The appalling callousness of the Arizona homebirth researchers

whatever in letterpress type

Imagine the following “analysis” released by the manufacturer of thalidomide, the drug that caused severe limb deformities in the children whose mothers took it while pregnant:

Thalidomide for morning sickness may be equally safe if not safer for women than other treatments. Unfortunately, thalidomide increases safety concerns for the child.

Such appalling callousness and nonchalant dismissal of the pain and suffering that thalidomide caused would suggest that the manufacturer was far more concerned with touting thalidomide than with the safety of babies.

Amazingly, the researchers responsible for the report Outcomes of Home vs. Hospital Births Attended by Midwives: A Systematic Review and Meta-analysis appear to have a similarly callous view of homebirth deaths.

As I discussed in yesterday’s post (New analysis from Arizona shows — yet again — that homebirth triples the neonatal death rate), the authors of the analysis, after demonstrating that homebirth increases the risk of neonatal death by a factor of three reach a bizarre conclusion:

The findings suggest that homebirths attended by midwives may be equally safe if not safer for women with low-risk pregnancies.

Reader Lynnette Hafken, MA, IBCLC was so disturbed by the obvious disconnect between what the authors found and what they concluded, she wrote to the lead author John Ehiri, PhD, MPH, MSc (Econ.) for clarification. Ehiri thanked her for pointing out this “oversight” and informed her that the authors had added an additional sentence to the 34 page paper.

The conclusion now reads:

The findings suggest that homebirths attended by midwives may be equally safe if not safer for women with low-risk pregnancies. Unfortunately, home births attended by midwives increase safety concerns for the child.

Unfortunately? Unfortunately??!!

Frankly, I am shocked by the appalling callousness of dismissing preventable deaths of babies in such a brutally short and dismissive sentence.

The KEY ISSUE in any analysis of homebirth is its safety for babies. It’s not the only issue, but all others pale into insignificance next to it. The conclusion of the analysis ought to be:

Homebirth attended by midwives increases the risk of neonatal death by a factor of 3. Homebirth has no deleterious impact on the health of mothers and may reduce morbidity. Women should be counseled to weigh the increased mortality to babies against the decreased morbidity to mothers before choosing homebirth.

The fact that the authors reduced preventable neonatal deaths to an “unfortunate” side effect of homebirth suggests to me that authors were far more concerned with touting the safety of homebirth (regardless of what their own data showed) than with the safety of babies.

If Dr. Ehiri would like to contest my assertion that the authors have callously and deliberately ignored the immense pain and suffering associated with neonatal death, he can write to me at the email address listed at the top of the sidebar. I will publish his response/explanation in full.

But I have a better suggestion for Dr. Ehiri and colleagues:

Remove the absurd and offensive claim that “homebirths attended by midwives may be equally safe if not safer for women” and replace it with the language I suggested, giving primacy to the fact that homebirth increases the risk of neonatal death by a factor of 3 and offers only a small reduction in maternal morbidity as a result.

Even the drug company that promoted thalidomide didn’t dare tout its safety and effectiveness after it was shown that it caused horrible birth defects as a result. Surely Ehiri and colleagues could demonstrate as much sensitivity in promoting homebirth.

235 Responses to “The appalling callousness of the Arizona homebirth researchers”

  1. Wow
    June 4, 2013 at 9:02 pm #

    ………………………………..Seriously?? I work at a birth center, and in 650 births performed by the midwife in 40 years, only two babies have died. I realize you’re getting your facts from OBs, but I would like you to THINK long and hard about this fact right here: THE USA IS 47TH IN MATERNAL MORTALITY AND 50TH IN INFANT MORTALITY. The countries with the BEST outcomes for mothers and babies, such as Sweden and Norway, INTEGRATE care between OBs and Midwives. Low risk births are attended by midwives in the parent’s choice of venue, and high risk pregnancies are cared for by OBs. OBs and midwives respect each other, teach each other, and collaborate to provide the best possible outcomes for mother and baby. NOT SO in the USA. OBs ATTACK midwives here, and try to stomp them out. Low risk pregnancies are encouraged to go to SURGEONS for prenatal and delivery care. Because that’s what OBs are. SURGEONS. Medical schools don’t even teach natural birth to OBs. OBs are trained to act as though the pregnant woman is sick, or injured, and find a solution. This is not the correct approach to take with a normal low risk pregnancy. Drugs should NOT be pushed on laboring moms, whether for pain relief or for induction. It is shown that the more drugs, the more interventions, the higher the risk of complications that can result in serious side effects (incontinence, paralysis, death), and OFTEN result in C-sections, which carry risks all their own that are rarely discussed with women during prenatal care. I understand where you’re coming from – We, as women, have been taught from a young age to be ABSOLUTELY TERRIFIED of birth. We are shown graphic, violent birth scenes in TV shows and movies, told by everyone we know as well as magazines, news sources, etc, that birth is the most painful thing you can possibly experience. I understand your fear. But maybe try to overcome your fear instead of contributing to the fears of other women. You’re doing our gender a disservice. Birth is powerful, and yes, painful. But it is a natural, usually SAFE process which does not need drugs or forceps or episiotomies to happen the majority of the time. American women are just as capable as women in any other country with midwife attended, out of hospital births. The difference is that we have been taught to fear our bodies instead of work with them. I hope you never have daughters, because I am sure you will put this same unfounded fear and intolerance in their hearts as well.

    • Jocelyn
      June 4, 2013 at 9:27 pm #

      Oh, man, this has so many homebirth bingo phrases I don’t even know where to begin.

      • Bombshellrisa
        June 4, 2013 at 9:49 pm #

        You didn’t yell Bingo!

    • Amy Tuteur, MD
      June 4, 2013 at 9:33 pm #

      Only 2 babies have died? I guess you are so clueless that you don’t realize that is a rate of 3.1/1000, nearly 700% HIGHER than the rate of 0.4/1000 for term babies born in hospitals.

      Thanks for dropping by and demonstrating why CPMs should not be licensed in Arizona or anywhere else, because they are ignorant and dangerous.

    • Bombshellrisa
      June 4, 2013 at 9:46 pm #

      ” THE USA IS 47TH IN MATERNAL MORTALITY AND 50TH IN INFANT MORTALITY” But the US has one of the lowest MORBIDITY rates. That is the correct benchmark to measure with, not MORTALITY.

      You sound like every other person who parachutes in here. Do you think that nobody here has birthed at home or has attended a home birth?

    • Eddie
      June 4, 2013 at 10:10 pm #

      Wait, you’re bragging about a death rate of 2 / 650 of properly risked out mothers? That is 3.1 / 1000 in what is supposed to be the lowest risk group. That’s actually terrible. Also, you have so many obvious inaccuracies and biases in your post that it’s just not worth responding to each one. But hey, you hit all the standard memes. Congratulations.

      Keep in mind that *most* babies who die in the hospital are babies born to high-risk mothers.

      Yes, many countries with the best outcomes integrate care between OBs and midwives. However, every single one of those midwives is college educated. Quite unlike the situation in the US. Let’s compare apples to apples, shall we?

      • Bombshellrisa
        June 5, 2013 at 12:58 pm #

        I used to be so fascinated with Sweden when I was studying to be a midwife. I didn’t like it as much when I read a little further and found out that homebirth is super, super rare in Sweden and things like waterbirth and homebirth are considered undesirable by Swedish midwives. The public healthcare system does not allow for funding homebirths, so if someone wants one, they have to find an attendant and pay for all costs themselves.

        • Eddie
          June 5, 2013 at 2:33 pm #

          My youngest brother (who married a Swede and has become a permanent resident there) is very, very impressed with the Swedish medical system, especially in the area of pregnancy, birth, and pediatrics.

          • Bombshellrisa
            June 5, 2013 at 2:55 pm #

            I am impressed with it too. From what I understand about the hospitals is that there is a lot of support for breastfeeding without resorting to the tactics of “baby friendly” hospitals

          • Eddie
            June 5, 2013 at 7:52 pm #

            Re-reading my response, it could be taken as a counter to what you said, as a, “You’re wrong, it’s actually a good system.” I’m sure you understood my response (agreeing with you about how sensible their health care system is), but for context for someone coming across this later, I just wanted to comment.

          • Bombshellrisa
            June 5, 2013 at 8:19 pm #

            No worries, I knew what you meant!
            Interesting though, because someone who is a CPM and willing to trot out the numbers about Sweden and Norway ought to understand the reasons behind the outcomes.

    • KarenJJ
      June 4, 2013 at 10:29 pm #

      Keep reading Wow. You have a lot of arguments we have rebutted many many times. Read what our answers are and then see what you think of your post above. Take a look around the blog.

      People have already pointed out that other countries with midwives working with Obs are strict on who can call themselves a midwife and who can be classed as low risk and deliver at home (I live in one of these countries). What is the US like?

      People have also pointed out that the death rate of 2/650 is much much higher then low risk births in a hospital. What is your response to that now?

      You say that people are terrified of birth in the US. What do you think of women who live in countries where they have much higher numbers of mothers and babies dying during childbirth. Do you think they are also terrified having often seen terrible things first hand?

      We love having new people come on here discussing these issues and getting a bigger picture on what is going on in the natural childbirth movement in the US and other western countries. Most people do admit that there are negligent midwives, there are women having homebirths that should have been risked out and there are babies that are being delivered to low risk mums that have died or been brain damaged without expert medical care in a hospital. I imagine you could easily admit that there have been things you’ve seen that have made you nervous about some of the practitioners in the birth centre that you work in.

      Navelgazing midwife is also a good blog that discusses some of these issues if you find the tone here not to your liking. Many of us here can be pretty blunt. Not everyone likes that.

      • Eddie
        June 4, 2013 at 10:57 pm #

        I just wanted to say, your response was a great one. Very productive, sticks to the facts, no sarcasm (I couldn’t entirely avoid it today). Kudos. I aspire to always respond productively to people who argue productively, and to do my best to respond productively even to those who don’t. But with the latter group my success rate isn’t as high as I would like.

        Your response was calm, reasoned, and logical in the face of a comment that was anything but. Again, kudos.

        • KarenJJ
          June 5, 2013 at 8:18 am #

          Aw thanks. Some really nice people have come around by giving some thought to the information on here and keeping open to new ideas. Sometimes it’s nice to give them the benefit of the doubt. I hope she’s one of them.

          Plus I have a headcold. I can’t seem to do sarcasm when I have a headcold.

      • Lizzie Dee
        June 5, 2013 at 7:21 am #

        Women are terrified of unnecessary procedures or unkind words in a hospital, but not terrified of the risks at home. Terrified by the thought of a needle in the spine, but not of hours of unrelenting pain. Terrified of over-cautious doctors, but not of under-trained gung ho midwifes who will write them off as failures.


    • Amazed
      June 5, 2013 at 7:36 am #

      650 births in 40 years?!… I wouldn’t go anywhere near that birth center, let alone allowing this woman to place her hands anywhere near my vagina. Less than 20 births in a year. It defies belief.

      It makes sense that the birth centre employing this aging lady – and yes, advanced age does matter when combined with inexperience – would be ready to employ someone bragging about a horrifying death rate and said inexperience. Please, do some reading besides what your birth centre offers you. You are spreading DANGEROUS misinformation or rather, distort information in a way that makes it dangerous. Such level of experience and death rate is nothing to boast about.

    • LynnetteHafkenIBCLC
      June 5, 2013 at 7:40 am #

      When I came to this blog, I could have written the exact same post, except that I was uncomfortable with lay midwives having no way to assess their basic level of skill. Now I realize that I was kind of arrogant to try to educate obstetricians on obstetrics, something that they have spent many years actually practicing, and now that over 50% of OB/gyns are actually women, they likely actually have personal experience going through childbirth. Dr. Amy herself has had natural childbirth and breastfed 4 kids. She is an advocate not for a particular way of giving birth, but for accurate information so mothers can make informed, guilt-free decisions.

      My friend, a lot of what you have been taught about NCB is mythology. You don’t have to believe me, but you have nothing to lose by challenging your assumptions. I loved my natural births, and I’m glad I did them, but I now recognize that my reasons were grounded more in my personal wishes, and other women have the right to do things differently if they wish to, without being accused of being sheeple who can’t stand up to their bullying doctors.

    • theadequatemother
      June 5, 2013 at 7:59 am #

      two dead babies in 650 births in women who are *supposed* to be low risk is an APPALLING DEATH RATE. I wouldn’t go to a center if the risk of my baby dying was 1/325. Seriously? Why are you bragging about that?

