Midwives are panicking over a new study.
According to the Society for Maternal Fetal Medicine, where the data was presented last week:
[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Interventions improve birth outcomes and letting nature take its course in pregnancy is far from the best decision.[/pullquote]
In a study with more than 6,100 pregnant women across the country, researchers randomly assigned half of the women to an expectant management group (waiting for labor to begin on its own and intervening only if problems occur) and the other half to a group that would undergo an elective induction (inducing labor without a medical reason) at 39 weeks of gestation. Results include:
• Lower rates of cesarean birth among the elective induction group (19%) as compared to the expectant management group (22%)
• Lower rates of preeclampsia and gestational hypertension in the elective induction group (9%) as compared to the expectant management group (14%)
• Lower rates of respiratory support among newborns in the induction group (3%) as compared to the expectant management group (4%)“Safe reduction of the primary cesarean is an important strategy in improving birth outcomes,” said William Grobman, MD, MBA, who presented today’s findings and is professor in obstetrics and gynecology at Northwestern University’s Feinberg School of Medicine. The research presented is part of, “A Randomized Trial of Induction Versus Expectant Management,” more commonly referred to as the ARRIVE Trial, which was funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD).
You can read the brief presentation here:
…Women in the IOL [induction of labor] group delivered significantly earlier than those in the EM [expectant management] group (39.3 weeks (IQR 39.1 – 39.6) vs. 40.0 weeks (IQR 39.3 – 40.7), p<.001). The primary perinatal outcome occurred in 4.4% of the IOL group and 5.4% of the EM group (RR 0.81, 95% CI 0.64 – 1.01; p = .06). Need for neonatal respiratory support was significantly less frequent in the IOL group (Table). The frequency of CD was significantly lower in the IOL group (18.6% vs. 22.2%, RR 0.84, 95% CI 0.76 – 0.93), as was preeclampsia/gestational hypertension (Table). A priori baseline subgroup analyses showed no differences by race/ethnicity, maternal age > 34 years, BMI > 30 kg/m2, or modified Bishop score < 5 (all P-values for interaction > .05) for either the primary perinatal outcome or CD. IOL at 39 weeks in low-risk nulliparous women results in a lower frequency of CD without a statistically significant change in the frequency of a composite of adverse perinatal outcomes.
This is not surprising. It confirms a variety of studies that have been published in the last 6 years. The central reality of the timing of labor is this, which graphs the risk of stillbirth against the length of pregnancy.
Contrary to the claims of natural childbirth advocates that babies are “not library books due on a certain date,” there is an optimal time to be born and the death rate rises on both sides of that optimal time.
We’ve known that elective induction decreases perinatal mortality:
Stock, Sarah J., Evelyn Ferguson, Andrew Duffy, Ian Ford, James Chalmers, and Jane E. Norman. “Outcomes of elective induction of labour compared with expectant management: population based study.” BMJ 344 (2012): e2838.
Induction improves maternal and neonatal outcomes:
Gibson, Kelly S., Thaddeus P. Waters, and Jennifer L. Bailit. “Maternal and neonatal outcomes in electively induced low-risk term pregnancies.” American Journal of Obstetrics & Gynecology 211, no. 3 (2014): 249-e1.
Induction lowers the risk of C-section:
Mishanina, Ekaterina, Ewelina Rogozinska, Tej Thatthi, Rehan Uddin-Khan, Khalid S. Khan, and Catherine Meads. “Use of labour induction and risk of cesarean delivery: a systematic review and meta-analysis.” Canadian Medical Association Journal 186, no. 9 (2014): 665-673.
Obstetricians have been discussing the wisdom of recommending routine 39 week inductions for years. The issue was debated at the 2016 ACOG annual meeting, with Dr. Errol Norwitz recommending routine induction:
“Nature is a terrible obstetrician,” he said, referring to the “continuum” of pregnancy and birth: the large number of zygotes that never implant, the 75 percent lost before 20 weeks, and stillbirth.
And, he said, the risk of stillbirth and neurological injuries rises after 39 weeks. “Stillbirth is a hugely underappreciated problem,” he said. “There are anywhere between 25,000 to 30,000 stillbirths a year in the United States.”
And Dr. Grobman himself explored the issue in a 2016 commentary in The New England Journal of Medicine.
In this issue of the Journal, Walker et al. … report the results of a trial in which more than 600 women who were at least 35 years of age were randomly assigned to labor induction between 39 weeks 0 days and 39 weeks 6 days of gestation or to expectant management. This study was powered to detect at least a 36% relative difference between the two groups in the frequency of cesarean delivery. A total of 32% of the women assigned to the induction group, as compared with 33% of the women assigned to the expectant-management group, underwent a cesarean delivery (relative risk, 0.99; 95% confidence interval, 0.87 to 1.14). There were no significant differences between the groups in other adverse maternal or perinatal outcomes, but such outcomes were uncommon…
The authors note the need for “a larger trial to test the effects of induction on stillbirth and uncommon adverse neonatal outcomes.” I am the principal investigator of such a trial (ClinicalTrials.gov number, NCT01990612), which is currently under way …
It is this study that is being reported now.
Midwives are appalled and nurse midwives have rushed to reaffirm their support of “normal physiologic birth”:
ACNM President Lisa Kane Low, PhD, CNM, FACNM, FAAN cautioned against any rush to change practice … “ACNM has consistently noted there are a number of potentially negative implications when we disrupt the normal physiological processes of labor and birth,” Kane Low said. Research related to the longer-term effects of induction of labor is emerging, but is still insufficient to determine its full impact. Additionally, spontaneous labor offers substantial benefits to the mother and her infant, as ACNM has affirmed in its Consensus Statement on Physiological Birth.
She wrote on Facebook:
What’s missing is the focus on process …
Wait, what? Induction at 39 weeks improves multiple outcomes — lowers the C-section rate, lowers the rate of pre-eclampsia, lowers the need for newborn respiratory support — and Kane Low thinks we should focus on process instead of outcomes? Really?
I’m not surprised midwives are panicking about this study. It undermines the entire raison d’etre of contemporary midwifery theory, the belief that birth in nature is better than birth with interventions. This study shows in the clearest way possible that interventions improve birth outcomes and letting nature take its course in pregnancy is far from the best decision.
Of course, everyone except contemporary midwives have known that since the beginning of recorded history. Midwives were in charge of childbirth for more than 1,000 generations and the perinatal and maternal mortality rates were hideous throughout. It took modern obstetrics only 3 generations to drop the neonatal mortality rate by 90% and the maternal mortality rate by more than 90%.
Midwives did a terrible job when childbirth was midwife-led and childbirth is just as dangerous as it has ever been. Indeed, in every time, place and culture, childbirth has been a leading cause of death of young women and THE leading cause of death in the 18 years of childhood. No matter. Contemporary midwives believe that increasing their market share and profits depends of pretending that childbirth is safe and that obstetricians (the folks who reduced neonatal and maternal mortality by 90%) are the ones who made it dangerous. Many of them even believe it.
Midwives have proceeded to whip up a moral panic over the issue of C-sections and interventions. As I noted last week:
A moral panic is a widespread fear, most often an irrational one, that someone or something is a threat to the values, safety, and interests of a community or society at large…
This moral panic serves to reinforce and strengthen the social authority of midwives. They fear they are losing control of childbirth and they are desperate to gain it back.
It is too soon to change clinical practice based on these findings; we haven’t yet seem the complete paper. Moreover, extraordinary claims require extraordinary evidence.
I suspect that evidence will be forth coming. It makes sense considering what we know about pregnancy and about C-sections. The most common indications for a first C-section are a baby too big to fit or possible fetal distress. Babies are smaller at 39 weeks than anytime thereafter (they gain approximately a half pound a week at this stage) and the placenta is usually in optimal condition. It’s hardly surprising that babies are more likely to fit and less likely to experience fetal distress.
