly qualified ones in the larger numbers needed; there has been a nursing shortage in the US for some years now –I could go on and on.

      Increasingly, the payment burden on the public will go up, too. It has already begun. What I see happening eventually is a two-tier system developing, with those who can afford it going to private medicine, and those who can’t waiting very long times for very inadequate care.

      • Gatita

        Celebration isn’t premature because whatever the flaws of the law, this is a validation of the entire concept of socialized care. It sends a message to the Republicans that they can’t dismantle the ACA through the courts.

        • Cobalt

          It also means I can get my own insurance!

        • Daleth

          It also did something excellent: where previously the rule that people in every state could get subsidies was just an IRS rule, which could be changed by the IRS at any time (so imagine the possibilities if an anti-ACA candidate wins the White House and Senate and appoints an anti-ACA person to head the IRS)… NOW, it is the law of the land forever, until the Supreme Court reverses itself… which isn’t going to happen.

      • The Computer Ate My Nym

        The ironic thing about the ACA is that it’s really just the Heritage Foundation’s counter-proposal to Clinton’s original universal coverage plan repurposed. Yep, the evil socialist Heritage Foundation, you know.

        That being said, it’s working. Not perfectly–I will definitely agree to that–but it’s working. Hospitals are providing less uncompensated care, more people are getting necessary outpatient treatment instead of spending their time in ERs, pharma firms are suddenly finding it worth their while to research treatments for diseases affecting primarily poor people. The doctor/nurse shortage goes back at least to the 1990s and doesn’t appear to be either notably better or notably worse post-Obamacare.

        • Gatita

          The part of Obamacare that always gets overlooked is the financial incentives for hospitals to improve care. For example, hospitals with high readmission rates are penalized with a cut to their Medicare reimbursements while hospitals with low readmissions get a bonus. Same with hospital acquired infections. And that part of the law is working like gangbusters. Rates are down and there’s a huge amount of energy and enthusiasm in the healthcare community to tackle these longstanding problems. And as care improves, that will also help to keep costs down.

          • The Computer Ate My Nym

            I’m less than enthusiastic about the readmissions thing. It creates a perverse incentive to not readmit patients who have complications and need readmission. Also with some conditions, i.e. sickle cell disease, it’s almost impossible to avoid readmissions because some patients are simply ill in a way we can’t treat and need frequent hospitalizations. OTOH, it’s worked really well for things like CHF where intensive outpatient management does reduce the risk of readmission, so it’s a mixed picture. I think it needs further refinement.

          • Dr Kitty

            If the hospital sends someone home who is elderly and while medically fit isn’t yet able to manage at home, and there isn’t an adequate care package in place, they’ll bounce back into hospital quickly.

            You can either solve that with better home help programmes and more intensive outpatient management, or you can keep them in hospital until they are back to baseline.

            Sometimes it can be very difficult to get hospital clinicians to understand that no, this person CANNOT stay home, because they have no family support, they have no food in their house and they aren’t well enough to be left alone for 23hrs a day with carers calling out 4 times a day for 10 minutes at a time.

            Sometimes people are discharged home before investgations are completed…and then when the test is done it becomes clear that they need to go back into hospital.

            Sometimes people are discharged home and then fall and break a hip or have the bad luck to have a new issue arise which requires re-admission.

            Unless you look at each specific re-admission to see if it could have been prevented, you can’t actually use that metric alone as a judgement on standard of care.

          • The Computer Ate My Nym

            One problem is that there is also pressure to reduce hospital admission length so patients are often discharged before they’re really ready. This can work if they have adequate support at home but if they don’t they just bounce back.

            The situation where I’ve seen it work well is patients with CHF who go home and get worse because they eat differently, forget to take their meds, etc. For those patients a case manager calling them twice a day to adjust lasix dosage and remind them to take their meds can be very helpful. But it doesn’t solve every problem that leads to bounce backs.

      • Liz Leyden

        The hospitals closing as a result of the ACA are almost exclusively in states that have rejected Medicaid expansion. The two Massachusetts hospitals that closed in 2014 had severe financial problems for years before the ACA.