    • Amazed
      June 5, 2013 at 8:12 am #

      Wow who works at a birth centre: “I work at a birth center, and in 650 births performed by the midwife in 40 years, only two babies have died.”

      I’m citing this, just in case the author actually realizes how ignorant she sounds and decides to delete evidence.

      In case anyone comes here convincing us how professional birth centres are, I’ll cite it under their posts, too.

    • Dr Kitty
      June 5, 2013 at 8:59 am #

      Wow indeed.

      I’m in one of those countries you speak of, with a well integrated antenatal model of care. I work with well educated, sensible, clinically competent midwives. Most of the pregnant women I see only see an OB once during their pregnancy, because they are low risk, and if all goes well, they don’t see an OB at all in labour.

      I still think CPMs are a f**king disgrace and should be outlawed. They are under-educatated, under-skilled incompetents who don’t know the limits of their own ignorance and don’t see enough cases to get their 10,000 hours.

      An NHS midwife who presided over 2 intrapartum deaths out of 650 low risk women would be under investigation, not held up as an example of good practice.

    • Bombshellrisa
      June 5, 2013 at 12:48 pm #

      Wow, you have been a midwife for 40 years and have seen only 650 births?

      • Box of Salt
        June 5, 2013 at 1:08 pm #

        40 years and have seen only 650 births?
        I did the math: 1.35 per month.

        • Eddie
          June 5, 2013 at 2:27 pm #

          Doing the math sadly seems to be something that only advocates of evidence-based-medicine think of doing. I really wonder why that is.

        • quadrophenic
          June 6, 2013 at 10:45 am #

          And doing the math, 2 deaths in 650 isn’t that much lower than the national neonatal mortality rate. Which is a bit scary since these are supposed to be only low risk births.

      • realityycheque
        June 6, 2013 at 10:25 am #

        No, I think she’s trying to say that the birth centre itself has only had 650 births in 40 years.

        If this were a game of homebirth bingo, this lady would’ve won.

  2. Ashley Wilson
    May 2, 2013 at 3:08 am #

    The fact that this is coming to AZ is making me ill. I just know someone who is going to pursue becoming a homebirth midwife once all of these changes get made. While I hate the stupid cow, I adore her husband and really regret the rift that has come between us because of his wife (as do all of our friends, whom she has managed to completely cut himself off from). Even if she doesn’t become a midwife, this is what she’ll try with her next kid… God. At least I don’t have to deal with her anymore.

  3. April 15, 2013 at 1:00 pm #

    As a native of the Grand Canyon State, I can honestly say I have never been prouder that my degree was granted by Arizona State and not the University of Arizona.

    Seriously, Wildcats, you guys are better than this.

  4. Momoftwins
    April 14, 2013 at 12:03 am #

    Off subject but just had to say that I came across this site while looking up the ridiculous practice of Lotus Birthing and I’m relieved to see that not everyone in this world is out of touch with reality! Thanks for restoring my faith in mankind and giving a a small amount of hope that Idiocracy doesn’t happen.

    • LibrarianSarah
      April 14, 2013 at 3:17 pm #

      I’m sorry but every time someone mentions Idiocracy I have to post this. Contractual obligations and all that.

      So rest assured the world is safe. 🙂

  5. Captain Obvious
    April 13, 2013 at 7:04 pm #

    Save Illinois from CPM.

    • Box of Salt
      April 13, 2013 at 7:26 pm #

      ” [CPMs] are specifically trained in out-of-hospital birth. This means that
      they can resolve complications in a low-technology setting.”

      I suppose the author actually believes that.

      • KarenJJ
        April 14, 2013 at 2:28 am #

        Yep. Keep breathing that cinnamon on the woman that’s hemmorhaging.. That’ll fix it.

        • Bombshellrisa
          April 14, 2013 at 2:17 pm #

          Which makes no sense, as cinnamon is supposed to have blood thinning properties.

        • Eddie
          April 14, 2013 at 2:48 pm #

          That leads right into the pseudo-science and anti-science beliefs of so many of that group. As BoFA mentioned a few weeks back in a different post, the myth of the noble savage, that these “primitive culture” beliefs are superior to modern medicine. It’s unfortunately indeed that so many people today are immune to fact-based discussions and so easily fall into the trap of believing that nonsense.

      • April 14, 2013 at 9:12 am #

        …resolve complications….define complications!

        A baby gets stuck, the midwife tries the Gaskin, and the baby gets unstuck. Has she resolved a complication, or was the baby only slightly stuck? The emergency comes when the obvious and easy doesn’t work. Did chewing on the placenta resolve the haemorrhage? Or was it not the same kind of complication as those where women die or need transfusion after transfusion?

        It wasn’t the skill of the (well trained, ill equipped) midwives that saved that recent baby’s brain, it was the skill of the hospital neonatologists and some pretty fancy high tech.

        If low technology settings were such a good idea, pre-20th century graveyards would have fewer graves for young women and babies.

        • Wow
          June 4, 2013 at 9:10 pm #

          The IDEA is to use midwives and OBs in conjunction, for them to work together to provide good outcomes for moms and babies. OBs are not trained in low risk birth, and midwives are not trained in high risk birth. So they work together and parcel out their patients according to their specific skill sets. This is the best way.

          • Amy Tuteur, MD
            June 4, 2013 at 9:38 pm #

            How would you know what obstetricians are trained in? Did you do an obstetric residency? Let me guess, you read homebirth propaganda and believed it.

          • Karen in SC
            June 4, 2013 at 9:56 pm #

            OB’s deliver plenty of low-risk women, since most women do deliver without much fuss. I was one of those women, twice. No drugs, skin to skin etc and this was 20 yrs ago. But I was in a hospital. A safe birth should be the priority.

            Too many midwives do not transfer high risk patients, nor are they as trained as you think they are.

          • KarenJJ
            June 4, 2013 at 10:07 pm #

            This already happens with CNMs, doesn’t it? Where I live, US lay midwives and CPMs would not be allowed to practise. You want to work with OBs, then you need to have a level of training that makes you useful.

            Where I live midwives and OBs work together, the midwives are all licensed and university trained. There are strict requirements for low risk birth.

            This doesn’t happen in the US, because you have too many numpties with no idea that are pretending to be midwives with very little training or knowledge. Catching babies doesn’t count. Recognising problems and timely referral is part of that and being an ‘expert in low risk’ does not train people well enough in these problems.

          • Eddie
            June 4, 2013 at 10:13 pm #

            Why would an OB need training in low-risk birth? I mean, it’s rubbish that OBs are not trained in low-risk birth, but for the sake of argument, what training do you need exactly to handle a situation where everything is going swimmingly?

          • theNormalDistribution
            June 4, 2013 at 10:27 pm #

            OBs are not trained in low risk birth, and midwives are not trained in high risk birth.

            You’re probably right. Midwives *are* experts at doing nothing, which is something I’m pretty sure they don’t cover in medical school.

      • The Bofa on the Sofa
        April 14, 2013 at 11:47 am #

        You know, if the “low technology” approach for resolving complications were so damn good, we wouldn’t have developed high-technology approaches.

        OTOH, they could just as well come out and say, “If the midwife can do it, it’s an acceptable intervention. If it requires a doctor, it is not”

    • Bombshellrisa
      April 14, 2013 at 1:05 am #

      ” They do not provide well-woman care, treat disease, prescribe drugs, or handle high risk pregnancies. They are trained to recognize, prevent, and if necessary stabilize complications in labor.” So….how exactly can you stabilize complications without treating disease or having access to medications? This is what got Katie McCall into trouble, it wasn’t that she stayed and delivered a baby as a student, it was that she sutured a tear badly and used drugs that she had no business carrying as a student.

      • Squillo
        April 14, 2013 at 1:51 pm #

        I’m also wondering how you prevent complications in labor. Diet, maybe–try not to grow a huge baby, particularly if you have GD. But other than that? Seems to me preventing labor complications as a homebirth midwife would largely mean turfing out riskier cases to OBs. Who mostly prevent them with the dreaded c/s.

      • Eddie
        April 14, 2013 at 2:45 pm #

        +100. I would *love* to see a comprehensive response from an NCB advocate that explains what problems they can and cannot address, what interventions they can provide. What fraction of hospital transfers they would expect. And so on.

        • fiftyfifty1
          April 15, 2013 at 9:27 pm #

          Like from the head of MANA. But she’s far too sly to be pinned down.

          • Bombshellrisa
            April 16, 2013 at 6:01 pm #

            And she uses words that are half Klingon half CPM speak-seriously, reading anything she has written and I feel like my reading comprehension skills are absent.

      • Wow
        June 4, 2013 at 9:08 pm #

        Midwives DO carry certain medications which can stop unexpected complications. In most states, midwives carry pitocin for hemorrhaging. They are also trained extensively in neonatal resuscitation, how to deal with shoulder dystocia, and a multitude of other common issues that can not be risked out. Midwives who are actually well trained do not hesitate to seek consult and/or refer patients to other care providers if necessary, nor do they balk at transport when necessary. They are trained in these things, and know how to respond.

        • Amy Tuteur, MD
          June 4, 2013 at 9:36 pm #

          Do they bring an operating room, blood transfusions and doctors who can intubate a baby? No they don’t. That’s why in every state that has investigated planned homebirth attended by a non-nurse midwife has found appallingly high death rates.

        • Bombshellrisa
          June 4, 2013 at 9:48 pm #

          Some do. A great deal do not, especially in states where CPMs are not recognized as healthcare providers. Anyway, you are responding to a comment about a STUDENT midwife, who didn’t have a preceptor with her and should not have been carrying the drugs or suture kit to birth she was attending on her own.

        • Lizzie Dee
          June 5, 2013 at 12:37 pm #

          I wonder how many people who have had a serious brush with death in a hospital would say “I wish I had stayed at home…I didn’t need those transfusions/my baby did not need NICU…

          I know there are those who tell themselves that if they stay at home it won’t happen, but that is not QUITE the same.

    • yentavegan
      April 14, 2013 at 7:39 am #

      Does the author really wonder why the hospital is “hostile” when a home-birth goes wrong and transfers?
      Um… how about no medical records? No history of potentially contagious disease? they don’t have a list of drugs/health problems of mother …

      • Wow
        June 4, 2013 at 9:05 pm #

        ACTUALLY, asshole, midwives take a comprehensive and thorough history of past medical problems when they accept a woman into their care. It is a midwife’s job to risk women out of her practice, which means a comprehensive history and detailed charting of the current pregnancy are necessary. And these are always given to the hospital upon admittance during a transfer.

        • PJ
          June 4, 2013 at 9:29 pm #

          How can you possibly claim this when, unlike in every other first world country, there are NO national regulations in the US requiring homebirth midwives to do this? And I’ve read scores of birth stories describing women who have contracted midwives willing to do VBACs, twins and much, much worse at home. Clearly they are NOT doing their “job” of risking out women.

          • Amazed
            June 5, 2013 at 8:09 am #

            She can. She doesn’t have a clue. Just look at her proud boasting about her birth centre death rate and “the” midwife’s experience spanning 650 births over 40 years.

        • Bombshellrisa
          June 4, 2013 at 9:51 pm #

          If the midwife accompanies. Some people can’t cough up the extra $750 fee to have the midwife go with them and there are many midwives who include wording in their contracts of care that the midwife is not expected to accompany the woman during a transfer.

        • Amazed
          June 5, 2013 at 8:08 am #

          ACTUALLY, asshole.

          Classy. Ignorant and proud of it.

        • yentavegan
          June 6, 2013 at 10:11 am #

          do homebirth midwives have authority to order lab work? Do homebirth midwives have their clients pre-register at the nearest hospital so that maternity has mothers’ records?
          And what’s with the name calling?

    • April 15, 2013 at 10:42 pm #

      That link caused my anti-virus software to have a fit.

  6. Anne
    April 13, 2013 at 9:49 am #

    “The findings suggest that homebirths attended by midwives may be equally safe if not safer for women with low-risk pregnancies. Unfortunately, home births attended by midwives increase safety concerns for the child.”

    And that’s why we recommend not planning homebirth if your child’s safety is your main concern.

    Any questions?

  7. Something From Nothing
    April 12, 2013 at 6:04 pm #

    “The KEY ISSUE in any analysis of homebirth is its safety for babies. It’s not the only issue, but all others pale into insignificance next to it.”