Given the amount of evidence that already exists, we should share this information with pregnant women so they can decide for themselves if they wish to be induced at 39 weeks. Medical ethics demands that we share what we know with our patients, not withhold the information in order to pressure women into a decision the provider might prefer. That goes for midwives as well as obstetricians.
I predict that going forward we will hear a lot from midwives about “nuance” and putting the findings “in perspective.” They are going to do everything they can to ignore the scientific evidence for as long as they can. Their profits depend on it, but more importantly, their fundamental beliefs depend on it and most people don’t give those up without a tremendous fight.
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Here are some fun screenshots; they said I was marked as a “spammer,” so I saved them:
I think that’s what people tend to do around here; and the closest real hospitals are all an hour and a half away. I’m told most people schedule an induction so they don’t have to use the local “hospital” or drive that far while in labor.
I’d also bet that you have better outcomes in part because everyone knows to expect you, you are more likely to get the doc you know, and the doctors and nurses are less likely to be exhausted already.
I don’t like this. But it’s OK – we don’t always have to like facts, we just have to use them.
Mmmm, this is a lot of food for thought.
“DON’T PANIC!”
And carry a towel. ^_^
“Mostly Harmless”.
So long and thanks for all the fish!
On topic, my own personal anecdote and a really happy induction birth story: I had my third baby two weeks ago. Elective induction at 39+2: cervadil over night, but still only 2cm; pitocin in the morning and then my doctor broke my waters. Contractions picked up right away, and I requested an epidural about half an hour later (after two unmedicated homebirths, I loved loved loved my epidural, btw! :-D). 45 minutes later, I was free of pain and very happy. I progressed from 4 cm to complete in less than 90 minutes, the doctor was called, and my baby was born in one contraction (three good pushes!). It was amazing!!! My favorite birth of them all 🙂 All in all, it took less than 4 hours from starting the pitocin to holding my baby in my arms.
The induction helped us plan for our two older kids (my father-in-law, who lives 14 car hours away, arrived the night before to stay home with them while my husband and I spent three nights in the hospital) and, more importantly, it helped me make sure I would be able to receive an epidural in time (my second child was born in less than 4 hours from start of contractions, too). I had a lot of very bad anxiety about this labor because my other two experiences had been somewhat traumatic, especially because of the pain. I cannot stress enough how important it was to me to make sure I would not have to go through that again.
Tldr: I loved my elective induction at 39+2! 🙂
By the way, it wasn’t easy to get the doctors in my practice to agree to the elective induction. In the end, my OB granted me the induction only because she saw how terrified I was of labor starting naturally and me not making it to the hospital in time for an effective epidural. From what I gathered at the hospital, she was very happy when, after the cervadil, my bishop score had increased to a six, because otherwise she would have had to answer questions in front of some commission or review board (?) to explain why she induced me before 40 weeks.
Congratulations on the safe arrival and an awesome birth!! That sounds absolutely wonderful; I’m so glad your doctors listened and made it as easy as possible.
Thank you, Mishimoo! 🙂
Congratulations! I’m so happy to hear that you had such a good birth!
I also love this birth story!!! What a great & happy birth!
Congrats!
Congrats! *clap* Boy or girl? Unless you’d prefer not to share.
It’s a girl 🙂
Thanks for all the kind responses!
Question: does this study suggest that bishop score may not be an important factor in decision making for elective induction? The groups didn’t differ in their score <5 and over 60% of patients were unfavorable. I thought the other most recent study required a certain bishop score (but I could be wrong).
I wondered that too. I was offered elective induction vs c-section but my OB said that because my bishop score was 0 and I showed no signs of readiness (I’m sure there’s a more technical way to say that), that he expected I would labor and then still need CS. I have zero regrets about going with CS, but am curious about this.
So here is my understanding: the Bishop score IS useful in predicting the likelihood of a particular induction working. For instance if you are a woman at 39 weeks who presents for induction and your score is high, your chance of a vag birth are better than if you happen to show up that same day with a low score. In the past, this fact was used to guide recommendations: if your score was high then go ahead with an elective induction, if your score was low then don’t (obviously if baby had to come out for medical reasons you would go ahead anyway.)
But here’s the thing–a woman doesn’t have the choice between a high vs. low Bishop score at 39 weeks. She has the score she has. If she has a high score, then lucky her (obviously even luckier would be to walk in at 39 weeks already in active labor.) If the woman at 39 weeks has a low Bishop score, she is not so lucky. Her choice is to induce that day (probably with cervical ripening agents to help her score) vs. watchful waiting hoping that her Bishop score improves on its own and that in the meantime her baby doesn’t get too big and her placenta doesn’t degrade too much. There are a lot of ifs there. There is no guarantee that the B score will improve any time soon, while it is pretty likely that the placenta will age and almost certain that the baby will grow (half pound per week.) So they did the trials, and it turned out that the best bet is to induce at 39 even with a low Bishop score.
(And that is not even counting the stillbirths that are bound to occur during watchful waiting. Rare of course, but obviously devastating. The trials have not been huge enough yet to prove a reduction in these rare events with sufficient statistical power.)
Univ of Penn has put out an induction calculator. Interesting to play around with the questions to see the modified Bishop Score and prediction of C-Section. http://www.uphs.upenn.edu/obgyn/labor-induction-calculator/
Of course, this does mean that gestational age has to be accurately calculated, and that can be problematic. In the US there still are significant numbers of women who have either no, or inadequate, antenatal care.
Sure. But who is talking about inducing early when dates are not known?
Which is riskier: Induction at 38-40 weeks (“early”) or waiting to 40-43 weeks (post-dates)?
Personally, I’d rather be on the “early” end of the spectrum, but that’s just me. Admittedly, I did have a MRCS, so I clearly failed at natural birth. I also formula fed, so the EBF thing was a big fail on my end as well.
I don’t think that is even close, is it? Given the full ranges you list.
The only way it’s even close is if you compare the induction near 40 weeks with the delivery near 40 weeks. But even in that case, it’s not overwhelmingly better to wait.
But by the time you are talking induction at 39 weeks vs waiting to 41? I think that’s pretty clearly in favor of induction.
OT: Lisa Barrett in court. Sans dreads.
https://au.news.yahoo.com/sa/a/38846692/manslaughter-accused-midwife-in-sa-court/
Not sure why shes so fucking happy. Probably because shes enjoying messing with the families. She’s so “with woman”.
Let’s hope she doesn’t start her own franchise of Wize Wimmen Resterent™️.
http://www.skepticalob.com/2014/01/when-is-a-hospital-like-a-restaurant.html
I wouldn’t trust her with salad Niçoise.
they can serve placenta and breast milk.
With a garnish of kale?
Shes doing a law degree. Possibly focusing heavily on fetal personhood laws. I suspect her defence is going to be that neither baby was a person when she knowingly let them die.
I think she’d be wasting her time, if that is her argument.
Yeah I think the ambos effectively lost her that defence. Fortunately, and it makes you wonder a lot about the one where they drove to the hospital instead of calling an ambulance.
Not only that-though you are right-but running an argument that a baby isn’t a person won’t look good when her whole story is what a loving, caring birth hobbyist she is.
I have all kinds of philosophical problems with personhood for the unborn, but I’m not trying to make a living pretending to be good at supporting mothers during births despite knowing absolutely nothing about the subject.
Unfortunately, I doubt it won’t be about what looks good at all but what is legal, as far as the law is concerned.
Once she’s out scot-free (please God, don’t let it happen!), she’s going to spin the loving birth hobbyist story once again, there will be loons ready to believe her once again, more children will die once again, and there will be a general “Birth rights!” from that crowd again – oh, and let’s not forget the attempts here, on this site, to make sense of the despicable mothers by claiming that they were solely victims.