        The US does NOT have a nursing shortage. There may have been one before the 2008 financial crisis, but the field currently has a glut. It’s not unusual for new grads to search for a year or longer for their first job. In California, 47% of 2011 nurse grads were still looking for their first job 1 year later. Hospitals would rather use contract nurses and search for purple squirrels than develop their staff. Some of the same hospitals that spent years refusing to hire new grads now complain that they can’t find experienced nurses

  • Sue

    The lack of effort to improve is a core aspect of false naturalism, which claims that the “natural” or “traditional” way has to be the best, forever.

    It’s interesting to see how selectively this principle is applied, however.

    Not many people think that ancient methods of transport or communication are best, and could never have been improved on. The same for building and road construction, lighting and heating our homes, educational and social principles – it is part of human nature to strive to learn, achieve and improve.

    It’s fundamental to naturalism, however, to preserve the ancient ways. That precludes doing case review or root cause analysis, because the answers might suggest that things should be done differently, when the aim is to keep doing them the same way. That;s ideology, or faith – maintaining a principle for its own sake.

    Even within religion, beliefs and practices change with knowledge and culture. Most religions have revised their view of human choice and the role of women.

    One has to fight very hard to resist the forces for improvement. Just like those people who cling to outdated models like homeopathy, or the “subluxation” model of chiro, radical NCBers have to invoke “other ways of knowing”, or conspiracy theories, to support their refusal to develop and improve.

    • Chi

      It makes me want to scream whenever I hear a homebirth advocate going on about how women are built to give birth and that we’ve been doing it ‘naturally’ for hundreds of years.

      And before modern medicine, women and their babies died in droves.

      I told my sister as much when she fed me that line when informing me of her decision to homebirth – with her midwife’s blessing of course.

  • Amy

    What I don’t get with regard to “freebirthing,” is the alliance of homebirth midwives with freebirthers. Aren’t freebirthers a direct threat to the financial livelihoods of homebirth midwives? And as such, wouldn’t many homebirth advocates want to discourage freebirth?

    After all, nobody can FORCE a woman to see a doctor or leave her home when she goes into labor. I know many women who fully intended to attempt unassisted birth and engaged either a hospital-based or homebirth midwife, and then just “didn’t call in time” when labor began. Unassisted childbirth threrefore doesn’t really have, as a movement, the financial incentive that homebirth midwives do to avoid responsibility.

    • Angharad

      Maybe they like it because it normalizes homebirth, trusting birth, and the idea that interventions are unnecessary? Probably if the average woman hears about a lovely freebirth, it wouldn’t convince her to give birth unassisted but it might sway her to thinking giving birth at home with a midwife would be safe.

      • Who?

        Yes perhaps the freebirthing movement becomes the new dangerous-‘see how responsible I’m being, I was going to freebirth but now I’ve decided to homebirth, supported and sooo much safer and better.’

        • Cobalt

          Homebirth makes birth centers look more reasonable (at least there’s professionals and some equipment), UC makes midwife attended homebirth look more reasonable (at least someone with some training and experience is there), completely bizarre stuntbirths makes UC at home look more reasonable (at least there’s no large predators).

          Pushes the “middle ground” or “compromise” position way out to the edge.

          • Ash

            Birth centers in the usa can just be someone else’s home or building. No guarantee of the equipment available or training of the staff.

          • Cobalt

            True, but it sounds good. In reality, it doesn’t matter where you are if it’s not a hospital when things go wrong. After the first five minutes of dystocia or hemorrhage or prolapse or abruption, it doesn’t matter if you’re in the hospital parking lot or on top of a mountain…it’s likely too late.

    • Zoey

      Not midwives, but I do know that doulas accredited through DONA are not supposed to attend free births, or they risk losing their certification. I’m assuming this is liability thing, because doulas are NOT medical professionals and they definitely shouldn’t be the only attendant for a woman giving birth. However, the doulas I know took a lot of heat for this from the freebirthers, saying that a doula should be able to support women in whatever way they choose, including attending and assisting freebirths. The few underground midwives we have here (as midwives are licensed in my part of Canada) often advertise themselves as doulas too, which muddies the whole thing even more.

      • Roadstergal

        Wait, ‘freebirth’-ers want a doula? “I want to be attended, but only by someone who will be of no use medically”?

        • Zoey

          Apparently! Someone to fill up the birth pool and help you chant mantras, perhaps?

          Also, the way that unlicensed midwives operate around here is to attend a “freebirth” as a “doula” at least officially to avoid getting in trouble with the law. I’m sure that’s at least part of it.