    I don’t entirely agree with this statement. I agree that safety for babies is a key issue, but I disagree that safety for mothers pales into insignificance. It does the argument no good to imply that safety of babies is the key factor, when safety for both mother and baby is the KEY ISSUE. A mothers health is severely compromised if she loses her baby. A child needs an intact mother. They are not issues that can be separated IMO. I know that Dr. Amy would likely agree with that, but the wording matters.

    • fiftyfifty1
      April 12, 2013 at 7:48 pm #

      Unless a person interprets this as “a mother’s health is severely compromised” = “badly disappointed that she had a c-section”.

      Except for perhaps some sort of catastrophic injury to mother (e.g. post partum bleed so severe it ends in brain damage), I think most mothers would choose to trade injury to themselves for the life of their child.

      I have permanent injuries from my first delivery (vaginal delivery) but this is nothing but an annoyance when compared to the idea of loss of a child. NCB types will say that a healthy child isn’t ALL that matters, and that is true. But sometimes what is best for the mother is not what is best for the baby. And vice versa. Sometimes in childbearing one of the two individuals involved has to get the short end of the stick. NCB likes to pretend that if you do everything the NCB way that this dilemma will not occur.

      • The Bofa on the Sofa
        April 13, 2013 at 9:04 am #

        It is true that “a live baby is not all that matters.” However, as noted below, if the baby dies, nothing else matters.

        • Becky05
          April 17, 2013 at 11:05 am #

          I’d prefer that my life be saved over a baby’s, and I’m sure my husband would prefer it. It may not often come to this anymore, but it sometimes does.

          • The Bofa on the Sofa
            April 17, 2013 at 11:17 am #

            My wife and I discussed it before our first. My wife indicated that she wanted me to choose the baby.

          • Poogles
            April 17, 2013 at 2:10 pm #

            “My wife and I discussed it before our first. My wife indicated that she wanted me to choose the baby.”

            My husband and I have discussed this, hypothetically (no kids yet), and though I have stated my wish to have the baby take priority over me, he is vehemently against that choice. Something we’ll have to talk over more, obviously. It is an extremely difficult choice to ask someone to make…

          • Something From Nothing
            April 19, 2013 at 9:58 am #

            From the point of view of an obstetrician, generally speaking, moms health takes priority.

          • Becky05
            April 17, 2013 at 9:35 pm #

            It would have been different with my first, but it’s not just about me anymore, it’s also about my other kids who need me.

  8. Aunti Po Dean
    April 12, 2013 at 5:27 pm #

    I wonder why he didn’t just say ” Homebirth attended by a CPM is safe or safer than hospital birth if you don’t count the fact that 3 times as many babies die”?

  9. Hannah
    April 12, 2013 at 3:46 pm #

    I thought this article might interest people, here:

    • c
      April 12, 2013 at 4:55 pm #

      “I feel a pang of guilt when I think that my refusal of medical intervention deprived them of steroids in the womb. These are used to develop lungs if a birth is likely to be premature. But this is tempered by the fact that my pregnancy was calm because I wasn’t constantly monitored and filled with anxieties. I am, however, relieved and grateful that they were born in hospital, because it saved their lives.”


      • Hannah
        April 13, 2013 at 9:07 am #

        The other interesting aspects of this article are the possible anecdotal evidence for one of the benefits of free birth over a birth with an unskilled midwife, possible resulting in a false sense of security- she realised something was wrong and went to hospital- and also the description of the birth- the first twin’s head essentially becoming trapped by the second twin- which seems to match something Attitude Devant raised as a possible complication of first twin breech, in one of the Lisa Barrett threads.

        • Sullivan ThePoop
          April 13, 2013 at 1:04 pm #

          Unless the mother is too wooy or a midwife herself, it does seem that a free birthing mother is more likely to go to a doctor or hospital if there are complications which could explain why unassisted births in either the Colorado or Oregon study showed a lower mortality rate for unassisted than midwife attended.

      • PrecipMom
        April 13, 2013 at 10:00 am #

        Oh wow.

      • Dr Kitty
        April 17, 2013 at 1:48 pm #

        Would she still feel like that if either child was dependent on oxygen?
        Because THAT is a possible outcome.
        Not just death and longer NICU stay, but permanent, disabling lung disease are consequences of not having antenatal steroids. Silly woman.

        • Poogles
          April 17, 2013 at 2:18 pm #

          “Would she still feel like that if either child was dependent on oxygen?”

          It’s certainly a possibility, after all I’ve had at least 1 mom say she would make the same choices even though her daughter has a severe HIE injury that means she can never speak, never swallow, never crawl or walk, and will very likely have an extremely shortened life span (IIRC, at 5 years old, she has already lived longer than the original prognosis).

    • April 12, 2013 at 5:54 pm #

      Wait, wait, wait. She risked her babies’ lives by not having any prenatal care at all, learning she was having twins at delivery, and she’s happy about how her pregnancy went?

      Yes, learning about things that can go wrong and taking care of them is stressful. You know what’s more stressful? Having things go wrong with nary a clue beforehand that they might!

      EDIT: Not to mention how much the 6 week NICU stay cost. Steroids to develop the twins’ lungs could have reduced that stay (and associated cost) tremendously. Her selfish desire to avoid stress cost NHS money it simply does not have to spare.

    • Eddie
      April 12, 2013 at 9:13 pm #

      That she would take the risk again is pretty stunning.

  10. attitude devant
    April 12, 2013 at 2:41 pm #

    Wait, what?!?!? This is a government publication, right? And the lead author is in public health, with a specialty in economics of healthcare, right? So is what he’s saying is that dead babies are cheap so it doesn’t behoove him to look beyond the maternal outcomes? Maybe he should talk to his colleagues in Oregon about what the Abel Andrews case is going to cost the state?

    Also, I just want to shriek every damn time I hear that canard about fewer lacerations at home birth. Well, yeah if you don’t look for them and don’t note them and don’t repair them, then your (completely wrong) numbers are going to be lower

    • Anne
      April 13, 2013 at 9:59 am #

      Hear, hear! I have taken to ignoring the “better APGARs; fewer perineal lacerations and reduced PPH” findings which accompany all analyses of hospital/non-hospital birth outcomes. Subjective findings, all- and I have wondered about the motivation of NOT accurately diagnosing pathology, as if there is pathology, transfer for further care might be advisable.

      And those objective outcomes- reduced operative birth rates are at the expense of perinatal mortality.

      Sigh- anyone else tired of this?

    • April 13, 2013 at 12:10 pm #

      It is rather depressing the work done by economists on birth…as an economist, I find it incredibly disappointing and am amazed by how small changes in the approach would greatly improve the quality of the work (little things like looking beyond the first month post-birth). However, if real analysis were done, it might not support the mantra that a normal birth is an ideal outcome in and of itself.

    • Renee Martin
      April 14, 2013 at 3:42 pm #

      It’s easy to have less of anything you totally ignore, vs HCPs that have to chart every detail, under supervision.

  11. EB
    April 12, 2013 at 1:35 pm #

    There is no greater harm to me than to have something go wrong with my child. How can you claim to care for maternal health and not know that?

  12. JenniferG
    April 12, 2013 at 1:21 pm #

    Losing a baby has a long-term effect on the mother’s health, where health includes mental health, effects from stress and so forth. Honestly.

    • LukesCook
      April 12, 2013 at 3:44 pm #

      Increased mortality too. Cardiac events, suicide, and a host of long term health problems associated with behaviors such as alcohol, tobacco and drug abuse (especially prescription drugs), poor self-care and weakened social relationships.

      • Eddie
        April 12, 2013 at 4:32 pm #

        Increased risk of divorce as well, as many marriages do not survive the death of a child. And divorce, itself, is associated with many of the things you mention, plus increased poverty for the mother and other children, which is itself…..

        • fiftyfifty1
          April 16, 2013 at 8:28 pm #

          There are not any really good quality studies, but the few that do exist say that there is NOT an increased risk of divorce following the death of a child.

          • Eddie
            April 16, 2013 at 8:39 pm #

            That’s good to hear. That means what I’d heard/read before was incorrect and probably just based on anecdotal evidence. Thanks for the correction.

  13. Renee Martin
    April 12, 2013 at 12:15 pm #

    “Safe or safer” sounds like they took it right from the NCB playbook.

    I cannot believe that he thought this was an appropriate change to make.


    • MnaMna
      April 12, 2013 at 12:52 pm #

      He made changes a line buried deep within the paper, but it didn’t get changed in the abstract. That abstract results section that talks about child health outcomes being all peachy keen? Needs to be fixed to state that there are increased risks for the infants born at home.

      • anonomom_LLLL_IBCLC
        April 12, 2013 at 1:27 pm #

        The second sentence in the abstract does state: “Analysis of combined data from all 8 studies showed a three-fold increase in risk of neonatal deaths for homebirth attended by midwives, compared to hospital births.” This is good. However, they then say “There were no significant differences in outcome for home or hospital births attended by midwives for the other child health measures.”

        So, aside from that, Mrs. Lincoln, how did you like the play?

        • Renee Martin
          April 14, 2013 at 3:39 pm #

          So, other than DEATH, all else is equal.
          How reassuring.

    • Aunti Po Dean
      April 12, 2013 at 4:57 pm #

      I agree if you say “safe’ to a pregnant mother she will automatically think you are talking about the baby, if you are talking about her then you say “low risk”
      So saying its safe or safer but has unfortunate outcomes for the baby is absolute rubbish. That “argument” belongs in Dr Amy’s brilliant “illogical” post

  14. mollyb
    April 12, 2013 at 11:53 am #

    There seems to me to be a trend lately where it is assumed that the “end goal” of childbirth is a spontaneous, drug-free vaginal birth and not a healthy mother and baby.

    • Renee Martin
      April 12, 2013 at 12:17 pm #

      Why do people go through pregnancy? TO GET A BABY!
      If the baby dies, all else is irrelevant.

    • Eddie
      April 12, 2013 at 3:18 pm #

      I was wondering about that when I read this paper and how it referred to stuff like the increased risk of forceps delivery or assisted deilvery. Risk? An increased risk of something that will have to be repaired, like a tear or episiotomy I understand. An increased “risk” of an event happening that is not itself damaging … I’d say that “increased chance of” is the more logical way of putting it.

      But since I am not only not a doctor but not a medical researcher (there are many things I am not) I wondered if this was just how it is typically put. To this lay person, it seems like a subtle way of making something sound dangerous. But maybe it is. (?)

      • anonomom_LLLL_IBCLC
        April 12, 2013 at 3:22 pm #

        I think you’re totally right. I hate it when people say that in the hospital you’re at increased risk of a c-section. Um, isn’t having access to surgery if your baby might be in trouble a BENEFIT not a risk?

        • Eddie
          April 12, 2013 at 4:58 pm #

          Exactly. At best, they could say you’re at higher risk for an “unnecessary C-Section.” Which then opens the discussion of which ones are truly unnecessary. 🙂 But higher risk of a C-Section, without context, is meaningless, because it doesn’t account for selection effects. (Women who NEED C-Sections are way more likely to end up at a hospital than not.)

          • The Bofa on the Sofa
            April 13, 2013 at 9:14 am #

            Exactly. At best, they could say you’re at higher risk for an
            “unnecessary C-Section.” Which then opens the discussion of which ones
            are truly unnecessary. :-

            Considering that this study itself indicated a 3 fold increase the baby dying, it’s hard to see how it is a bad thing.

            In fact, if you wanted to, you could spin it as “look, C-sections save babies!”

          • Eddie
            April 13, 2013 at 2:36 pm #

            Actually, “look, C-Sections save babies!” is precisely how I look at it, and quite a reasonable way to look at the statistics. But you have to actually look at the statistics, not close one eye, look to the side, and then choose the ones you like, as so many researches seem to do.

            It’s irritating to me how the NCB crowd keeps quoting the American rate at which children die before they are 1 as being so much higher than Western Europe as evidence at how bad our (so called) medicalized system is. When if they just looked at the APPROPRIATE statistic, they would see we are right in there with Western Europe as having among the best numbers in the world. But to see that, one has to actually be willing to be swayed by evidence, which so many in the NCB crowed are not.

        • Karen in SC
          April 13, 2013 at 1:17 pm #

          Right! I had two natural births in the hospital because immediate access to a c-section was available, if necessary.

      • Amazed
        April 12, 2013 at 3:56 pm #

        To this lay person, it seems like a subtle way of making something sound dangerous.

        That’s because it is a subtle way of making something sound dangerous. Sure, an increased risk of something necessary that a midwife is simply unable of doing. Somehow, they dropped this very necessary addition.