Was it you who said, “Please explain me how does it make sense to put someone at the risk of death and then their death is YOUR punishment?”
I won’t forget what Sarah Kerr and her partner, baby Tully’s parents, said. They had witnessed the inquiry of another twin death by Barrett’s hands and still took her as their midwife. They looked proud that no one could say they were not educated. I was like, what, you fuckards? Your baby died! If I killed my baby by hiring a professional baby killer who has recently killed another baby in similar circumstances, you can bet your sweet asses that I’ll be scrambling for anything that gives me a shred of delusion that I was deluded and taken advantage of, not a proud owner of my child’s death.
It is as I’ve already written here: for these people, it’s worse to be considered stupid than babykillers. Even their own baby’s.
I know the parents of the two babies in the case and they are not despicable people. They made a mistake. A big mistake and they admit it and they suffer for it every day. When the inquest was held originally that was 3weeks after the death of Tully that Ms Kerr had to testify. I’m not going to speak for her here but I can tell you 3 weeks after my homebirth loss I wasn’t eating, I was sleeping 16hours a day to escape reality and I was in no way ready to even consider that my choice to homebirth was responsible for my baby’s death. LB is a very charismatic person who manipulates people and at the time she was very well regarded still in Adelaide. Even OBs sang her praises. I also knew LB and I had her as a midwife too – (not for my baby that died) and I thought the sun shone out her arse. When I first found out what she did to these two families I didn’t want to believe it. Its so much more than just negligence. It has to be to warrant a manslaughter charge. You cannot judge these parents based on their actions and testimony at the worst time of their lives, while they were under the spell of a sociopath and felt under attack. I lost my baby at a homebirth too and I’m not a terrible person. Its taken a lot of counselling for me to be able to believe that and I still don’t at times. One of the ways I can convince myself I’m not a piece of shit that doesn’t deserve anything good is by reminding myself of people like the Kerr/Kavanagh family and many other homebirth loss Mums who are loving parents who are heartbroken and they made a big fucking mistake but they are not babykillers. They’re loving Mothers that made a big mistake. And so am I.
I’m not saying that homebirth parents are despicable beings or unloving parents. I’m saying this about those who will still hire Ms Barrett after her recent notoriety. I admit it’s incredibly hard for me to fathom how one could sit at an inquest where one’s part in a twin baby death is discussed and then, less than a month, have a twin homebirth with this same attendant. Where I live, there was a big hospital fuck up with an elective c-section some ten years back. A young woman went into a wake coma – I don’t know the term in English. For a few years, the hospital maternity patient load went significantly lower. Women were scared and their instincts for preservation kicked in. Even now, when they seem to have cleaned up their shit, women who think of having a c-section there still take this old case very seriously. I simply can’t understand how anyone can choose a participant in a death with the same risk factors as their own attendant and then claim that they didn’t know.
I don’t know how well you’re acquainted with this site but a strong attitude here is to say the mothers were just misled, absolving them of any mistakes and so on, any decision making of their own. I disagree and as far as I can see, you do as well because you say you made a mistake, trusted the wrong person, no matter how charismatic they were. And I think one cannot really make mistakes if they’re as infantile as many posters here make homebirth mothers to be in attempt to show that they were victims. I understand what you say about charisma and mistakes and I do hope you’ll keep faring better. But I’ll keep thinking that anyone who hires Lisa Barrett after this is despicable and the “they didn’t know” defense doesn’t hold water.
I do understand what you’re saying but its just not that simple. I’ve been following this blog for about a year now and I don’t think other commenters are absolving the parents completely. I think they are recognising, that is isn’t black and white. When SOB first started up it was very scathing of parents but I suspect that as more Homebirth Loss Mums reached out to Amy she started to see they weren’t hideous monsters that didn’t care if their babies died. There are some differences between how it works in the US and the other countries but among the Homebirth Loss Mums I know EVERY SINGLE ONE says they truly believed they were doing the safest thing. Its really like a cult – its so much more complex than just LB being charismatic but its also very hard to explain. I haven’t got a good explanation of how reasonable, intelligent people are able to be so manipulated that they will believe just about any lie they are fed. Certainly theres cognitive dissonance but its more than just that. When I hired LB I knew about the 2007 deaths under her care. The deaths amongst Homebirthers were always explained away – and we truly believed that there were more deaths happening in hospitals that were being covered up. Most of us also were not trained in scientific or medical fields so when the Homebirth groups throw up these studies that appear to show Homebirth to be safe we took it at face value. I remember being shown stats on the Stillbirth rate showing it was far worse in hospital. How was I to know that those figures included micro-prems, TFMR and abnormalities, as well as those stillbirths that no-one can predict or necessarily prevent?? Most Homebirth advocates don’t realise that either, but the leadership does. I also didn’t want to believe anything negative about Homebirth, so somehow my brain accepted what I was told and pushed the other stuff down. When I had my second homebirth I knew about Tully and another woman from my homebirth circle had lost her baby just months before. I was able to tell myself that that happened because she was 43weeks and I would never go that far, and I had hired a registered professional midwife so I was safe. The story we were fed about Tully Kavanagh is the parents refused to transfer (lie) and that abruptions happen ALL THE TIME in hospital and the babies usually die and I know it sounds stupid but I believed that. I trusted LB implicitly. I knew personally another woman who’d lost her second twin in a homebirth. I still couldn’t see what was right in front of me, because I believed I would never take that risk. That was twins so its different! is what I told myself. Here in Australia most of our midwives are university trained and registered professionals endorsed by the government. Are we completely stupid if we trusted what they say? We have very highly paid, very highly regarded midwifery professors that refuse to explicitly speak out against high risk homebirth and the actively campaign for less regulation. When I hired LB she was “the” midwife to have in SA. She was reverred. 8-10 years ago, before the whole LB thing blew up Homebirth in Australia was much more accepted even amongst medicos. One of LB’s apprentices is now a lecturer at a Sydney Uni. Shes paid to teach other young hospital midwives. LB is STILL to this day – being held up as a hero in the Universities. So its not just the Homebirthers that believe her story. People want to believe it, so they do. I could bang on for hours about this, but to be honest I’m still trying to make sense of it myself. I’m not trying to absolve parents of responsibility completely. Most of us accept some responsibility, some Homebirth loss parents choose to go into a deep denial and believe themselves that nothing could have been different. The women that I talk with though we do all accept we made a terrible mistake and we were wrong. I’m not trying to infantilise I’m saying its way more than that. Maybe I am a despicable person? I dunno. I think that LB is and the people who protect her are and the people who continue to lie about homebirth safety are. I know who isn’t despicable and thats those two Mothers, and their families, who are the victims in this manslaughter case.
From a legal perspective, for now at least, the unborn baby is not a person who can be killed. And that’s a good thing, for my money.
I do think that negligent parents should be punished for their negligence, and not just by its result ie the death of the child. Where the child is born dead, though, that’s hard to do.
We’re talking though about this birth hobbyist. She is also protected by the fact that the unborn child is not a person for the purposes of the law, but it appears this baby breathed, which means those who were there are fair game if there was some kind of misfeasance.
Unfortunately the practical effect of all this is likely to be more dead babies, as now no one will want to call an ambulance for them.