      • I find a DONA cert being revoked a bit hollow though. I doubt many people bother to check and it doesn’t prevent anyone from working or claiming that they had earned the certification.

        • Zoey

          I can’t imagine many people check. I didn’t even know what DONA was when I hired a doula with my son. She never mentioned having any sort of certification to me either.

          Maybe that was just a way of saying they were uncomfortable attending freebirths, without sounding like they were condemning the idea of freebirth itself? Blame the association instead of having to admit that they didn’t feel qualified to basically deliver a baby on their own.

          It was just so weird that the whole thing caused this huge schism between all these birth worker types I knew.

  • The “peer review” policies from midwives that I have read are a JOKE. There are stricter reprimands for causing a patient to have their blood drawn twice in a hospital than there are for midwives that literally kill and maim people at home births.

    • Mattie

      what policies are these?

      • https://safermidwiferyutah.wordpress.com/2014/05/26/utah-midwives-make-a-mockery-of-peer-review/

        the main one I highlight is that if anything illegal was done you aren’t allowed to bring it up. You also aren’t allowed to ask “why did you do ____?”. They will kick you out for that. Can’t learn a lot if you are forbidden from telling the truth, right?

        • Mattie

          :O wow yeh that’s awful, like completely shocking 🙁

        • Ugh, can’t.

        • KeeperOfTheBooks

          What. the. HELL.
          That sounds like nothing more than a giant circle-jerk. What’s the point? (Obvious answer aside.)

          • “education only”, so not peer review at all. its story time where adults make-believe that they are medical professionals.

          • KeeperOfTheBooks

            How the hell is it educational not to learn from your mistakes?!

    • CharlotteB

      I was clicking through some of the links on your site–and saw this:

      http://www.hypnobirthingutah.com/birthing-gowns/

      A site selling “birthing gowns” and which features ones of the Ina May quotes I find most loathsome: “If a woman doesn’t look like a goddess during birth, then someone isn’t treating her right.”

      I mean, yes, hospital gowns are ugly (although the maternity gowns at my hospital were like large nightgowns and covered the rear) but honest to God, if there was one time that women should be allowed to look “ugly” and wear a utilitarian garment, labor would be it.

      Obviously, I’m not talking about wearing a nice nightgown or whatever for family pictures, or heck, even wearing one of those gowns for labor–but it just reinforces that the whole thing is a performance in which the woman (I’m sorry, GODDESS) is the star of the show.

      I realize it’s not as serious an issue as peer review, but really? How do people not see that quote and the focus on appearances during labor, (as evidenced by the number of people who hire fancy birth photographers) as really really antifeminist???

      • Amy M

        Well, I suppose I looked like A Goddess…maybe Astarte, Freya or some other war goddess, what with all the blood.

        • Mishimoo

          The Morrigan for my last – blood and black-green ick everywhere because meconium is the best way to say hi!

          • KeeperOfTheBooks

            *giggles in a juvenile fashion*
            Nothing says, “Hi, world! I’m here, and I REALLY didn’t think much of the transit process!” like a giant newborn poo.

          • Rosalind Dalefield

            LOL, my last baby (of four) shat his meconium right in my vulva. Just as well that was the only birth in which I didn’t get an episiotomy or a tear.

          • KeeperOfTheBooks

            …..
            ….
            …..
            Reason #457 I’m glad I had a C-section.

          • Rosalind Dalefield

            LOL!

      • RMY

        Why is it being implied that looking like a goddess has to do with the clothing being worn? I mean, I get that they’re trying to sell it, but it seems like a non sequitur.

        • CharlotteB

          Because if you wear a hospital gown, you look like a patient. No matter how goddessy you appear otherwise.

      • Amy

        My God, in a best-case scenario, you’re going to get blood and probably a lot of other crap (literally) on whatever you’re wearing. WHY would you want to spend money on something that might never be fully cleaned and can’t really ever be worn again? Even wedding gown can be recycled, either as a hand-me-down to a younger female relative, or remade into a christening gown (if that’s your religion) for the woman’s children.

        And those things don’t really evoke the word “goddess” to me. They look like beach cover ups. At best, they’re slightly nicer versions of the hospital gowns that women are offered when they show up at a hospital in labor. The hospital gowns that SOMEONE ELSE launders and don’t cost you a dime.