        • Something From Nothing
          April 12, 2013 at 6:12 pm #

          It should be stated that they have an increased “likelihood” of forceps or caesarean. I never say increased risk of caesarean because it implies that Caesarean is a bad or undesirable outcome, when , for many it simply is not.

          • Amazed
            April 12, 2013 at 6:23 pm #

            Yes, “likelihood” is a much better word. And caesarean is not even an outcome, good or bad – it’s a means to an end. It speaks volumes of the mindset of these women that the method of birth is “the outcome”. Shouldn’t the outcome be the baby’s arrival?

            If you ask my grandmother who has only one child, born prematurely, tiny and to a very, very sick mother (she stayed at the hospital for 40 days afterwards), she’d rather have taken the method of caesarean if the outcome would be delivering living children in the pregnancies she lost.

          • Julia B
            April 13, 2013 at 9:40 am #

            Using the word “risk” is standard in epidemiology. There is a nice lecture (16) available on the use of risk available from the Johns Hopkins School of Medicine, if you are interested. I don’t see the scientific community moving to using “likelihood ratios” in the near future.

          • Amazed
            April 13, 2013 at 11:21 am #

            But this is not epidemiology. Is “risk” the only word used in obstetrics? The risk of delivering, the risk of getting pregnant, the risk of your baby inheriting dad’s blond hair instead of mom’s dark one?

            I am not a doctor or a researcher, so I cannot speak for their language preferences. I am, however, a translator and I am not allowed to use words that distort the real meaning of what I am translating. I can discern misleading language when I see it. It might not be misleading to doctors and researchers but to lay people? It most certainly is.

          • Susan
            April 13, 2013 at 12:29 pm #

            I am thinking about how difficult it was to explain the AFP test ( years ago before the new testing ) when it was a screening test and not a diagnostic test. Risk, odds, likelyhood, chances are really difficult concepts for some people to grasp. It becomes way more difficult when it’s something as emotional as a baby involved. Tie the topic of abortion to it and it becomes “false postives” rather than a test that says you might want to choose to have a diagnostic test. At least that is better now, but it’s a great example of the challenges inherent in looking at statistics and risk in pregnancy.

          • Amazed
            April 14, 2013 at 9:44 am #

            Susan, I sometimes joke with my doctors when they get all medical on me. “Please translate to this translator,” I say. Statistics and specifics in each individual field are like a foreign language and we are so very vulnerable and exposed to the good will of those doing the explanation. Especially when it’s something as emotional as a baby involved, as you say.

          • Julia B
            April 14, 2013 at 5:30 am #

            It is epidemiology since they are looking at a health outcome in a population. It seems that the authors need to reframe the conclusions, but I think you are over thinking the use of the word “risk”.

          • Amazed
            April 14, 2013 at 9:42 am #

            Quite possible. It still reads like “when you go to the hospital, you’re at increased risk of getting treatment for your baby.” That’s it – a C-section is a life and brainsaving treatment.

          • Siri
            April 14, 2013 at 5:42 pm #

            Sometimes it is, sometimes it isn’t. The vast majority of caesareans do not save a life that would otherwise be lost, or prevent brain damage. Some are genuinely elective, ie there is a decent chance the baby would have been fine had it been born vaginally. Most emergency caesareans are not crash sections, so the word emergency means ‘not planned/elective. And most women would prefer a normal birth to a caesarean; after a normal birth the cessation of pain coincides with the baby’s arrival, whereas caesareans are pain free during, and painful after. They also carry risks for further pregnancies, and make for a much longer recovery period. This is not trivial; many women who would have liked to have more than two children choose not to conceive again because they can’t face another operation. And the only women who had emergency hysterectomies at my hospital had had sections. So yes, I think risk is a reasonable word to use. Of course, none of the above is a reason to demonise caesareans, or any kind of counter-argument to those who are happy with their caesareans.

          • Amazed
            April 15, 2013 at 4:33 am #

            Of course, none of the above is a reason to demonise caesareans, or any
            kind of counter-argument to those who are happy with their caesareans.

            You might not sound like you want to demonise caesareans but it looks like quite the demonising for me. Is the vast majority of caesareans known to be unneeded in advance? Or do you consider it lie and abuse to mothers when monitoring shows that there might be a problem and mothers decide to have that C-section just in case something is wrong when that turns out not to be the case? Is this a risk or a precautionary measure?

          • Captain Obvious
            April 15, 2013 at 9:08 am #

            Found this comment in a legal thread…

            “The issue of offering elective primary cesareans is fueling some new types of malpractice cases against obstetricians. In the case shown here, one of the first of this type reported, the mother sued after delivery of a baby with Erb’s palsy. The issue brought to the court was whether the patient was informed that she could have an elective primary cesarean which would reduce the risk of her infant having an Erb’s palsy. The patient said, of course in retrospect, that if she had been informed that vaginal delivery had a risk of shoulder dystocia which increased the risk of Erb’s palsy, she would have chosen the elective cesarean. The court believed that this was a piece of information that a reasonable person would need to know to make a decision for vaginal versus cesarean delivery.
            The potential for FHR monitoring issues to come up in a similar complaint exists. If, for example, a laboring patient has a Category II or Category III FHR tracing then delivers a child with a bad outcome, she could sue and attempt to claim that if she had been informed that labor carries the risk of intrapartum hypoxia, which could increase the risk of a child having some deficit, she would have chosen to have an elective primary cesarean. Central to the decision in the case described was the assumption that informed consent is obtained for vaginal delivery that includes the option for an elective cesarean. While it is not considered the standard of care to offer every pregnant patient a cesarean without a medical indication at this time, there may be experts who can convince a jury that it is, or should have been in retrospect in a given case.”

          • Amazed
            April 15, 2013 at 9:30 am #

            Captain Obvious, thank you for citing this. I find it very interesting because it blatantly outlines the fact that vaginal delivery has its risks and they could and should be considered. Informed consent is a fascinating thing. A friend of mine could not be informed by three physicians because they were saying something she didn’t want to hear – that there was no way this baby would fit through her pelvis. So she went through the hell of unproductive labour and when she sobbed and begged for a CS at the end, there was no free OR. She had to wait for another hour. Now she hears VB… and flees before you can say AC. Her recovery was very hard indeed and she considers it a consequence of her labour than the CS.

          • LukesCook
            April 17, 2013 at 1:05 am #

            Can somebody please point me to the avalanche of malpractice cases which must surely be following all the deaths and injuries caused by all the supposed “unnecesareans”?

          • Siri
            April 15, 2013 at 1:35 pm #

            Well, you’re wrong. What did I say that demonised sections? I was a midwife, I am a health visitor. What do you do for a living? I support mothers, babies, fathers and families. I have assisted at countless caesareans, delivered hundreds of babies, and visited lots of homes with new and growing babies. I support breastfeeding, and formula feeding. I want women to have the births they would prefer, and do my best to make that happen. I supported one mother to get an elective caesarean because that was what she wanted, and weighed her baby at home for months when she had pain from adhesions (guess what, she was still glad she had the caesarean). The fact remains that caesareans lead to much greater morbidity than vaginal birth ON THE WHOLE, although of course there are exceptions. A vaginal birth can leave no trauma; a caesarean always leaves an incision.

          • Amazed
            April 15, 2013 at 3:41 pm #

            What did I say that demonised sections? I was a midwife, I am a health visitor. What do you do for a living?

            I didn’t say you demonized them. I’ve read comments of yours and I know you don’tI said it sounded this way to me because that’s how it sounded. You gave quite the number of reasons why caesareans were bad. You didn’t bother to mention why they were performed. It looked like any other c-section but a stat one was unneeded. A first time visitor would interpret this as “they do them just to make women sick”. Again, I’ve read comments of yours and I know that’s not what you meant.

            I am a translator. I work with words. Recently, a reader called the publishing house and suggested that they replace me because I had made a mistake. I wrote the camera Leica “Laica”. I am certainly not qualified to argue with medically trained people on medical topics. You’ll forgive me, I hope, for thinking that in a study, in a metaanalysis language is important.

          • Siri
            April 15, 2013 at 4:50 pm #

            I’m a translator too, and I know there are many pitfalls, some of which I’ve fallen into! I’m sure Laika the space dog took a Leica with her… My comment was in response to some comments that seemed to me to be overly praising of sections, and intended to give a different view. No mode of birth is without risks, but caesareans aren’t trivial, and there is value in trying to keep birth ‘normal’ as well as safe. I’m passionate about improving the lives of women, babies and families, and that is my starting point; not dogma, or pretence, or prejudice.

          • April 15, 2013 at 4:50 pm #

            I don’t think CS is any kind of panacea – I just think it is a bad idea to pretend they are some kind of catastrophe automatically full of awful consequences, and a vaginal birth is always better. Most women prefer the more usual option, and certainly if you want more than three children that makes sense. I didn’t want a CS, but accepted it was necessary without a lot of trauma, aware of the extra risks of surgery. To me, an emergency CS following a troubled labour is the worst possible option but give women good information not exaggerated accounts of the risks of CS and the benefits of vaginal and leave it at that.

          • Siri
            April 16, 2013 at 2:49 am #

            I never said anything that vaguely resembled that. I am getting a tiny bit tired of being jumped on as if I am saying sections are the work of the devil. I stand by everything I’ve said, and I recognise none of it in the objections I’ve received.

          • Siri
            April 16, 2013 at 2:52 am #

            Dr Amy is very welcome to denounce my comments if she finds them exaggerated; I hope she knows how strongly I support her cause.

          • fiftyfifty1
            April 15, 2013 at 10:04 pm #

            ” A vaginal birth can leave no trauma; a caesarean always leaves an incision.”

            On the other hand developing chronic fecal incontinence pretty much is an outcome only due to vaginal birth.
            When vaginal birth goes well, it can go very very well. But when it goes bad it goes horrid.
            A bad vaginal birth is much much harder to recover from than an average c-section if it can be recovered from at all. I live with this reality.

          • Siri
            April 16, 2013 at 2:45 am #

            I never said anything to the contrary.

          • fiftyfifty1
            April 16, 2013 at 9:49 am #

            No, you never said anything to the contrary. But then again, you didn’t paint a complete picture either. This is a form of bias, and that is a problem especially when it comes from a medical provider like yourself. It’s true that a c-section is guaranteed to need stitches. But many many vaginal births end in stitches as well. And a planned C-section will guarantee that you will not face the heartbreak of severe pelvic floor damage. Good evidence shows that it is also, on average, safer for the baby. Women, especially women planning only 1 or 2 babies (and this is the majority of women) deserve to hear the whole truth. Unless you think they can’t handle the truth?

          • Siri
            April 16, 2013 at 2:38 pm #

            I agree with every word you say. My original comment was in response to one that seemed to glorify sections; it was not intended as a comprehensive review of every facet of obstetrics and midwifery. We are not in opposition, and insinuating that I think women can’t handle the truth, or should be given a censored version, is just stupid. Eddie, you said no need to be defensive, but I think I’ve had it with this blog – no, not the blog, the aggression of some of the commenters. I know this may show me up as being able to dish it out, but not to take it, and it is not intended to be a flounce. Dr Amy, I salute you – your cause is a worthy one, and you are a force for good. Cheerio, all! It was good while it lasted. Xxx

          • Amazed
            April 16, 2013 at 4:13 pm #

            No one glorified C-sections. It’s just that some of us happen to think that the word “risk” is misleading and fearmongering because it makes it look as if it’s only about the mother and the risks to her health.

          • Eddie
            April 16, 2013 at 4:39 pm #

            No, you never said anything to the contrary. But then again, you didn’t paint a complete picture either. This is a form of bias

            Reading everything together that Siri said, I really don’t think she was disagreeing with you in this area, and I don’t think she intended what she wrote to be read as biased or one-sided as it’s being taken. I think she was simply trying to provide counterpoint and context to some posts extolling the virtues of CS, but without actually disagreeing with those posts. In a sense of, “Yes, that is true, but this is also true.”

            I obviously cannot speak for her, but since I am not emotionally involved in this specific discussion, I think I can dispassionately comment on what I saw going on. The truth is that CS is neither a panacea nor a horror. Everyone posting in this thread unambiguously agreed that CS saves lives. No-one argued that we “should” be doing a fraction of them. Everyone agreed that with today’s best medical knowledge, we have to do more than one section for every life saved or injury avoided.

            From my viewpoint, everyone was arguing for the exact same kind of informed consent, but providing different sides of it. Not in the sense of, “You’re wrong” but in the sense of “don’t forget about this piece.”