The cases have already had the effect of making it a crime in SA to work as a midwife unregistered. People still do it yes, but less. The restrictions on Homebirth for both the midwife and the birthing woman have been tightened. Its likely the other states will follow suit, I believe Victoria already has. I think the extremist birth workers may stall on calling an ambulance but I think the registered midwives are a lot more risk averse as a result of the LB deaths. Indeed many private midwives have stopped practicing because they don’t want to follow the guidelines and the guidelines now mean there aren’t enough customers and its become too expensive and difficult. There is the argument that restrictions on midwives has meant an increase in Freebirthing but I question that assertion. The data behind that has been gathered only from Homebirth groups and I believe its manipulated based on hypotheticals and the strongly held belief that most home and freebirthers have that if they trust birth everything will be fine. The nails are already in the coffin on private Homebirth in Australia and the evidence against LB will hammer them in. I think its a good thing. The public programs are as safe as homebirth can be – still not safe enough in my opinion but if the guidelines are strictly adhered to there will be less deaths and injuries. The loss of all those babies and the loss of Caroline Lovell in Vic has already made changes and we are already seeing less deaths as a result.
Hi Anna, I’ve been reading your posts with great interest. I’m particularly interested in your comments on freebirthing. My sense is that the desire for a freebirth comes from a different place from the desire for a homebirth.
Let’s hope for continued safety and knowledge improvements so neither parents or babies need to suffer unnecessarily.
Yes I think there are freebirthers that choose freebirth RATHER than midwife attended homebirth and there are some that cannot access a midwife, either due to cost, distance, two midwife rule or not fitting into the guidelines so choose to freebirth. What I think is happening, but I should say, I can’t prove it, and I may be wrong – is that midwifery leaders are claiming that the freebirth rate is rising because of the increased restrictions and the flow on effect of midwives stopping practice or being unable to practice while under investigation or suspension. There has been some data collected on this and recently there was a media story done on it. A doula who had a freebirth offered to be interviewed and she gave the impression that she chose freebirth only because she couldn’t access a midwife. I’ve heard whispers that she always planned to freebirth, for her it was always a preference and she just did the interview to try to “help” midwives strong arm the government into winding back the restrictions on homebirth. I think its dishonest because the women that choose freebirth, largely think its safe. They believe for example, that if they go to hospital they will be forced to have interventions that they believe are more dangerous and they have been convinced that their risk factors are not risk factors. I know it sounds like upsy down town but it really is.
When they say ‘they don’t want to follow the guidelines’ I assume the NHMRC ones? Also which ones exactly do they want to ignore?!
They don’t phrase it like that. They’ll say things like “I can no longer participate in a system which is not woman centred” “we are being forced out of authenticity and into risk based insurance centred midwifery” “we are being forced to follow non evidence based rules” “we cannot be with woman” “midwives are being witchhunted”. They want to do breech, twins, VBAMC, women who’ve declined all testing and scans – (not least of all because their midwives tell them they’re unnecessary), post 42weeks etc, but they don’t want to take any responsibility when it goes bad. They say its up to the woman to define her own risk based on her own research and innate knowledge. I’m not even kidding. I questioned a homebirth midwife recently elsewhere about a midwives responsibility to correct a woman’s beliefs around safety if they are incorrect. She said its the woman’s choice and if shes done her own “research” its the midwives role to support her. The Midwife Thinking blog and FB page would give you a taste of the way Homebirth Midwives try to shift the responsibility onto the woman. They talk about informed consent but that can mean referring them to Sara Wickhams work on Vitamin K or pointing out the shortcomings of the GTT and claiming they can detect gestational diabetes from urine tests, telling them that lying on your back causes uterine rupture and fetal distress and that they will just “know” if something is going wrong”. These are just a few examples. People like the author of the Midwife Thinking blog are smart enough to get out of it before they end up the subject of an inquest themselves.
I questioned a homebirth midwife recently elsewhere about a midwives responsibility to correct a woman’s beliefs around safety if they are incorrect. She said its the woman’s choice and if shes done her own
“research” its the midwives role to support her.
That is the exact opposite of informed consent.
I suspect LB’s defence will be that her actions did not cause the death of these babies. Their removal from life support did. Her crimes were during the birth – when they were not “people”. Its a dishonest and exploitative use of laws that are designed to protect pregnant women, not protect midwives or Drs from being responsible for wilful negligence.
We’ll see. I don’t think that’s an argument she’s going to look good running, even assuming it works. If she messed up the brakes on a car, and it subsequently crashed, injuring or killing people, she couldn’t say ‘it was just the car, the fallout is nothing to do with me’.
Perhaps more strongly, her crime might have been claiming she had capacities she didn’t have; not sharing information about her previous experiences that might have affected the decision to hire her.
I only recently read about the Hellena homebirth with twins over 2 days story that Barrett was in attendance for. There is honestly not enough WTF in the world.
Which is your favourite part? Mine’s the blow job.
I am not familiar with that incident but I’m pretty sure I can guess what happened. Just saying I imagine I might bite someone’s dingdong off had I attempted fellatio during labor. Odd I know, but I think sex was the furthest thing from my husband’s mind when I was in labor and giving birth. We’re just repressed like that.
Oh but you weren’t trying to open the cervix and restart labour after givng birth to one twin. Because obviously that’d be your first choice then, right? Seriously that whole thing still just leaves me shaking my head and going WTF?!
Yeah, I just let them induce me with pitocin, which I’m pretty sure is no longer derived from pig semen but even if, so what?
Because your mouth…is connected to your cervix…how, again? LOLOL
That couple are…uniquely bonkers.
They are quite the caricatures. These people can’t be real, can they?
They’re real. One of the twins was being treated for Acute Myeloid Leukaemia, hopefully he is recovering well.
I actually read that and was happy to see he’s getting conventional treatment. Honestly, I have a lot of empathy for her — she seems so frightened of many things and even getting her son treatment seemed like it took a lot of bravery on her part.
Yeah I was relieved that the acupuncturist in Nimbin basically told her that going the western medicine route was fine, and they could complement with alternative therapies in conjunction with chemotherapy.
Although I did laugh a lot at the hospital staff basically saying they were happy to do the alternative therapies in conjunction with the standard treatment, but if they decided to stop the standard treatment the hospital would get a court order to continue it. Sticks and carrots here people.
And I do feel sorry for her – the diagnosis would shake up any parent, especially given needing to move to be close to treatment etc. She is fortunate in some respects though – all the family was able to move, whereas if they had been running a small business or paying off a mortgage, or running a farm (just as examples) then she would have found herself in Brisbane with one, maybe two children, while her husband was back home with the others. There’s a lot of people in that situation, and it puts a huge amount of pressure on a family.
She had a “womb closing” ceremony after she was done having kids. /eyeroll
*so far gone in the woo-niverse that God Almighty Himself can’t find her with a radio telescope*
My sister simply had a hysterectomy, with no ceremony about it. Of course, her ovaries were trying to kill her.
The medical journal I worked at had a submission from a reader who’d had a hysterectomy; it was called “Ode to My Uterus,” and was about all the good times the author and her uterus had had. The poem was rejected, but we kept a copy on the wall.
Let’s hope they are really unique.
mine is the fake aboriginal name her husband uses. Nothing like a little cultural appropriation, while you give birth the way the noble savages do.
I took it as him taking the name of a bird, hadn’t even thought of that. Currawongs are everywhere down here.
I laughed out loud at the indignant edit about that – seriously, what did you think people were going to think with that??
My “favourite” was Barrett not being able to work out why the cord kept pumping blood. I mean really? I am not a damn medical professional and I could work that out.
Wait…I don’t think I’m familiar with this story. Is there a link? I can’t find anything online that mentions blow jobs during labor, and I really don’t want to google using that term, because it’s bound to return some less than useful links.
http://spunoutpost.blogspot.com/2010/11/natural-birthing-of-twins.html
That was horrifying.
Read the bit right at the bottom.
https://spunoutpost.blogspot.co.uk/2010/11/natural-birthing-of-twins.html
Jesus Christ. They are nuts. Wow.