        • CharlotteB

          My mom asked if I wanted a gown, but when I pointed out that if I got the hospital gown dirty, they would bring me a clean one, she said something like “oh right. Ick. Do that”

          I’m sure my mom wasn’t trying to imply anything by her offer–my guess is she thought they were cute and didn’t know that maternity gowns cover everything.

      • KeeperOfTheBooks

        Those things look nearly identical to what I wore in the hospital, and are, frankly, youuuu-gly to boot, plus stains will never come out of them. $65? Are they crazy?
        Now, I will say this: one of the mom-bloggers I read once suggested that one of the nicest gifts you could give an expectant mom would be a set of pretty PJs–say, comfy yoga pants, a nice nursing (if that’s what she’s doing) cami, and a coordinating cardigan/shawl-style sweater–to wear after she’s gotten all cleaned up, because then she’ll feel pretty and comfy and all those good things. I heartily second this. I’ll wear the nice snuggly PJs post-shower while someone else launders the gawdonlyknowswhat bodily fluids out of the hospital gown, thanks.

        • Guest

          For each of my three kids, I bought a shorty fuzzy robe and some pretty PJs to wear for after (cami top, yoga pants, etc). It was great because I wore the robe if I was cold and if I stained the PJs, I just changed into a new set (bought 3 for kiddo #1, added one new set for subsequent kids). And I could walk around the unit without worrying that my ass was hanging out in the breeze. But to labor in? Hellz no!

          • KeeperOfTheBooks

            I hadn’t thought of this with DD, but I am *so* doing this with subsequent babies. Also, as another poster suggested, black pants would (for me at least) be key.
            Random observation: I do hate that they don’t seem to make bootcut yoga pants for women who are 5’2″. Having to hem my PJs always irritates me.

        • Mishimoo

          I wore comfy nighties for two of my labours and couldn’t be bothered changing out of my nice warm pjs for the last. Just lost the pants once my waters were broken and used a warm towel and blankets instead. I did end up in a hospital gown for the first two because transition was messy, but the stains came out of my pjs pretty easily. My husband threw them in the washing machine at 95C with some washing powder and oxyclean stuff, came out perfect.

          • KeeperOfTheBooks

            Your husband sounds like a keeper, and then some!

          • anotheramy

            When I was deep into the woo, I believed the whole “you’re not sick, you don’t need to wear a hospital gown for labor/ you’ll be so much more comfortable in your own clothes” thing, so I insisted on wearing my own clothes. Trouble was, my labor began with my water breaking. I naively thought the pads would catch any leaks. Yeah… about an hour into labor, all 3 pairs of pants I brought to the hospital were wet, and I got into the tub so I didn’t have to notice all the leaking fluid. Not more comfortable in my own clothes, thank you.

          • MegaMechaMeg

            I don’t know why, but I find that story increadibly funny.

          • anotheramy

            Good! I laugh and shake my head at the memory, too! 🙂 ya think I would’ve caught on after soaking the first or second pair of pants, but no…
            And I thought I was “informed”.

        • Cobalt

          I’ll third that, and add that I strongly preferred black pajama bottoms to hide bloodstains. I always ended up bleeding on them in the weeks after.

      • The Computer Ate My Nym

        The gowns they used in the maternity ward where my daughter was born looked remarkably like those, except that I got one (actually several-it was a messy labor) for free instead of paying $65 for something I’m going to use all of once and get a number of bodily fluids all over when I do use it.

      • Liz Leyden

        Does the Venus of Willendorf count as a goddess?

        • Rosalind Dalefield

          You know, I’ve always wondered if the Venus of Willendorf and the many Stone Age figures like her, of pregnant women, were some sort of good luck charm against dying in childbirth, which must have been incredibly common in those days.

  • yugaya

    “Imagine, for example, that a new mother bleeds to death after giving birth.
    Doctors don’t throw up their hands and say, “There’s nothing we could
    have done differently; it would have happened at any other hospital,
    too.”

    And they most certainly don’t go around saying “some women were not meant to survive childbirth”.

    • Jocelyn

      Or, as I saw one UC-er say this week, “We need more natural causes of death.”

      • Who?

        As opposed to car accidents and shootings? Can these people hear themselves talk?