            In a conversation like this, is it necessary that each person couch their words so carefully that they have to say, “I agree with you but let me add this piece” so as not to be taken as an absolute disagreement? I have taken to doing so — to try to avoid exactly this kind of misunderstanding, but it does make every post longer. Siri very clearly said, multiple times, that she didn’t mean things the way people were taking it.

          • fiftyfifty1
            April 16, 2013 at 10:39 pm #

            “In a conversation like this, is it necessary that each person couch their words so carefully”…..?
            I don’t expect every comment to present both sides. But I feel that Siri has a bias against C-section. She states she is a midwife with a lot of experience, and yet her impressions seem very one sided considering that experience. In her world ALL women who have a VBAC are pleased. ALL VBAC women who have even high forceps (the kind that are so dangerous they have been banned) have ALL said they felt great and many skipped down the halls. In her world, pain stops as soon as a woman has a vaginal birth. But women with c-sections often have such a hard recovery that “they can’t face another operation”. One of the two women she knows who actually had a MRCS ended up with such bad adhesions that she was apparently house-bound for months (I have *never* heard of a case of adhesions from ANY cause that has ever caused someone to be housebound). When a poster answers her saying that her vaginal recovery was actually very long and very painful she dismisses it with “fortunately your experience is not the norm” and goes on to cluck her tongue a bit sympathetically but doesn’t really address her point. In her world, many doctors prefer to shove up and section a baby that is *on the perineum* because they can’t or won’t do an assisted vag delivery (absolute exageration, doing a section of a baby that far down is very difficult and risky and docs do NOT do this for fun).
            So my problem with what she says is not that she presents just one side. One side is fine with me. But one side full of inaccuracies and exagerations and at times what seems to be confabulation? No.

          • April 15, 2013 at 6:49 am #

            The vast majority of caesareans do not save a life that would otherwise be lost, or prevent brain damage.

            How do you know? Especially with the latter? As everyone keeps saying, most, but not all, may be precautionary – the large baby that might get stuck (and lose brain cells from oxygen deprivation – maybe not spectacularly noticeable, but worth avoiding anyway); the labour going nowhere fast and a baby/mother getting exhausted, breech, twins. The intrapartum deaths that can happen in a homebirth less likely in a hospital BECAUSE of CS. Then you have the ones like mine that would be stillbirths without monitoring. No it didn’t save mine from brain damage – because it wasn’t done soon enough. It is hard to accept that mothers/babies that were doing fine can get into serious trouble fast, but it happens, and is worth avoiding.

            The figures where CS isn’t available are awful. And if a mother truly believes it isn’t necessary, why isn’t she saying no?

          • Eddie
            April 15, 2013 at 10:28 am #

            Obviously, if it was possible to tell in advance precisely which C-Sections were medically necessary, there would be fewer of them. It would then be a little easier to weigh the risks of CS vs the risks of “normal” delivery. Clearly there are risks in both. If you have 7% fetal death without CS and 0.6% with, and you’re doing 30% CS, then the vast majority didn’t save a life. It isn’t evil to state this fact, is it? Even if you had to do several CS for each life you save (from death or injury) it’s absolutely worth it, and I think most parents would agree with this.

          • The Bofa on the Sofa
            April 15, 2013 at 11:00 am #

            I had a long reply to Liz’s comment, but Discus booted me out, but let me summarize:

            As Eddie says, it’s not incorrect that the vast majority of c-sections would not have been needed. However, our daily lives show us that turning out ok “the vast majority of the time” is not even close to acceptable. We buckle our seat belts, we don’t drink and drive, our kids ride in carseats, we don’t run with scissors.

            Shoot, a heart attack turns out ok most of the time (not quite to the vast majority, but certainly most (heart attacks have a 16% mortality rate in the US)).

            If we knew ahead of time which c-sections were unnecessary, we wouldn’t be doing them. If the NCB crowd were really serious about reducing C-section rates, they would focus on doing a better job of determining ahead of time which c-sections are not necessary. Unfortunately, the “everything is a variation of normal” approach isn’t working.

          • Siri
            April 15, 2013 at 1:20 pm #

            Thank you! Saying that most sections don’t save a life isn’t anything other than factual, and it isn’t the same as saying you know which ones are not needed. Pretending caesareans are a panacea without drawbacks is just as pointless as saying homebirth comes with free unicorns. There ARE ways of reducing the number of sections, including a) having plenty of good midwives with proper oversight by experienced senior midwives, b) ensuring obstetric consultants choose and teach their registrars well ( some registrars are unable to perform vacuum or forceps deliveries, and will do a caesarean even when the baby’s head is on the perineum), and keeping tabs on inductions. All labour ward staff know which registrars are trigger-happy, which are good at keeping things normal, and which ones are, quite frankly, a bloody menace.

          • theNormalDistribution
            April 15, 2013 at 4:05 pm #

            Clearly there are risks in both. If you have 7% fetal death without CS and 0.6% with, and you’re doing 30% CS, then the vast majority didn’t save a life. It isn’t evil to state this fact, is it?

            I realize that you’re trying to say that c-sections are worth it, but you’re still looking at it from the wrong perspective. If you have a 7% fetal death without CS and 0.6% with, and you’re doing 30% CS, then the vast majority of babies that were at risk of death did not die. That is the point of any preventative measure, and framing it as if some of those c-sections were unnecessary is wrong. Of course they were necessary! We don’t actually know which section saved a life and which didn’t. Each of those c-sections reduced the baby’s risk of complications and death.

            The proportion of c-sections is a function of their relative risk to vaginal birth. As the risk of undergoing a c-section decreases, the proportion of people who have one will increase. And so will the number of c-sections that were “medically unnecessary”. If the relative cost of having a c-section were similar to that of wearing a helmet when you go for a bike ride (i.e. a sacrifice of comfort and fashion), nearly everyone would be demanding one and I doubt anyone would be worrying about whether or not theirs was medically unnecessary.

          • Eddie
            April 15, 2013 at 5:48 pm #

            If you have a 7% fetal death without CS and 0.6% with, and you’re doing 30% CS, then the vast majority of babies that were at risk of death did not die.

            Well put. I’d had a longer post in my head where I discussed how the fetal death rate would vary with the section rate, given current best medical practices, that got to the point you made. (But I don’t have good facts in that area at my disposal, so I didn’t go there.) Since framing matters, the way you put it is much better than the way I put it.

            But the point is that a lot of lay people do not understand what you just said, that with medical science where it is, you have to more procedures than lives we will save or improve. Most lay people get it in theory, I think, but when it comes to specific examples like CS rate, they don’t get it. They get it in a specific example, I think, like their own delivery, but not always the implications for how it scales up to the whole population.

            Basically, it’s all about balancing risks and informed consent, right? It’s just life. We’d like it to be better. Over time it will get better. But this is where we are today. And where we are today is vastly better than where we were in the past.

          • Siri
            April 15, 2013 at 1:47 pm #

            I know because the caesarean rate is much higher than the rate of intrapartum death or hypoxic injury. The challenge, as you say, is knowing which ones are essential. There are ways of keeping section rates down without sacrificing outcomes; the Scandinavian countries are an example. Individual registrars also have vastly differing section rates. And the most badly damaged babies I ever met, were born after a long labour with problems that built up very insidiously; they never went to theatre, because theatre was always full of other women having emergency sections for less than life-threatening reasons. So they missed out on what would have been a brain-saving operation. Paradoxically, once the section rate reaches a certain level, individual babies get overlooked, with disastrous results. And Lizzie, ‘why didn’t they just say no?’. Come on, get real. You know the answer to that question.

          • Karen in SC
            April 15, 2013 at 3:37 pm #

            I don’t know that you can argue that you know that because the c-section rate is much higher than the intrapartum / hypoxia rate. Wouldn’t you have to compare similar groups of women, half of whom are denied sections (or can’t get them) when meeting certain medical criteria vs. women who have that option available and consent to a section, then compare rates?

          • auntbea
            April 15, 2013 at 8:37 pm #

            The analogy to that argument is this: we know that the appendectomy rate is too high because there are many more appendectomies than there are people who die or get sepsis from appendicitis.

          • Siri
            April 16, 2013 at 2:43 am #

            No, because spontaneous labour is not analogous to an infected appendix. One is a disease process, the other isn’t. The analogy would be if the majority of removed appendices turned out to be free of disease, and even then it is unsatisfactory, because an appendectomy does not place you at risk of further appendectomies.

          • auntbea
            April 16, 2013 at 12:24 pm #

            Please explain to me why the fact that labor is not a disease process negates the analogy that c-sections and appendectomies are both done to prevent poor outcomes and therefore, if effective, will appear to be uncorrelated with them.

          • Eddie
            April 16, 2013 at 1:30 pm #

            Running with this analogy, both are abdominal surgery with all of the potential side effects from that, and in both, the death rate is higher if the surgery is not done. For an appendectomy, the death rate is quite a bit higher if the surgery is not done, but this is a matter of degree. For not doing an appendectomy, the primary side effect of the “natural outcome” is death, unlike a non-surgical delivery where as others have expressed there are serious non-fatal side effects possible.

            No analogy is perfect, but there are indeed many parallels here.

            I think a lot of argument is occurring here among people who really agree about most everything. Siri, no need to be defensive. Yes, people are challenging some of your arguments. A lot of these challenges, IMHO, are really of the type, “I don’t like how you put that,” as opposed to “you are totally wrong about everything.” I don’t think anyone is really challenging the facts you brought up. People are just trying to be sure that both sides are presented in a way that they like, in a way that seems balanced to them.

          • Siri
            April 16, 2013 at 2:24 pm #

            Cheers, Eddie! 🙂

          • fiftyfifty1
            April 16, 2013 at 9:38 pm #

            The rule of thumb the old time (pre CT scan) surgeons used to say was “If at least half of your appy operations don’t turn out to have a normal appendix after all, then you are waiting too long to be sure of the diagnosis before operating and you are going to kill someone sooner or later”.

          • Eddie
            April 16, 2013 at 9:48 pm #

            This is a great example of how as diagnostic imagery and other technologies improve, the previously necessary “interventions” become unnecessary.

          • LukesCook
            April 16, 2013 at 2:05 pm #

            “There are ways of keeping section rates down without sacrificing outcomes”

            Maybe, although you’d have to provide the details. The problem, as an individual mother, is that you don’t give a rat’s about “the outcomes”, as long as your baby isn’t one of them. Your mean-spirited insinuation, unsupported by any evidence, that the blame for brain-injured children lies with mothers who are acting perfectly rationally and justifiably to protect their own babies exposes more of you than I think you intended.

          • Siri
            April 16, 2013 at 2:28 pm #

            My mean-spirited what? Have you lost the plot? Are you drunk? Please go back, read my comments, and try again.

          • Amy Tuteur, MD
            April 16, 2013 at 2:50 pm #

            Whoa! There’s no reason to respond that way.

          • Siri
            April 16, 2013 at 3:23 pm #

            Sorry, Amy, I was just really shocked. I apologise. It’s upsetting to find that someone can misinterpret my comments like that. Anyway, I’ve already flounced off; just couldn’t leave without saying sorry. I still think you’re fabulous.

          • LukesCook
            April 16, 2013 at 5:13 pm #

            “And the most badly damaged babies I ever met, were born after a long labour with problems that built up very insidiously; they never went to theatre, because theatre was always full of other women having emergency sections for less than life-threatening reasons. So they missed out on what would have been a brain-saving operation.”

            So how should that statement have been interpreted?

          • Eddie
            April 16, 2013 at 5:40 pm #

            I, personally, would take that to say the hospital was routinely understaffed and/or didn’t have enough theaters.

            For the sake of argument, let’s assume that these mothers were having sections for totally frivolous reasons. Odd are they were not, but for the sake of argument, let’s run with that. It is the job of a hospital to properly triage so that when resources are limited, the most in need get the resources first. it’s not the job of the mother who is concerned — rightfully so — with her own well being and that of her to-be-born child or children to then worry about what others may or may not need in the hospital. She could not possibly have the context to be able to have good judgement in that area. It’s the hospital’s job to decide.

            So again, to me, this sounds like a failure of the hospital to 1) properly staff, 2) have enough theaters, and then 3) triage properly when they failed to meet demand.