Additionally, spontaneous labor offers substantial benefits to the
mother and her infant, as ACNM has affirmed in its Consensus Statement
on Physiological Birth.
This statement kind of gives away the game. You don’t affirm facts, you confirm them with evidence.
And plus – well, if you go into spontaneous labor at term, you don’t need to be induced! That’s a nonsensical statement because the people you’re considering inducing are the ones who _aren’t_ going into spontaneous labor. And those are the ones this trial looked at.
Evidently, I don’t. :s
🙁
I mean – it’s almost like saying it’s better to go into spontaneous remission from cancer vs getting chemotherapy. Well… yes, but if your cancer doesn’t remit, chemo is way better!
Exactly. And this is the reason that inductions were initially thought to increase CS rate. If you compare a woman who comes in in active labor at 40 weeks with a woman who presents at 40 weeks for an induction with an unripe cervix, sure the woman with spontaneous labor has a better chance of avoiding CS.
But one doesn’t get to choose to go into spontaneous labor at 40 weeks. The actual choice for many women is inducing at 39 weeks with a fresh placenta and a 7.5 lb baby vs inducing at 42 weeks with a failing placenta and a 9lb baby who has already passed mec.
Yeah, that was my mother in law, though her 42 weekers were pushing 10 and 11 pounds. Her grandbabies were also big, but were not allowed to hang out that long.
Excellent post, thank you 🙂
Kidlet #3 was induced a week early. I was already dilated to 5, had been in the hospital a few days prior with contractions that stopped, and the doctor asked if I just wanted to do this now. So we went home, packed the other 2 to the sitter, had dinner, and came back for the induction. He was obviously “done” enough, what would sitting around have accomplished?
I am reminded of when President Obama went to Notre Dame, and talked about how everyone wanted to reduce the number of abortions, and that things like proper sex ed and contraception has been shown to be effective in doing that. We should all agree, then, that those are good things.
But no, that is not acceptable. It is more important to prevent the use of contraception and avoid proper sex ed even though that leads to more abortions.
You can see why they end up the same: their goal is not to “reduce the number of c-sections” they want to abolish them completely.
I think the problem with midwives and pro-lifers is that they are dishonest about (or simply unaware of) what their ultimate crusade is. These groups claim their ultimate crusade is against one thing, c-sections and abortions, when really it’s against something else, all birth interventions and non-reproductive sex. That’s why the solution to their claimed Big Bad is unacceptable to them, because it involves the thing that they’re really against.
Beautifully stated
It’s a purity test, fundamentally. It’s not about whether or not a woman has an abortion, but whether she is a ‘pure’ woman who avoids premarital sex. It’s not about whether or not a woman has a C-section, but whether she is a ‘pure’ woman who avoids interventions.
This.
I kind of wish I’d gotten an induction the week before with boybard. I ended up needing one anyway and my blood pressure went to 200 over something. Anyway, I had heard too much of the woo for it to be something I was then willing to do. Girlbard was induced at 38 weeks anyway, and my bp never went that hight.
I’m enjoying watching my son alternate between staring intently as some shiny advertisements, ripping those papers into shreds and rolling around on the shredded pieces with every indication of happiness.
The process by which Spawn and I got to this point was absolutely chocked-full of medical interventions for both of us – and I can’t imagine that I would enjoy my baby more if we had had a “normal healthy physiological” birth.
Me too – in fact much more focus on “normal physiological birth” from my healthcare providers would have resulted in a normal physiological stillbirth. I find it hard to see how I could have enjoyed attempting to bond with a corpse more than with the cheerful, curious, stubborn as hell 16 month old I’ve got instead. Yay interventions!
And this is one reason that makes statements implying unmedicated physiological birth was more “worthwile” so damn infuriating.
http://nursing.umich.edu/faculty-staff/faculty/lisa-kane-low
Not sure how “Mexican” ended up in the body of the article; but Dr. Kane-Low received her PhD in Michigan and practices at the University of Michigan. However, the point of process over outcome being silly, if not, dangerous, is obviously on point! 🙂
Lisa also spent a lot of time sharing office space with a doula service and a lay midwife practice. Obviously, she had leanings toward home birth well before she became ACNM president for the second time, but sharing office space in an echo chamber entrenched those beliefs.
Truth. I am an Ann Arbor gal myself, so I know a bit of the oddball history.
This is timely, since I believe I came on here a week or two ago to comment that if I have another kid I would probably ask to be induced on my due date. I went 11 days post dates and had a super long induction and pushed for 3.5 hours. Those 11 days were so miserable and then the labor was so hard – I’d rather just get it all over with! Glad to hear that the current science suggests that that wouldn’t be as selfish as it felt when I originally said it, haha
I had a due date induction with my 2nd. Best thing I could have asked for. Only 5 hours from start to holding my baby.
If I had another kid I would definitely get induced. My last labor started in the middle of the night and was 3 hours from first contraction to holding my baby. I was so lucky that my in-laws were already in town to watch the older kids and asleep on our futon. I assume that outcomes with inductions are even better for multips because our bodies have done this before.
why it’s….it’s almost as if interventions can be beneficial!
It’s almost as if… we intervene… like, for a REASON or something!
to disempower women and rob them of their life-affirming birth experience, right?
Oh totally. I mean, why else, right?
Yes. Preventing incidents works better than responding to them.
Who would have guessed?
And this post is a perfect example of why I can no longer recommend midwifery care to my patients—OB leaders change their recommendations when new evidence becomes available, CNM leaders do not.
If you go waaaay back in the SOB archives, you can find a post by Dr. Tuteur where, based on the then-available evidence, she recommends against elective inductions. Since that post was written there have been a number of well designed studies that show improved outcomes for elective induction at 39 weeks, and so Dr. Tuteur, like her OB colleagues, has changed her advice. And mind you, this change of advice is the exact opposite of what would be convenient for OBs–now instead of patients showing up in active labor, you have to monitor them for hours while the induction slowly takes effect, clogging up L&D beds.
OB leaders change their recommendations when new evidence becomes available, CNM leaders do not.
Omg can we print this on banners and have airplanes fly it around over every midwife-led birthing center in America?! I’ve heard plenty of NCB folks and midwives talk about the importance of “evidence-based care”–and guess what: that means care that pays attention to evidence and changes in response to evidence.
It does NOT mean “doing it as our foremothers did thousands of years ago because surely they knew everything already and there’s nothing more that we need to figure out.”
That’s the difference between science and religion too. Science changes based on new evidence, religion doesn’t.
This doesn’t just apply to obstetrics, nor even only to medicine, but to all of science. How does one tell real science from pseudoscience? By how its practitioners react to new evidence.
If the new evidence agrees with their theory, both scientists and pseudoscientists will accept it. If, however, it contradicts their pet theory, a real scientist will change their theory to account for the new evidence whereas a pseudoscientist will either reject the new evidence outright or proclaim that ‘further study is needed’.
My understanding has been that CNMs are not the problem? (It’s CPMs etc.)
No, CNMs are also the problem.
CPMs are a wholenuther issue.
The response that Dr Tuteur provides above is from the ACNM. They may be better medically equipped, but they are still neck-deep in the shit and don’t act appropriately.
While the proportion of irresponsible CPMs is pretty near 100%, the proportion of irresponsible CNMs is not 0%.
For an example, British midwives are trained much more like CNMs than CPMs, but there have been multiple independent hospitals with issues of their midwives behaving recklessly.
I can’t really think of a profession where the proportion of irresponsible people is 0%. Certainly not mine! I’m a social worker and irresponsible social workers most definitely happen! But I’m still happy my profession exists and am proud to be in it. I wouldn’t want to tar all CNMs with the same brush used to paint the worst of them.
” I wouldn’t want to tar all CNMs with the same brush used to paint the worst of them.”