      • KeeperOfTheBooks

        …dude, say what?!?!!

      • Smoochagator

        Cancer is natural. Heart attacks and strokes are natural. Tetanus, food poisoning, lightning strikes and animal attacks, all natural. And I have zero desire to die from any of them.

  • Liz Leyden

    OT- The California Assembly has approved a bill that would eliminate the philosophical exemption for vaccines. Next step is the governor’s desk, and he’s expected to sign it.

    http://www.latimes.com/local/political/la-me-pc-vaccine-mandate-bill-up-for-vote-thursday-in-california-assembly-20150624-story.html

    • Roadstergal

      Good on our Assembly. I hope he doesn’t play with the language like he did the last vaccine bill.

    • Daleth

      So fantastic. Yay California.

  • MaineJen

    “In contrast, homebirth advocates and homebirth midwives from lay midwives on up to the Royal College of Midwives in the UK have no policy of root cause analysis. Indeed, root cause analysis is implicitly or explicitly discouraged or even forbidden.”

    HOW is this allowed in a modern hospital? I can buy that American homebirth midwives don’t want to explore root causes; it would shut down their entire profession. But RCM midwives, working (ostensibly) with the support of physicians? Every single other person in that hospital is subject to root cause analysis in the event of a disaster, from physicians through pharmacy staff, on down to janitorial. Why not midwives? Why are they allowed to be musketeers, when everyone else has to play by the rules and be accountable?

    • Amy M

      I am American, so I know nothing about the NHS, and this is speculation. But I wonder what other areas of medicine are being underfunded/reduced quality of care? Are they delaying screening mammograms (for women at age 50 instead of 40?) How about colonoscopies? Are there other areas of medicine that have two or more tiers, like OB has OBs and midwives? Is there a first line of defense as it were, in geriatrics or immunology (just random examples), so that patients see the lower tier (and cheaper) provider, unless the shit hits the fan? I guess the pattern would be to cut preventive care/screenings for the general population, and limit that stuff to people with known high risk?

      • Mattie

        Mammography is offered routinely for women aged 50-70, although this is being extended to women aged 47-73. This is due to studies showing that routinely screening pre-menopausal women is less effective. Cervical screening (smear tests) are offered routinely to women aged 25-65, again as screening younger women is not as effective and often yields false ‘positive’ results (especially in young women), women over 65 are not screened routinely as it’s unlikely women over that age will go on to develop the disease.

        This is totally different for women who have problems, so a previous abnormal result on any test, a breast lump, any symptoms of any kind of cancer or problem. Those women SHOULD (I highlight should, because things are missed and that is unacceptable)be referred for screening/diagnosis by their GP. Their future screening should then follow a different level of ‘intensity’.

        As for the two-tier system, I’m not sure whether there’s any other speciality where that is as obvious, but generally in the UK we don’t see specialists unless there’s a problem a GP cannot deal with. Most routine things are done by a GP or at a GP surgery, and that seems to work well for most people most of the time.

        • Roadstergal

          Yeah, the whole mammography thing is based on what makes a good test – once the thing getting screened for gets rare enough, the false positives outweigh the true positives, and overdiagnosis and overtreatment become a problem. Given the quality of the test, in normal-risk women under 50, the numbers just don’t work. As you say, if you’re not low-risk, more screening may be appropriate.

          Guidances were recently revised due to new and better data, as happens with SBM.

          • Mattie

            Yeh, for the most part the screening programs work as they are. Of course you hear (usually in the daily mail) about times when cancer is missed, the most famous incident in recent years was Jade Goody who sadly died of cervical cancer age 27, the media attention from that did cause the English government to review screening for women under 25 (but apparently they did not change anything, after assessing the evidence), it also made a lot of young women actually go to their routine screenings which is good I guess =/

            If anyone is interested, these are the NHS England screening programs http://www.cancerscreening.nhs.uk/index.html

    • Ennis Demeter

      The idea that woman’s natural fate is to give birth in pain and danger is so deep seated that it keeps re-surfacing in new ways, over and over again. People hold this belief so dearly that even doctors and hospital administrators accept it when it slimes its way into their workplace. It’s disguised as “empowerment”, and that makes it palatable.