          • LukesCook
            April 16, 2013 at 6:43 pm #

            Really? Siri has assisted at “countless” c-sections and delivered “hundreds” of babies, and all of the MOST damaged babies she ever saw were those who couldn’t get c-sections in time because the theatre was full of women having sections or less than life-threatening reasons? Not because the c-section was attempted too late, or not at all, not because the theatre was full of women having sections for life-threatening reasons, not because the theatre was full of people having their appendices or gall-bladders out (for less than life-threatening reasons, even), but ALL because of the women having c-sections not necessary to save the life of their baby (in Siri’s opinion)? In the unlikely event that this statement is true, the answer would seem to be to make more theaters available and perform emergency c-sections earlier so that it isn’t life or death by the time the mother is reluctantly offered a section. Is that what you meant, Siri?

          • Eddie
            April 16, 2013 at 7:32 pm #

            In the unlikely event that this statement is true, the answer would seem to be to make more theaters available and perform emergency c-sections earlier so that it isn’t life or death by the time the mother is reluctantly offered a section

            I can only answer for myself, but I absolutely agree with this.

          • LukesCook
            April 17, 2013 at 1:01 am #

            Yes, because if the interpretation you suggest is the right one, then this is the logical conclusion.

            With the entire thread as context, I’m reasonably sure that statement was offered up in support of the view that FEWER c-sections should be performed, because not only are most of them not necessary to save the baby’s life, but some of them are actually harming babies by jumping the queue and squeezing out those that ARE necessary. Since we all agree that one can’t tell which is which in advance, it would then follow that emergency c-sections should only be performed when and if the baby is at death’s door, and not merely in response to indications that there is a growing risk of something going seriously wrong. Is this how you believe the c-section rate can be lowered without sacrificing outcomes, Siri?

          • Eddie
            April 17, 2013 at 10:35 am #

            What Siri said, in full context, was:

            There are ways of keeping section rates down without sacrificing outcomes; the Scandinavian countries are an example.

            so I guess the question is: What do those countries do differently? My youngest brother, who married a Swede and lives outside Stockholm, has raved about the prenatal and delivery and child healthcare in Sweden. My belief is that Siri was talking bigger picture about how to improve things overall, and not, “given this specific bad example how do you improve it without adding money or changing other big picture things.”

            I think we all agree that in general, countries with higher C-section rates have better outcomes. But this correlation is not perfect. There’s a fair amount of scatter in the data. Is that scatter random, or are there truly countries with the same outcomes but different section rates? If the latter (which I believe is probably the case) then what are the countries with the same outcomes but different section rates doing differently, and do we care to learn from it?

            Finally, I agree with what someone else said earlier, paraphrasing, if C-Sections were made to be much safer even than they are already, that many, many more women would opt for one rather than experience labor. And I don’t have a problem with that. Of course, I don’t have any problem with purely elective sections either. It’s all about informed consent.

          • April 17, 2013 at 2:34 pm #

            Are there many small, narrow hipped Swedes?

            What is their Section rate anyway? Is it going up, down, stable? Birth rate, fertility problems, ages, poverty etc? I will take quite a bit of convincing that a low CS rate tells us anything much about a health system, as opposed to cultural attitudes.

          • The Bofa on the Sofa
            April 17, 2013 at 3:30 pm #

            so I guess the question is: What do those countries do differently?

            Have mostly Nordic people?

            Does the “they have better outcomes” claim take into account the difference in demographics?

          • LukesCook
            April 17, 2013 at 4:14 pm #

            The charts Dr Amy used to illustrate perinatal mortality rates in the piece about Dutch midwives didn’t fill me with admiration for the outcomes achieved by Scandinavian countries. Denmark, for example, comes off even worse than the Netherlands.

          • Eddie
            April 17, 2013 at 5:26 pm #

            Does the “they have better outcomes” claim take into account the difference in demographics?

            My guess is that no, they do not, because it is so very hard to do so and trust that you have correctly accounted for all confounding factors. Just as when people say that the US section rate is “too high.” We can clearly account for a lot of that as risk in American births that doesn’t exist at the same level in Europe, as people have discussed here in recent days.

            And from Lizzie Dee:

            What is their Section rate anyway? Is it going up, down, stable? Birth rate, fertility problems, ages, poverty etc? I will take quite a bit of convincing that a low CS rate tells us anything much about a health system, as opposed to cultural attitudes.

            I agree with you, because there are too many confounding factors.

            I am not personally arguing that any country “should” reduce its C-Section rate, nor that any country has a rate that is “too high.” I don’t feel informed enough to have an intelligent opinion in this area. I am just trying to show how I read Siri’s comments, how they came across to me in context.

          • Dr Kitty
            April 16, 2013 at 5:22 pm #

            You stated that the brain injured children you know are injured because their mother’s couldn’t access timely CS.
            You then said that this was because other women were having emergency CS for “less than life threatening reasons”.

            One could interpret that statement to mean that the women who GOT the CS for “less than life threatening reasons” are to blame for the brain injuries suffered by the children of the women who DIDN’T get CS. The implicit point is that because they selfishly used scarce resources on their “unnecessareans”, enabled by risk averse Drs, the children of other women were damaged.

            Now, I don’t actually think you meant to imply that, but I can see how someone could read your statement and take that away from it. Can you?

          • Sullivan ThePoop
            April 16, 2013 at 9:58 pm #

            There is only way one to lower C-section rates without sacrificing infants and that is and increase in other instrumental deliveries. We went to C-section instead because it is more reliably safe for both mothers and infants.

          • Sullivan ThePoop
            April 16, 2013 at 9:59 pm #

            That was supposed to be an increase not and increase

          • moto_librarian
            April 15, 2013 at 10:49 am #

            “. And most women would prefer a normal birth to a caesarean; after a normal birth the cessation of pain coincides with the baby’s arrival, whereas caesareans are pain free during, and painful after. They also carry risks for further pregnancies, and make for a much longer recovery period. This is not trivial; many women who would have liked to have more than two children choose not to conceive again because they can’t face another operation. And the only women who had emergency hysterectomies at my hospital had had sections”

            Well, the worst part of my unmedicated delivery was actually AFTER my son was born – manual examination of the uterus without pain medication is sheer hell – and my recovery was very long. The pain from my stitches from the cervical laceration required oxycodone for about 10 days, and it was 6 weeks before I really started to feel like myself again. I also had the added worry of wondering if I was going to end up with an incompetent cervix during my next pregnancy. A delivery is only low-risk in retrospect.

          • The Bofa on the Sofa
            April 15, 2013 at 11:36 am #

            I don’t disagree that “most women would prefer a normal birth to a caesarean,” but I wonder exactly how much is “most”?

            If you did a survey of women and asked, “If you were pregnant, and had your choice, would you prefer to have you child vaginally or by c-section?” what would be the result? More than 80/20? Less than 80/20? I don’t know, but anecdotally, I have heard plenty of women who have stated flat out that they would prefer to not have to go through a vaginal delivery (my wife among them). My 80/20 over/under is just made up, I realize, but I don’t think it is obviously wrong. I contend that 90/10 is almost certainly too high.

            Now, contrast that with the following question for women with children: “If you had a vaginal delivery, did you choose to have an epidural?”

            Given the extent of epidural rates these days, I wonder which would be higher, the number of women who would chose a vaginal birth over c-section, or the number of women who chose an epidural?

            (btw, note that you can’t actually ask “would you choose an epidural” because so many women try it without but then decide to go ahead and do it)

          • Siri
            April 15, 2013 at 1:01 pm #

            In my own experience, I have met three women who had truly elective (chosen by them) sections. All the rest have been a) failure to progress, b) fetal distress, c) abruption/cord prolapse/other rare emergency, d) elective for previous, e) elective for breech/twins/transverse lie, f) elective for prior traumatic vaginal delivery, g) elective for big baby/gestational diabetes/diabetes mellitus, or h) emergency/semi-elective/elective for other clinical reason. All the elective categories will contain some women who are pleased to have a ‘real’ reason to have a section, in other words women who would rather not try for a vaginal birth, but might not have felt able to ask for a caesarean ‘just because’. Of women with cephalic singleton term pregnancies, it is rare to encounter maternal request caesareans (but getting less rare); as risks start to go up (twins, breech, GD etc), these numbers shift. Anecdotally, I would say that more women want vaginal births (with the caveat ‘if everything is normal’) than epidurals prior to labour; during labour, epidurals become more desirable and caesareans more acceptable.

          • Siri
            April 15, 2013 at 1:06 pm #

            I distinctly remember requesting a general anaesthetic, an emergency caesarean and a bullet through my brain. Did I get my wish? Did I heck.

          • Siri
            April 15, 2013 at 1:07 pm #

            Bloody midwives.

          • The Bofa on the Sofa
            April 15, 2013 at 1:10 pm #

            Yes, of the women who get c-sections, there are going to be those who are “relieved” to have them (such as my wife). And given that purely elective (non-indicated) c-sections are not all that easy to come by, there are also going to be those who wanted a c-section but were denied, or didn’t bother to ask because they didn’t think they would get them (correctly or incorrectly).

            We know both forms exist, and I am asking how prevalent it is.

            I’ve sent an email to Pauline Hull. She might have an idea.

          • Eddie
            April 15, 2013 at 1:15 pm #

            I known of some people requesting non-indicated CS so their child could be born on a day and at an hour with a favorable horoscope. (I kid you not.)

          • Siri
            April 15, 2013 at 2:57 pm #

            Obstetricians face a problem that’s unique to them; even the woman who makes the most frivolous request for a section, could well end up with an emergency c/s. If I request a non-indicated kidney removal, the odds of me developing kidney cancer is very low. It must make it harder for OBs to say no categorically.

          • Siri
            April 15, 2013 at 2:52 pm #

            It’s difficult to establish accurate numbers, because of those that initially want sections and are denied or counselled out of them, some will have sections anyway, and as you say, some women won’t even ask. Oh, and Pauline Hull lives just down the road from me in Surrey; we share a post town. Do I get extra cookies?

          • The Bofa on the Sofa
            April 15, 2013 at 3:32 pm #

            It’s difficult to establish accurate numbers, because of those that initially want sections and are denied or counselled out of them

            Yes, it’s difficult to get accurate numbers by using THAT approach, which is why I didn’t suggest using that approach.

            If you did a survey of women and asked, “If you were pregnant, and had your choice, would you prefer to have you child vaginally or by c-section?” what would be the result?

          • Siri
            April 15, 2013 at 4:53 pm #

            Very different than if you polled those same women early, halfway and late in their actual pregnancies! Very, very different.

          • EmbraceYourInnerCrone
            April 15, 2013 at 2:19 pm #

            Personally I would choose a C-section if I had it to do over, I am 5 feet tall, small frame and had a 9 pound baby. Due to late decels/meconium they used the vacuum to get her out faster, I had an episiotomy and also I tore. I think I would have healed faster (and the incision would have hurt less in my abdomen!) or at least had pain killers to manage the pain if I had a CS. That I had a very fast labor and delivery(61/2 hours total) of a large baby probably didn’t help anything pain wise. The epidural helped but as I was 5 cm by the time they started it and I went from 5 to 9 cm in less than an hour(that was fun) it didn’t seem like it fully worked.

          • Siri
            April 15, 2013 at 12:38 pm #

            Ouch!! You had a really rough ride. Fortunately your experience is not the norm. Could you not have been given suitable anaesthetic? Perhaps there wasn’t time? I am sorry to hear you had such a terrible time. I bet the memory is hard to shift. Interestingly, I have seen many women who have had forceps deliveries after a primary caesarean, some even had ‘high’ forceps (Kielland’s, hardly ever used nowadays due to the potential for trauma), and they all said they felt great; some would practically skip down the hall. In contrast, after my own forceps delivery I felt mauled, traumatised and very vulnerable; it was my first experience of childbirth, of being at the mercy of my body and hospital staff. I have never had a section, but I always thought, wow, how painful must one be if a forceps delivery is so much easier to recover from? Every woman I have met who has had a VBAC (and there have been many) has been relieved and pleased. Even those who had forceps or ventouse.

          • Sullivan ThePoop
            April 16, 2013 at 10:13 pm #

            Absolutely! After I had my son, who was induced at 35.5 because I was leaking fluid, but natural other than that I had constant like bad period cramps and then when I had my first period I thought I was dying. I passed out from the pain. It turned out that a couple of really small pieces of placenta were not cleared and caused a type of endometriosis. Luckily all I needed was a D&C to clear it up. That is not as bad as your experience, but I was definitely in pain every day after I had my son until I had that D&C. I am probably lucky I formed scar tissue over them instead of getting an infection though.