Ok, but put yourself in my position. You care about your patients. One of them gets pregnant. She wants your recommendation on who to deliver with, the OB group or the CNM group. You know the OBs, and exactly 0% of them in the group are into the woo. You know the midwives and “only” 2 out of 13 of them are really nutty-woo, while another 3/13 maybe are moderately woo (but probably? not dangerously so) while the rest are good. Which group do you recommend? (Remember, when your patient shows up in labor, she gets whomever is on.)
You know the care providers local to you the best and I fully support and applaud the fact that you prioritize your patients’ health and safety. I’m sure you know what you’re doing and that you are doing the right thing. Some folks that I know have had different experiences with the CNMs in their area, including in instances where there were complications and the CNMs acted immediately to transfer them to providers who were trained to handle them, rather than maintaining loyalty to some kind of “natural” ideology. Ideally, I’d love it if everyone had access to woo-free CNMs and OBs.
“Some folks that I know have had different experiences with the CNMs in their area”
Is the situation in your area actually different, or perhaps were your friends just lucky to have drawn the good one when the emergency hit?
“including in instances where there were complications and the CNMs acted immediately to transfer them to providers who were trained to handle them”
And if they had been with an OB group already, no transfer would have been needed, your friends would already have been in the hands of providers trained to handle complications.
But that isn’t what they wanted. For various reasons, they wanted to be attended by a CNM as their Plan A. You don’t have to agree with it but I do think their ought to be some choice available as long as the risks of the available choices are minimal and well planned for. (Eg. CNMs working in hospitals or in birthing centers that are on hospital campuses so transfers can be quick.) Outcome over process and all that (I have no friends who disagree with that) and people’s feelings ought not to be prioritized over human lives but they’re not going to stop having feelings, so having multiple options (again, within reason) that honors them just seems smart as well as kind.
I’m glad this community exists but it can sometimes feel like there is one acceptable way to feel about everything birth-related and it’s the “logical” way. Like, if you don’t want an epidural, it must mean that you’re brainwashed by woomeisters or have surely internalized misogynist notions about female pain being necessary. But I know people who didn’t want epidurals because they found the idea to be terrifying and that emotional discomfort was worse for them than the fear of physical pain. Is that rational? No, these kinds of fears are not but they still exist and they’re not going away. People are allowed to be irrational within reason. They’re emotional creatures. What they value, fear etc. doesn’t have to make sense to others as long as their actions create no or minimal risk and any risks have a good Plan B.
I think that is a mighty big strawman that you are building.
Most (not all) reasons for anti-epidural viewpoints are woo-y though. I’m okay with staking out that claim. Unless you have a real medical/psychological issue with pain relief, it all comes down to the idea of women’s pain being empowering or necessary for bonding, or a straight up lie about pain relief being harmful to babies.
Oh, I agree, but I am happy to deal with it on a case-by-case basis.
If someone claims that they have a fear of needles, I can’t argue with it, and I don’t. But I don’t disagree that if really pushed, those “reasons” tend to resort to misinformation.
Totally – and I do know people who absolutely 100% despise and fear the sensation of losing feeling, or who have had drug reactions, or who have substance problems, and who avoid things for that reason. However, when I hear about pregnancy and childbirth out in the real world, it tends to be about that beautiful experience, how “I’d have asked for pain relief if I could have gotten it at the time, but I’m still going back to that birth center for my 2nd due next year #blessed!!”
I hate both needles in my gums AND the numb feeling… which is why I decline novacane for dental work. Yes even drilling. I’m probably going to be all for an epidural tho. Needles in my proper skin don’t bother me like ones in my gums.
Oh, lord, I’m with you. Needles anywhere in my skin don’t bother me at all, even the big one they stuck into my neck for a nerve block. But that needle in the gums… and that blow-up-the-balloon feeling in them… gah!
And you drool EVERYWHERE. AUGH. My childhood orthodontist was a sadist, but I have a great dentist now though. He has a system for ppl who want to just grin and bear it. You have to keep your forearm up perpendicular to the floor, like a dead man’s switch. I’ve only been drilled twice without Novocaine, cause I have strong teeth (I also take good care of them but some ppl are just born with teeth like fine china, they pamper the hell out of them and they still get messes up.) Once was a real cavity I had in college, and once I say categorically does not count, because it was CAUSED by the sealants they put on my molars as a kid, supposedly to prevent rear teeth cavities as a kid. Apparently in a lot of people they just fall out as you get older, other people have them all their lives, Mine stayed, but one of them didn’t QUITE stay as well as the others. It got a little gap, trapped stuff and started to become a cavity. Ugh.
Count me as someone who thought she didn’t want an epidural, and not on account of woo. I have had migraine for over fifty years, and labor and delivery without anaesthetic turned out to be, for me, a walk in the park compared to a bad migraine. I was terrified of the possibility of spinal headache – the odds against are good, but I took a wait-and-see attitude. Indeed, if the pain of labour had been unbearable, I’d have asked for the epidural. For me it wasn’t. YMMV.
Yup. There are indeed valid reasons for not wanting an epidural. I know one woman who has serious needlephobia, others don’t like the loss of sensation in their extremities. What’s important is ensuring that women aren’t being told lies about pain relief that alter their decisions.
And I don’t hear anyone here actually suggesting anything other than that. Which is why I consider PP’s claim that “If you don’t want an epidural, it must mean you’re brainwashed” a total strawman.
Jeez, here we have a bunch of commentors talking about their reasons for not wanting an epidural, and no one has judged them in any way.
I am not seeing that attitude here right now either. Nor did I say I was seeing that right here, in this instance, in this conversation. I am just saying that I have in the past and in other skeptical circles. I sometimes think that people in such circles can fall down a bit when it comes to taking into account that people have irrational feelings sometimes and that good care sometimes involves taking them into account within reasonable bounds. Even people who are not on the woo train are not perfectly logical creatures because that is not A Thing. And it is has been my observation that respectful acknowledgment of this reality is sometimes but not always lacking. It was really an extremely mild statement. Everyone settle down. Good lord.
“Everyone settle down. Good lord.”
Who is unsettled?
If you write something and others disagree, they don’t need to “settle down.”
I don’t even think we do disagree is the thing.
“I don’t even think we do disagree is the thing.”
Actually there were a number of points we disagreed on, starting with your idea that CPMs are a problem but not CNMs. And it is ok to disagree, and express that disagreement in a written reply. This is an internet forum, not a ladies’ auxiliary luncheon.
Actually, that was not an “idea” I was committed to but a question I asked of you. Hence the question mark at the end. I asked you because you clearly have superior knowledge and I actually wanted to know. I have since learned some things, from you as well as others, about systemic issues in the CNM field of which I was not previously aware–I had thought that the woo stuff was mostly confined to the small proportion of CNMs that are into homebirth and thus easily distinguishable from CNMs who practice in conventional settings. Apparently I was wrong about that and it is certainly disheartening to learn that it is not so easy to sniff out a woo-embracing CNM. On the whole, it seems that the CNM field, since they are actually trained medical professionals, is more salvageable than the CPM field (which just isn’t redeemable at all), but it also certainly seems to be the case that CNMs need to do some more work within their own ranks. I support that and I hope that they do it.
Some people actually ask questions because they want to learn stuff. Not because they want to passive-aggressively couch an opinion they already have in a question format. I was doing the former. I was just asking questions, not Just Asking Questions. Do you understand why I’m getting a little frustrated here?
“I have since learned some things..”
Yes, and the way you learned those things was by commenters telling you that your initial assumptions were wrong, i.e. disagreeing with you. But then you go and dismiss the people you are learning from (“Everyone settle down. Good lord”) by implying that their disagreement is due to them being too emotional. It’s like you want it both ways, you want to learn, but you get offended by the very comments that expanded your knowledge.