  • Squillo

    This, a thousand times. Whenever homebirth advocates point out that “mistakes happen in hospitals too,” as a way of deflecting criticism of avoidable homebirth tragedies I want to scream. Especially when they bring up the stats from “To err is human.” Has anyone even looked at errors in homebirth midwifery, much less done a nationwide analysis that is published in a major medical journal and promoted in the media? Has any homebirth organization participated in anything like the “Choosing Wisely” campaign?

    In the U.S., we have large, systematic examinations of hospital and physician error, in addition to hospital-based RCA and M & M. For homebirth, we have small coffee-klatches of midwives and Facebook. It’s shameful.

    • Gatita

      The “To Err is Human” report led to the 100,000 Lives campaign, which literally saved more than 100,000 lives in the U.S. due to preventable medical errors. The healthcare system can still do better for sure but the idea that these little hen parties with tea and backpats are comparable to RCAs and real quality initiatives is actually offensive.

  • Dr Kitty
    • Lawyer jane

      Scary. Patient B’s story reminds me of my midwife – she refused to believe I was actually in labor for a few hours after the prostaglandin was inserted despite my contractions. I think either she was mad at me for being induced or just had little experience with inductions and did not know that cervadil alone is enough to start labor. I remember saying exactly what patient B did: “if this isnt labor I don’t know how I am going to take it!” Luckily I had enough and demanded an epidural, which meant monitoring, which meant eventually an OB came along and demanded that I deliver the baby ASAP.

      • Professor Monkey for a Head

        I’ve just been through something similar. I went into hospital with contractions and was found to be 2cm. Because the contractions got closer and more intense when I walked I chose to stay and was placed on the maternity ward. I spent 12 hours with increasingly severe pain there being told that I wasn’t in active labour because my contractions were irregular and I was having less than 4 in 10 mins. I wasn’t allowed any pain relief other than paracetamol as I wasn’t felt to be in active labour. I was repeatedly asked why I was in hospital and was told that this would go on for days. I was on the verge of choosing to go home as they weren’t doing anything for me but I didn’t think I could handle the car journey. It was only after becoming incredibly distressed when 2 contractions stacked that they agreed to repeat the cervical exam – 12 hours after the initial one – and found I was 7cm. Then I got moved to the labour ward pretty sharpish and got the epidural I needed.

        • FortyMegabytes

          Sounds very similar to our story. My wife was in labor for several hours and we went to the hospital. They sent us home because the contractions weren’t long enough or happening with enough frequency.

          My wife had give birth several times before and knew what her labor felt like. She has a medical condition that requires her to have a cesarian, so her labor symptoms are a little different from most women’s. Her attempts to explain this to the on-call OB/GYN and the nurse fell on patronizing years. The nurse smugly told her she’d been doing this for fifteen years and new true labor from false. My wife growled she’d been giving birth for fifteen years and also knew when she was really in labor. Nevertheless, we went home.

          Next morning we went to a regularly scheduled OB/GYN appointment. We explained what had happened at the hospital, and my wife’s OB/GYN initially supported what the on-call OB/GYN had said about the contractions and frequency. She then put on a glove and checked my wife’s cervix. I am not kidding; she put her hand inside my wife for all of two seconds, then pulled it out and said, “We need to get you into surgery immediately.” My wife actually cried in relief that someone finally believed her. An hour later our daughter was born.

          I don’t envy the fine line some doctors and nurses have to observe. Yes, you have patients who overreact and are certain about things despite all evidence to the contrary. But sometimes the patients do actually know what they’re talking about and do need to be listened to. The difficulty health care workers face is how to distinguish between them.

        • Cobalt

          I’ve shocked L&D nurses more than once walking in telling them I’m in labor (confirmed by cervical changes at OB’ s office) but not having recognizable contractions or more than mild discomfort. When I finally get my cervical exam, complete with patronizing attitude, and am discovered to be 6 cm dilated, it’s all I can do to not yell “I told you so!”.

          Labor patterns don’t always follow the book, and metrics should be taken before judgement is passed. Especially in multips with a history of unusual labor. And dammit, pain matters. If a woman is in severe pain, that means something and deserves evaluation and treatment.

          • Labor patterns almost never go by the book — one of the first things a competent midwife learns

        • Who?

          I’m so sorry that’s horrible. Am I right thinking you are in Oz? Some ‘constructive feedback’ as we call it here in mealy-mouth land is definitely in order.