          • fiftyfifty1
            April 16, 2013 at 9:06 pm #

            I agree. Risk is an unfortunate word choice. But Julia B is right in saying it is what is usually used. The problem is that “likelihood” is already used in a different technical term “likelihood ratio” that means something else.
            There are a lot of unfortunate terms in medicine. For instance “The patient complains of 3 days of cough” just means “the patient said he has had 3 days of cough” and doesn’t mean anything about being a complainer or whiner. And “The patient denies drinking alcohol” doesn’t mean you think the patient is lying or hiding something. But the worst of all is Borderline Personality Disorder. Don’t even get me started about what a crappy name this is.

          • Amazed
            April 16, 2013 at 10:06 pm #

            Fair enough. I don’t even have this much of a problem with the fact that “risk” is the word that is used. I have a problem with people trying to have me convinced just how risky, like full of risks, a c-section is and therefore the word is the right one. Surgery has risks – I don’t think there are any people who deny that. But the level of risk and potential benefit just isn’t comparable.

          • LukesCook
            April 15, 2013 at 3:27 pm #

            So would it also be a standard use of the word “risk” to say that you have a higher risk of pain relief in hospital?

          • Siri
            April 15, 2013 at 4:56 pm #

            No, you’d say, you’ll have more OPTIONS for pain relief in hospital; at home you can only have Entonox or pethidine.

      • suchende
        April 15, 2013 at 9:50 pm #

        I would rather have a section than a forcep delivery.

        • Eddie
          April 15, 2013 at 10:02 pm #

          Being absolutely ignorant about the matter, what is involved in forceps delivery? I know what forceps are, saw them in the delivery room, saw an example on a life-sized doll in a life-sized plastic pelvis in the class my wife and I attended before her one delivery in America. But that didn’t explain why or how it is so unpleasant.

          I did see the vacuum get used! It provided just enough extra “oomph” (that’s a technical word) that no other “interventions” (I dislike that word, as it strikes me as emotionally loaded) were needed. Moments later, I cut the cord myself. A powerful moment.

          But forceps … seems like it would be more uncomfortable to the baby. So I know I’m missing something.

          • Susan
            April 15, 2013 at 11:36 pm #

            Just my opinion but I have seen more complications from vacuum than forceps. They really aren’t totally interchangable; and vacuum appears more benign to the point some paint it as risk free. It appears to me what could be a difficult vacuum delivery might be an easy forceps delivery. What I used to teach when I taught prepared childbirth is that you can refuse anything but don’t tell your doctor which to use. Much of the time you can just refuse an operative delivery and have a cesarean, for instance if the assistance is just that the mother is exhausted and a little bit of help will get things over with. But sometimes its for a nonreassuring monitor strip, in that case I would go with whatever the doctor judges safest for the baby. It can be faster than doing a cesarean. I have wondered if some residency programs don’t teach doctors to use forceps because I have noticed that some OBs absolutely never use them. Still, I think if I was in an emergency and my doctor said forceps were indicated, that I would be glad the doctor knew how to use them. I’d rather have a doctor that is comfortable with either technique.

          • fiftyfifty1
            April 16, 2013 at 8:48 pm #

            All OB residencies teach forceps. It’s just that some teach them more than others. But the “old time” forceps techniques such as high forceps and complicated mid forceps deliveries are seldom if ever used. They were a big reason that the C-section rate was so much lower in the 1950s and 60s etc. But C-sections became safer and women started having smaller families so the risk/benefit ratio of c-section compared to forceps changed and now forceps are done much less often.

          • Becky05
            April 17, 2013 at 11:26 am #

            First, a large episiotomy has to be cut to make room for the forceps inside the vagina alongside the baby’s head. Serious tears, including through the anal sphincter, are more common with forceps deliveries compared to spontaneous ones. Forceps deliveries increase the risk of long term issues with fecal and urinary incontinence.

            The pressure on the baby’s head by the forceps can cause bruising, which is a minor problem, but can also cause nerve damage. The use of forceps increases the risk for intracranial bleeding.

            You can read more here:

            Now, that doesn’t mean that forceps shouldn’t be used at all. They have their place, but they do have some significant risks. If one can reduce the need for assisted delivery and increase the rate of spontaneous vaginal delivery without negatively affecting other outcomes (such as by ignoring a baby in distress) then that is a good thing.

          • Eddie
            April 17, 2013 at 12:19 pm #

            Wow. That explains it very thoroughly. Thank you. This list of problems was not at all obvious from the demonstration in the pre-birth class! Thanks also for the link.

          • auntbea
            April 17, 2013 at 12:58 pm #

            Can the forceps do anything a vacuum extraction can’t do? And is there usually indication that they will be necessary before the baby is in the birth canal? As in, are people choosing forceps over a section, or are they getting surprised?

          • Becky05
            April 17, 2013 at 9:33 pm #

            “Can the forceps do anything a vacuum extraction can’t do?”

            In my understanding, they can be used to help turn a baby with a malpositioned head, which a vacuum can’t. I think there are some other times they’re more appropriate. Delivery tends to be quicker with forceps, according to what I was reading the other day. And vacuum has risks, too.

        • Siri
          April 16, 2013 at 2:57 am #

          And am glad, in spite of the trauma, I did have forceps; had I had a section, there is no way I would have gone on to have four more children. Two would have been my limit. And I rather enjoy my three youngest.

        • theNormalDistribution
          April 16, 2013 at 11:22 pm #

          On a somewhat unrelated note, this post led me to decide to learn a little more about forceps deliveries. So I’m sitting in a study room taking a break from studying and watching a video of a baby being delivered, and as the doctor cuts an episiotomy, ignoring the horrific gush of blood while he continues to manipulate the baby’s head out of the mother’s vagina, I start to feel like I may vomit or pass out. I’ve never passed out from anything other than not having eaten or accidentally poisoning myself with modelling glue fumes, so it took me a really long time to realize that it was actually the video that made me feel sick.

          Fuck you, nature.

          • Eddie
            April 17, 2013 at 10:37 am #

            While I completely believe you and others who have said this, I cannot picture in my head what is bad about forceps deliveries. Is this something that can be explained? The way it was shown in the hospital’s pre-delivery class my wife and I took didn’t seem that bad, so clearly I am missing something.

          • Amy Tuteur, MD
            April 17, 2013 at 10:48 am #

            It always seemed to me to be like picking up your baby by the head using salad tongs.

          • Guestll
            April 17, 2013 at 11:15 am #

            My mother (retired L&D nurse) had a mid-forceps delivery with her fourth pregnancy. Three previous unmedicated, uncomplicated vaginal births, all babies between 6 and 7 lbs. Then she quit smoking, quit working, and grew a fourth baby (me) who was posterior, weighed almost 9 lbs, and who did not tolerate pushing well at all. She said that in retrospect, she’d rather a section than forceps — she found the recovery quite difficult.

          • April 17, 2013 at 2:23 pm #

            Believe it or not, I am quite suggestible, and I would love to be convinced that birth is, after all, safe. When I read that X is a variation of normal, and Y does not always lead to disaster, I WANT to believe it. I can, nearly, believe that forceps are not always that bad, certainly willing to believe that vacuum may be a better bet than a CS. But have you SEEN them? I think I would have died of fright at the prospect.

            That must have been some very soft focus film they showed you. Maybe, in the hands of an expert, and when things are not too fraught, one barely notices. Still not for me, thank you.

            I found this link, which definitely reinforces my prejudices, even though I know the Daily Mail is an awful joke of a newspaper.


          • Eddie
            April 17, 2013 at 5:10 pm #

            They did use vacuum on our littlest, and it seemed quite innocuous. I remember that it did leave a little mark — not quite a bruise — that faded after a couple days. My wife could not quite push hard enough, and the vacuum added just enough extra oomph.

            In the class, they showed an actual set of forceps on a life-sized infant doll with a fake female pelvis skeleton. If it had been a movie showing cutting a a large episiotomy so both forceps and baby would fit, it would have been VERY clear! But it was just a skeleton of the pelvis region only. With no visible soft tissues, it was not obvious at all that there wouldn’t be room for both the forceps and the baby.

          • Dr Kitty
            April 17, 2013 at 5:12 pm #

            Eddie, are you familiar with Sly Stallone?
            His unique speech is a result of nerve damage from a forceps birth injury.

            Forceps are roughly the size of salad tongs. No woman wants those in her vagina, especially with someone hauling in the other end.

            I’ve spoken to a lot of women, and forceps recovery is considered worse than CS by many.

          • April 17, 2013 at 11:36 am #

            I have read in a vague and desultory way that there is a form of lunacy which arranges for adults to re-experience birth. Maybe this should catch on and be made more realistic, so that we could all experience getting in the optimum position and wriggling down a tight tunnel. If you get stuck, you can have the option of a)suffocating b) having your head grabbed by forceps and hauled out or c) using an escape hatch that ends your misery.

            Of course, as sentient adults we would be aware of what was happening so not quite equivalent. But the idea that babies are fazed by bright lights or spending two minutes away from mother but are not put out by forceps has never made much sense to me.

            I know three mothers of children with CP who had forceps deliveries.

          • Squillo
            April 17, 2013 at 2:14 pm #

            Apparently, in some cases it’s all too realistic; a few years ago, a practitioner of “re-birthing” was convicted of child abuse leading to death stemming from the suffocation of an 11-year-old whose parents believed she was suffering from an attachment disorder.

    • Grumpyshoegirl
      April 12, 2013 at 6:38 pm #

      I quit reading the ICAN list (and flounced pretty angrily, though I didn’t stick around to see how it was received) when people posted about the birth of a list member whose baby died of a nuchal cord at a homebirth. They were all happy because “at least she got her VBAC.” Sadly, the number of women reading that list who planned pregnancies SPECIFICALLY to “get” a VBAC was staggering.

      • April 12, 2013 at 7:11 pm #

        That is horrifying. The only reason I would contemplate pregnancy and child birth is to have a child, since I don’t find either one intrinsically valuable enough to go through them without getting a healthy child.

        • auntbea
          April 12, 2013 at 8:24 pm #

          Pregnancy is fun (assuming you are not sick the whole time.) Lots of attention, cute clothes, so much chocolate. I would do that again in a heartbeat. Childbirth? Not so much.

          • LynnetteHafkenIBCLC
            April 12, 2013 at 8:49 pm #

            I liked childbirth; people surrounding me, caring about everything I was feeling, encouraging me, bringing me whatever I wanted, and at the end a blissful relief and joy in seeing my baby. Pregnancy however, felt like an alien life form taking over my body in many painful and embarrassing ways.

          • April 13, 2013 at 7:02 am #

            The problem is the distance between the myths – the public, accepted version – and the reality.

            When I was young, the accepted myth was that Wife and Mother was the best, the must fulfilling, very nearly the only acceptable role for a woman. And it was the first of those that ranked highest. 70s feminism dismantled the idea that a meal served on time (with a smile and make-up in place, children out of sight) and a shiny clean kitchen floor was the pinnacle of achievement – but left the second not only intact, but ripe for a whole new level of oppressive myth making.

            I found pregnancy – and birth, if I can count my very abnormal experiences – fascinating. A whole new world of getting in touch with something or other, something mystical, elemental and profound. Ditto for certain aspects of mothering. The whole thing does put women in a special, maybe privileged, space. It is also a trap, a pit you can fall into. Being a Birth Goddess, or a Queen Bee Housewive can only be achieved by settling for being Less Than and buying into roles that serve some rather dubious ends – and still allow the things that women need to be marginalised and ignored. As someone recently said, we are not delicate little flowers, but by prettifying birth and mothering, we do reduce it and surrender a whole lot of the power that could be used more constructively.

            Politicians, legislators and other powerful figures who shrug off the realities (especially the plight of women in less priveleged places) in the name of “supporting” women infuriate me. It is patting us on the head in the hope that we will stay quiet.

          • KarenJJ
            April 13, 2013 at 8:34 am #

            “It is patting us on the head in the hope that we will stay quiet.”

            I always enjoy your posts, but this line especially, is how I feel about this study. And, the recent ruling by the judge about the lawsuit, come to think of it.

          • The Star-Spangled Whapio
            April 14, 2013 at 5:12 pm #

            Hatting us on the head, you mean. Attempted murder.

          • Squillo
            April 12, 2013 at 10:08 pm #

            Not me. Pregnancy was miserable. Birth was a lot shorter and more fun for me.