The comments that bothered me were not the ones that expanded my knowledge. The comments that bothered me were the ones that presumed opinions I didn’t actually have, such as that I think that everyone in this community casts automatic aspersions on any woman who doesn’t want an epidural, when what I was actually doing was pointing out a tendency I have sometimes noticed for people to be dismissive of “emotional” reasons to make certain choices. I got jumped all over for that and my actual view was greatly exaggerated and it was kind of annoying. All of a sudden people were referring to what “we” think, as if I’m not part of the “we.” Just seemed a little hair-trigger to me.
Yes, this. Couldn’t agree more.
I didn’t want a catheter. And in the hospital I gave birth in, an epidural means you’ll have a catheter in for 24hrs. Ofc when it came to it I was like “idgaf give me the fckn epidural I will have it even if it means staying in bed FOREVER”. I was lucky that I didn’t get any resistance (and also that I had the epidural in as it sped everything up when I had my EMCS) but I do think there are plenty of valid reasons for wanting to avoid one if at all possible. So long as women are given an honest overview of the pros and cons and are free to change their mind if they decide they do want one during labour, even if they thought they didn’t beforehand, I don’t see why electing not to have one if you can manage well without would be a strange choice to make.
My mom made the same choice for the same reason.
Would having, say, a phobia related to the process of epidural be considered a “real psychological issue” as far as your concerned? Real question.
Definitely yes in my opinion. Phobias are psychological issues that I would divorce from the social programming that valorizes childbirth pain.
It’s not a straw man. It’s an observation about the direction I’m which I sometimes but not all the time see discussion going in this space. If you want a fight, I’m not the droid you’re looking for. I don’t have any major disagreements with you.
Nobody is suggesting banning CNMs. That is a strawman. What I said is that I no longer can recommend them.
Nobody here has a problem with a woman deciding against an epidural. That’s a strawman. Dr. Tuteur herself went epidural-free twice. What most of us are against is women being led to believe that epidural births are dangerous or “less than”, which unfortunately is a belief I have seen endorsed by a number of CNMs (but never an OB.)
And I back up your decision to not recommend CNMs based on your experience so I don’t understand what you think we’re arguing about. I never suggested anyone was talking about banning anything. I was just making some observations about the way I sometimes see certain choices discussed. No strawmen.
Well, the “logical” way is less likely to lead to injury or death.
All we care about is that a woman who chooses not to have an epidural does it without having been lied to about how evil epidurals are. And we care that women who choose to get an epidural actually get one, instead of getting the run-around by midwives, as people have reported getting in Britain.
Yes, I also care about those things. Don’t know if that will please or disappoint you, since it seems some folks are fixing for a fight I absolutely do not want. I wish a real troll would show up and suck up their energies instead.
I have sometimes witnessed an attitude of judgmentalism towards women who prefer not to have epidurals for their own reasons in circles such as these. It is not universal, so I am not accusing individuals. It just seems pertinent to bring it up in a discussion of birth choices. And to be clear, I only support birth choices to the extent that the differences of risk are small and that there is a good safety net for anything that goes wrong (again, CNMs practicing in hospitals or birth centers that are on the campuses of hospitals so that transfers are easy if things go wrong quickly.) But, of course, I already said that and if anyone perceives any support of reckless birth choices in my words, it’s because they want to. I can’t do anything about that.
They aren’t all a problem, but they can be depending on the way they practice. The group I work with is more resistant to epidurals, uses homeopathics, let patients push way too long…I could go on. I’m sure there are great CNMs, but from my personal experience I would not see one for my pregnancies.
I have no experience from practice because I am not a medical professional. But I see problems when the competences of doctors and midwives overlap. In some European countries, doctors and midwives can share the prenatal care. Postnatal care in firmly the midwives domain.
It does nothing but unnerve pregnant women, when midwives claim to empower you, but actually just fight their turf war on your body. On top of that they often function as multipliers for quack companies. I could not find a midwife who was not offering homeopathy in my area. The magazine of their organisation presented vaccinating and not vaccinating as two equivalent choices. This is the info they might give their clients.
In the worst case you have defiant parents who do not listen to sound medical advice or doctors have to spend time reassuring insecure parents. There is a lot of lamenting about midwives getting priced into oblivion by liability insurance. But with those quacky attitudes they bring about their own demise. Too bad, the professional ones I encountered were great.
In my part of the world (Israel) there are no CPMs or labor & delivery RNs. As a CNM, I have considerable autonomy, but I am not absolutely independent. Even when an MD takes over management of a case, which happens if the patient’s condition changes from low to high risk, I still care for the patient. Often, if the OB has worked with me previously, and trusts my judgement, I still make most of the decisions, and countersigns. I have (almost) always liked having backup, to be honest.
Certainly CPMs are worse, but CNMs are also a problem when they worship “natural birth” and refuse to change their recommendations, and that’s what their leadership does. The tweet above that Dr. Tuteur links to is from Lisa Kan Low– she is the president of the ACNM.
Fair enough, but leadership doesn’t always reflect the rank-and-file. I certainly know a lot of people in various professions (mine included) who are pissed off with the actions of their various professional organizations. It just seems heavy to write off an entire group of highly trained medical professionals.
If the rank-and-file were really in opposition, they should do something about the leadership.
No doubt, there are many CNMs who know better. But there are far too many who apparently don’t. And fiftyfifty has described, it is so many that she is no longer willing to let her clients take the chance.
As long as the rank and file are silent, the problem will grow. They need to fix it.
Last I heard, less than 50 % of CNMs are members of ACNM. Those who are members are frequently of the woo mindset. Several years ago ACNM had a working group that was tasked with setting evidence based guidelines for home birth. Much of what they wrote was sensible but they also found out that the majority of CNMs doing birth center and home births thought the guidelines would be too restrictive based on their current practices and that fewer women would qualify for their services. I believe they published a paper explaining the problem and the guidelines were scrapped.
“Last I heard, less than 50 % of CNMs are members of ACNM. Those who are members are frequently of the woo mindset.”
I just went and checked the bios of the CNMs who deliver at my hospital. 12 out of 13 of them are members of ACNM….nope I won’t be recommending midwives any time soon.
It was discussed here:
http://www.skepticalob.com/2014/04/homebirth-standards-cnms-dont-need-no-stinkin-homebirth-standards.html
A subcomittee of midwives looked at international standards for homebirth, saw that those standard involved rejecting potential clients for being too unsafe, and the American midwives balked at “losing their autonomy”, namely, their right to take on dangerous clients.
“seems heavy to write off an entire group ”
Yes it does, but I’ve come to the sad conclusion that I don’t have any other choice. And for me it is a sad conclusion. During residency some good CNMs helped train me. I chose to deliver my first with them. But the problem is that one good apple spoils the bunch. 9 out of 10 CNMs in a group may be solid but if 1 out of 10 is infected with the woo, and that’s the 1 who is on call the night you deliver, then for you it might as well be 100%. And I DO fault a group when they elect bad leadership, or fault them when at minimum they don’t call out their leadership. And then the fact that CNMs as a group don’t call out and distance themselves from CPMs is especially damning. Instead they say crap like “we are all sisters.” Nope, no more midwives for me.
So I just enabled text to voice on my phone, and used it to “hear” your comment. Now I just need to figure out how to get a different voice for every commentor
Make my voice sound wrathful!
Actually, I upped the pitch and so it sounds perky….