          • Monkey Professor for a Head

            Yeah, I’m in Oz. Overall I’m not too traumatised by the whole thing – unmedicated labour really sucked, but my epidural was great and when things got scary for both me and the baby then I was really glad to be in hospital. Funnily enough the interventions ended up being my favourite part of giving birth – I loved the epidural, I’m really glad that I had continuous monitoring that picked up my baby’s decels and signalled it was time to get him out, I’m glad I had an IV line in so I could be treated for my PPH straight away, and whilst it’s not exactly fun I’m really grateful for the episiotomy that got my son here faster.

            And if Im in the same situation in future, you can be damn sure I’ll be demanding a cervical check much sooner (or maybe I’ll just go for an MRCS!)

          • Who?

            Delighted to hear it, sounds like a perfect birth story with a fantastic outcome.

          • Monkey Professor for a Head

            My son had APGARs of 9 and 9. I needed a blood transfusion but otherwise I’m ok. I think it was a great outcome and the rest of it doesn’t matter in comparison!

          • Who?

            Not quite perfect, but glad you’re okay with it all.

            And it’s not that your experiences don’t matter, but they are part of a bigger story with a great ending, not an end in themselves. Kids change your life, and not always in the ways you imagine.

  • superhappycamper

    Thank you for this excellent post. This is why I can’t take them seriously and I find the spread of the NCB cult into mainstream medical establishments disturbing.

  • The Computer Ate My Nym

    I agree with this post for the most part, but think that it leaves something out: Why are midwives being allowed to avoid the root cause analysis? Yes, there is a midwife lobby with a certain amount of power and that contributes. But I suspect that a major reason that the NHS is so keen to avoid a root cause analysis of neonatal deaths on midwife units and at home is the same reason that they keep pushing the “normal birth” thing: It’s cheaper, at least in the short run. It’s cheaper to not do an epidural than to do one.

    It’s cheaper to have a woman delivery vaginally than to do a c-section. Sure, the unrelieved pain may lead the woman to need years of counseling and medication for PTSD and the vaginal birth may result in a baby with hypoxic injury that requires lifelong care, but those costs don’t show up on the balance sheet of the bureaucrat responsible for cost cutting in the obstetric realm. And that bureaucrat is being pressured by the politicians to cut costs at any, well, cost so he or she is going to do what is cheaper in the short run, damn the long term consequences.

    The NHS bureaucracy is not a feminist organization, not even of the Ina May branch of feminism. They are not promoting “normal birth” out of a desire to empower women. They aren’t promoting it out of fear of the midwife lobby. They’re promoting it because the NHS is underfunded and getting more underfunded all the time and they have to find some way to cut costs, even at risk of cutting quality of care.

    The root cause of this failure, I suspect, is the conservative government and its gutting of the social safety net, including the NHS. Improve that and you’ll see better OB care, including by midwives whose practice is science based and who welcome a root cause analysis.

    • Amy Tuteur, MD

      I certainly agree that NHS is promoting homebirth because they erroneously think it will save money. However, I don’t think we should discount the tremendous influence of unions in the UK including the RCM. They are extremely powerful and largely avoid accountability. The government appears to be afraid of them.

      • The Computer Ate My Nym

        The “natural birth” campaign is also a cheap way of placating the union: If midwives started agitating for better working conditions (for example, better support for home births or fewer cases per midwife so they could provide better care), the poltiicians could then say, “Sorry, we can’t give you that, but look, we supported the normal birth campaign and didn’t press for accountability when things went wrong at Morcombe so that shows that we’re totally on your side.”

    • Inmara

      So agree with this! In Latvia we are seemingly in similar situation (underfunded public health care system) and there is a push from health officials to reduce C-section rates (as in, reduce indications which guarantee government-paid C-section; if you can afford 2k EUR out of pocket – welcome!), epidurals are in general paid by women themselves etc. Fortunately, homebirth is still seen by health officials as something “off-charts” and despite some organisations pushing for it to be government-funded, it is completely private service (though midwives has to meet standards as high as hospital midwives). Therefore homebirth numbers are still low and due to simple statistics we haven’t had any disasters yet (I guess that few homebirth midwives practicing here are very careful with their reputation and don’t take women with any pregnancy risks, as in our small country any homebirth death would be all over headlines soon).