          • Amy
            April 12, 2013 at 11:05 pm #

            Ditto! Hate being pregnant, LOVED my unmedicated births (in hospital). The top three best things about giving birth for me: 1) healthy babies 2) NOT being pregnant anymore 3) overall birth experience.

          • Sullivan ThePoop
            April 13, 2013 at 12:01 am #

            I didn’t mind being pregnant too much except with my last. I was 80% efface at 7 months and I would wake up either in pain or not being able to feel one leg. Either way I had to pee and sometimes I would have to crawl to the bathroom. It also affected other functions which had a lot to do with the pain.

          • fiftyfifty1
            April 16, 2013 at 8:35 pm #

            Boy I wish there were some way to clone your birth experiences. Good births are really lovely aren’t they?

          • Eddie
            April 16, 2013 at 8:46 pm #

            My mother has always said that she absolutely loved everything about being pregnant. The best thing I’ve heard her say about delivery, however, is that for my younger brother, she was glad when the water broke all over the face of the no-bedside-manner, grating, paternalistic OB who was handling the delivery. 🙂

            In my case, the water broke a week before labor started so she walked around for a week leaking, and I was still premature. I’m pretty lucky I didn’t get infected. People complain about being induced, and for my wife, it definitely got more painful after the induction. (As I’ve said before, she LOVED the epidural.) But the alternative … people forget the alternative.

            It gets back to the famous quote that people who forget history are doomed to repeat it. (Or however that goes exactly.)

          • April 15, 2013 at 1:26 am #

            OMG! My pregnancy was the worst experience of my life! I know most people don’t spend their pregnancy in a hospital bed for months, but I did! I literally have nightmares I’m still on bed rest! The csection was awesome just wonderful! The recovery was sheer Hell! Ouch!!! Breastfeeding sucked for the first 4 months! Having an oversupply is really difficult and I wasn’t prepared because I only thought undersupply was an issue. However, havinh a baby is amazing and the best thing to ever happen to me! The way he laughs at me, hugs me and wrinkles his nose in pleasure! I’m so in love with him! Crazy how many different emotions and physical sensations I experienced through the whole process to this point!

          • Karen in SC
            April 15, 2013 at 7:07 am #

            did you ever get any closure on your botched-up recovery? Glad to hear the baby is amazing!

          • KarenJJ
            April 13, 2013 at 8:30 am #

            I loved pregnancy. Felt better than I’d been in ages once I got past that first 12 weeks (and even then I only had some nausea – wasn’t very sick). Turns out it had sent an undiagnosed condition I had into a kind of remission.

        • desiree
          April 13, 2013 at 3:54 pm #

          I mostly agree with you Anj, but there is a slight possibility that I will get pregnant again just for pregnant sex… mmm… Ok, pregnant sex AND the amazing rack I grow when I’m nursing.

      • Dr Kitty
        April 13, 2013 at 9:15 pm #

        I puked a lot . Zofran was a godsend, but only because it kept me out of hospital, not because I felt much better with it.
        I had the most lovely, chilled out, peaceful birth-it was a planned pre labour CS at 39 weeks, but I think it was actually the best thing that could have happened.

        But I put up with months of nausea and another surgery so that we could have our cute little madam, who says “oh you silly thing” when she puts her shoes on the wrong feet and loves “family sandwich” where she gets to be the peanut butter in a cuddle with her parents.

        Being pregnant isn’t the goal, being a parent is the goal.

        • April 14, 2013 at 7:46 am #

          I am a big fan of experience as a teacher. We all have ideas in our head of how things are or ought to be, but experience does sometimes lend authority – so long as you remember that the lessons can still be subjective. Pregnancy and birth are definitely experiences that teach, but we ain’t all going to learn the same things. I very mildly regret missing out on the vaginal birth bit – not because I feel I was deprived of a birth rite, but because I have no basis on which to argue “That was not my experience” Generally I believe that for most it is a fairly horrible experience cancelled out by a happy ending, excitement and a sense of triumph and that pinning your hopes and dreams on a choreographed birth is foolish. I cannot believe that in the last few years the idea that gritting your teeth through natural brings some special reward has taken such a hold. I happen to believe that my very negative experiences taught me a lot, and made me a better mother. (Not better than you – better than I might have been if it had all been easy.) When it looked like I might not have a living child – might never have a living child – I did comfort myself with not having entirely missed the experience, but it would have been very cold comfort indeed if things had gone badly.

          My pregnancy was not that bad – low risk, you know. I loved the feeling of a baby kicking. Regardless of the law, mine were people from that point on.

          • Siri
            April 14, 2013 at 5:20 pm #

            A fetus first becomes a baby in her mother’s mind. It’s the only relevant cut-off point. The baby’s soul enters the body when her mother acknowledges it and claims it as hers.

          • Poogles
            April 15, 2013 at 3:53 pm #

            “The baby’s soul enters the body when her mother acknowledges it and claims it as hers.”

            So, if a woman is pregnant without realizing it and goes into labor, does the baby not receive a “soul” until she realizes she isn’t dying and is just in labor and about to have a baby? What if a woman goes into a coma before finding out she is pregnant and does not regain consciousness until after the baby is born, at what point does the “soul” enter the baby then? What if the mother “acknowledges” the fetus, but doesn’t claim it (plans to give up for adoption perhaps)?

            Personally, I’m an atheist, so I don’t believe in anything like a “soul”, I’m just wondering how this logically works for someone who does believe in such things…

          • Susan
            April 15, 2013 at 6:43 pm #

            Yes, how does that work? I have seen some women give birth in total denial (rare) but it happens. So is that why there are zombies in this worldview? Since there mothers never admitted the babies existed do they never become human? Might make an interesting unscience fiction/horror book.

          • fiftyfifty1
            April 15, 2013 at 9:41 pm #

            All of you are full of shit. Everybody knows that the baby’s soul enters the body when the mother pushes it out of her divine yoni. Zombies are C-section babies, natch.

          • Eddie
            April 15, 2013 at 10:04 pm #

            That proves it. The soul is made up of bacteria. We’ve just solved the riddle of the ages. This also explains the appeal of water births.

          • Siri
            April 16, 2013 at 2:40 am #

            Zillions and zillions of tiny, crawling soul-germs… Ewwwww.

          • fiftyfifty1
            April 16, 2013 at 8:32 pm #

            Yes, this is the reason that the soul lives on after the body dies. Because the soul is actually bacteria, zillions and zillions of bacteria.

          • Siri
            April 16, 2013 at 2:38 am #

            You’ve stumbled upon a gruesome secret. I will have to kill you now, or at least render you undead.

          • Siri
            April 16, 2013 at 2:35 am #

            Actually, I am one too – it was meant as a statement in favour of maternal choice, whereby no one besides the mother has any right to dictate when a fetus becomes a baby. The soul bit was just a bit of fluff, because I recall someone talking about the soul entering at conception. For soul substitute personality, personhood, whatever. Truly undiagnosed pregnancies are rare, and were not included in my little comment. Ditto women giving up babies for adoption, which thankfully is also rare. You noticed I said claims it as HERS. Anything else I can help you with?

          • Siri
            April 16, 2013 at 2:37 am #

            Oh, and the woman in a coma? Her baby doesn’t get a soul. Sorry, but even atheists have to have limits.

          • April 16, 2013 at 3:54 am #

            Aww, I had a little rant all ready to go about how atheists don’t actually think souls exist, and then you ruined it by showing that you already knew that. I can’t tell that you were simply using an analogy, and with religion so common in this country (assuming you live in the US), most people would take that as you actually believing that souls are a real thing.

          • Siri
            April 16, 2013 at 2:22 pm #

            Not religious, not in the US, just a Scandinavian atheist feminist living in the UK..

          • April 16, 2013 at 3:59 pm #

            Ah cool. I’m too used to people being entirely literal about souls. It’s a common argument used against women’s reproductive choice in the US (but zygotes have soouuuls!), so I get twitchy about it sometimes.

          • April 16, 2013 at 5:15 am #

            A mother owns her body, but she doesn’t own her child once it is capable of independent existence outside her body. That is a dilemma that it quite hard to solve, as you cannot force a mother to abandon her own rights, but in my view can’t regard the child as disposable or abstract either.

            I don’t believe in souls either, but it is a useful signifier for acknowledging the otherness, the potential personhood. In a post anaesthetic haze, I thought I was still pregnant, still had the inner child AND one in NICU, which was temporally weird.

  15. Eddie
    April 12, 2013 at 11:00 am #

    The study as written was so flawed that no single language change will improve it. I could just as well study auto safety and come to the conclusion that station wagons are safer than sports cars because fewer people die in station wagon accidents than in sports car accidents. I am not convinced that they controlled for *why* people chose to have a home birth or a hospital birth, for example.

    They also confuse the “direct entry” midwives of other countries with the DEMs of the United States, as if they are similar. They also don’t comment on whether hospital births attended by a midwife were transfers or were intended to be hospital births. I could go on, but I won’t.

    Finally, their grammar and spelling errors convince me that they were just not very careful overall. Maybe this is unfair. Maybe this is my generation. But when I see any published paper with such obvious spelling errors and poor grammar, I doubt the care taking in the whole thing.

    • fiftyfifty1
      April 12, 2013 at 11:26 am #

      Yes a lazy and sloppy paper. It is unbelievable that the discussion did not even mention that most of the studies they cite are from countries where “direct entry” midwives are trained in rigorous university programs. The lead author, John Ehiri, must be aware of this as he trained in the UK. Is he attempting to hide this very important difference or is he too lazy to mention it? Or perhaps this paper was written by the co-authors and he just rubber-stamped it to get another publication to his name? Very embarrassing for him.

  16. KarenJJ
    April 12, 2013 at 10:59 am #

    The entire reason I was pregnant was because my husband and I wanted to have a baby. The decisions made during pregnancy (to not drink much alcohol, to not take certain medications and at one stage to not take a much needed medication to control my immune system), were done so with the health of the baby in mind. The decision to be conservative and move to a c-section fairly early during labour and the decision to go through IVF to start with, were all done largely at the expense of my health in order to have a healthy baby.

    It beggars belief that people forget what women put themselves through to get that baby and that there are so many hopes and desires involved in getting pregnant and having a baby. To continually ignore some of these issues in the US seems crazy. We should be demanding the best evidence, not this sort of mealy-mouthed rubbish. We are not fragile little flowers that can’t handle the truth.

    • Captain Obvious
      April 12, 2013 at 1:20 pm #

      Exactly, if you want to have a good pregnancy experience and the risk of fetal or neonatal death is just an unfortunate hiccup then I have a pregnancy itinary that will blow all other pregnancy experiences away. Other mothers will be jealous of how great your pregnancy experience was. First off, after we diagnosis your pregnancy with a first trimester ultrasound we are going to celebrate! To the bars, drink and party til morning. The. We are going to plan a vacation because, you know, once the baby is here, we will have to delay any vacations for awhile. Lets go to Jamaica and climb Dunn’s River Falls and swim with dolphins in Ocho Rios. Then go tubing on the White River followed by zip lining through the jungle and scuba diving . Later on in the pregnancy we’ll go to Horse back riding and ATV riding through the dunes on the beaches this summer while we eat Tuna sushi and white wine. What, can’t stay awake? Try some red bull to keep up. You will need it for what we have planned next. “Unfortunately, births attended by my experience package increase safety concerns for the child.”

      • April 14, 2013 at 6:57 pm #

        perfect.. except that: even the purveyors of these tourist sites are smart enough to know when the thrill of the experience can be overshadowed by injury involving a pregnant woman and her fetus! read the fine print of the tour sites.. they all say ABSOLUTELY NO PREGNANT WOMEN allowed.

  17. Antigonos CNM
    April 12, 2013 at 10:39 am #

    i would change the text considerably: that home birth MAY be NEARLY as safe IF the woman is low risk, and the midwife is a CNM with OB backup. However, the text as written makes no mention of [1] inadequately trained midwives who [2] accept high risk patients and [3] have no emergency fallback whatsoever. Since the very word “midwife” is, in the US at any rate, so imprecise, it cannot be used with any degree of reliability unless precisely what kind of midwife is meant. Nor can the term “low risk” be used without explication since there are midwives who regard nearly all high risk patients as “variations of normal”.

    It’s a classic case of setting out to prove a pet theory, getting data which contradicts that theory, and then refusing to accept the data as “biased”.

    Theory: the sun rises in the West
    Data shows that the sun rises in the East, but…
    We will continue to postulate that there isn’t really any reason why the sun shouldn’t rise in the West.
    Conclusion: more studies are needed

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