Upping the pitch on your voice–don’t give me any ideas…
But even the best CNM practices are tainted by NCB ideology. I used a midwifery practice affiliated with a major university medical center, and while my primary midwife was definitely an evidence-based practitioner, some of her colleagues had real issues. Let me list a few things that I found problematic:
1. The birth class that was recommended by the CNM practice was long on ideology and short on facts. I wouldn’t say that they demonized c-sections, but the very first chapter in our book of handouts was the good old “cascade of interventions” chart (which has no basis in evidence). My husband thought it was ridiculous from day one. I, regrettably, did not, although I did feel a bit uncomfortable when everyone else in the class stated that their goal was unmedicated vaginal birth. I was on the fence, and felt slightly ashamed that I wasn’t on board to their extent.
2. When I was pregnant the second time, I had severe SPD. I asked for a referral to a physical therapist. The CNM that I saw at that appointment strongly encouraged chiropractic care. I asked again for physical therapy, and she pretty much insisted that chiro was better. I was so desperate for relief that I took that referral. I still doubt that the idiotic tool that she used on my lower back did anything, but each session was followed by 30 minutes of massage which did help. Of course, I was in pain again within 2-3 days, necessitating additional appointments. Convenient.
3. There is now a boutique birth center in our city that is loosely affiliated with the medical center (as in, they transfer their patients to our hospital). It is staffed by CNMs who were previously in the hospital practice. The woo is very strong at that center, and that’s a problem.
4. After the significant problems with my first delivery, no one warned me that a second vaginal birth might not be the best idea for my pelvic floor. I was dealing with stress urinary incontinence and urge bowel incontinence, but the latter problem got much worse after my second vaginal delivery. I really wish that someone would have evaluated my pelvic floor. At that time, I hadn’t done much research on it, and was relying on my CNMs. That was a mistake.
I’m really sorry you had those experiences. 🙁 From what folks are saying, it does sound like CNMs as a group need to do some house-cleaning, even if a lot of them are individually good. Who wants to take those chances on getting a bad one? I suppose that the main difference I still see between CNMs and CPMs (besides, ya know, the huge difference in actual training and experience) is that the field of certified nurse-wifery is a house that can be cleaned. Because they are real medical professionals and there’s no reason that their practice has to include woo or toxic ideology. The CPM “profession,” on the other hand, cannot be saved because there’s just no way to make undertrained people attending births into a thing that’s ever okay. So the CPM field is a problem in the way that the CNM one is not, which is maybe a better way of expressing my original thought. But that doesn’t mean that the CNM field doesn’t need to a better job actually making itself unproblematic. I have always been aware that there are bad CNMs out there but I thought they could be pretty easily identified by being the homebirth-attending minority. It’s a shame that is not so easy to pick out the “bad apples.”
Yes. Our CNMs our the only providers that allow their patients to go to 42 weeks. Way more often than not their strips look like crap because the placenta is most likely also crap. It makes for a stressful labor that can then lead to more interventions that these people seem to despise (internal monitoring, oxygen, etc).
What is the current policy on inductions in the US?
SOME CNMs. I never had the slightest problem conferring with my OB colleagues when there was any question of the best program of treatment. But then, I worked with, not in opposition to, the doctors in my unit.
Why don’t you just say it: “Not all CNMs are like that….”
I also think that Antigonos CNM practiced before the woo infestation was running rampant through the ranks of midwives.
“Nature is a terrible obstetrician”
Put that on a gorram T-shirt.
Was human gestation originally ‘set’ at 40 weeks because it’s a nice round number?
Um, it’s actually of Biblical origin. I’m not kidding.
Really? Yikes, like three score years and ten? Hardly a reliable source.
i’m kind of impressed bronze-age shepherds were kind of close to the actual number. No EPT tests or rabbits back then.
Eh, not much else to do besides fuck and count, I suppose. As we say in my family, “there was no Daily Show back then.”
I’d be interested in hearing/reading more about how they came to that number. Do you have any good links that explain that?
I haven’t researched it or anything, but if I recall correctly, the Old Testament was really specific about when people couldn’t have sex, wasn’t it? Absolutely no sex during menstruation and then no sex a week after bleeding completely ceased. Since the average menstrual cycle is about 28 days, that puts sex right at most women’s fertile times and not much outside of their fertility with the exception of a week or two after ovulation. That would be my best guess at how they figured out how long approximately pregnancy was?
Wow…
This emphasis on ‘process,’ by itself, feels like mere defensiveness by people who can never admit that they’re wrong, no matter how bad the consequences.
But combined with all the rest of their sloganeering – some babies ‘not meant to live,’ ‘nature doesn’t make mistakes,’ all of it especially including their unwillingness to let women ‘back out’ of their non-treatment during labour by calling an ambulance – it starts to take on a very ugly hue of Eugenics.
As if they’re lying in order to accomplish something beyond ‘let’s play all-powerful healer heroes in a live-action LARP!’ and the reason they seem so uncaring about dead babies and even dead mothers is they really DON’T care, because they see anybody who doesn’t survive unassisted by modern medicine as unworthy of living and no value to the species. ‘If you wouldn’t survive in the Wasteland, you’re a waste of food’ sort of thing. Same with the fanatical lactivists.
A nasty fusion of ‘social Darwinism’ and actual Darwinism, but all camouflaged under talk that SOUNDS warm and affirming and woo-woo, so long as you don’t look at it closely or think about what it really means, under all the ‘birth goddess in you!’ talk.
I am a bit surprised they didn’t see a statistically significant reduction in perinatal death in the IOL group, since this would be so strongly protective against stillbirth.
The study that would pick that up would have to be much more highly powered – with probably 10x as many women enrolled.
The expected difference in stillbirths between delivery at 39 weeks gestation and 40 weeks gestation is 0.1 stillbirths per 1,000 deliveries. With a control and experimental group of 3,050 women in each, there would be 1-2 stillbirths expected in the induction group and 1-2 stillbirths expected in the experimental group.
If OBs are allowed to offer 39 week inductions – and women are allowed to chose to wait for labor to occur naturally (which seems reasonable since the outcomes in the study between the two groups are pretty close), in a few years researchers might be able to do a retrospective study to try and suss out the difference.
Our bodies fail us all the time. If you’ve ever had any type of chronic illness or serious injury, you have to face that fact. People do deal with it in various ways, and denial is indeed a coping mechanism for some. Having birth go awry is the first time that some women have encountered this reality, but given the number of women getting pregnant later in life and with conditions that used to preclude pregnancy, I’m sometimes surprised by just how large the disconnect is. Midwives and NCB adherents aren’t helping with this at all, particularly by promoting the idea that having anything other than an unmedicated vaginal birth is some sort of moral failing. They also conveniently ignore the fact that this type of birth is the default setting for billions of women, and that they and their children suffer the consequences every single day.
All these idiots have to look at is the miscarriage rate. Heck, just ask a woman who has had a miscarriage, especially one who miscarries before being able to experience a live birth. I don’t think there’s anything that exemplifies the “my body failed me” mindset more than a miscarriage, especially if it turns out to have been caused by something in your own body and not by something not forming correctly in the embryo. So many women have at least one miscarriage of a very wanted baby in their lifetime–why can’t we just celebrate the babies that make it, however it happens?
“Women in the IOL [induction of labor] group delivered significantly earlier than those in the EM [expectant management] group (39.3 weeks (IQR 39.1 – 39.6) vs. 40.0 weeks (IQR 39.3 – 40.7), p<.001)."
So this study didn't even really delve into the 41, 42 and 43 weekers (read that as 40 plus 76 days, or however they say it to make it sound less absurd). I imagine these findings would be exacerbated if they had.
This!!! Most Aussie NCB midwives froth at the mouth over 40 and 41 week inductions. If they had their way there’ be no inductions before 43weeks completed! And im not even kidding. This is going to panic a lot of midwives into public rage posts that will show very clearly their ideological bent. Its very clear in posts Ive read thus far that they value the natural process above all else.