Guest Post: What We Say to Loss Moms

Please welcome today’s guest blogger, Martha Reilly, M.D. Dr. Reilly is an Oregon OB/GYN with whom I have recently been corresponding about the state of homebirth in our great state.

One of the most curious features of homebirth loss stories on the web and elsewhere is the closing remark, most often seen on Mothering.com, that “the doctor said this would have happened in the hospital too.”  Some examples  (all are taken from publicly accessible blogs):

  • A healthy mother labors with very painful contractions at home and, when the baby’s heart rate drops into the eighties, is taken to the hospital where a complete placental abruption is discovered and she undergoes emergency cesarean, but baby is born dead and mom nearly dies from the complications of the abruption
  •  Breech/breech twins are delivered at home,  with a particularly traumatic birth of the second (described in harrowing detail by the father) resulting in a depressed skull fracture. A mom is transported when the fetal heart rate drops and delivered by emergency cesarean, with the infant in for brain surgery and a long NICU stay.
  • A HBA2C with several hours of painful labor and no progress which ends in uterine rupture, the death of the baby, and near-death of the mother.
  • A twin birth with placental abruption before the delivery of the second twin, resulting in the death of that baby.
In all these stories, the narrator takes time out to report that the doctors said that birthing in the hospital would not have prevented the complication. The father of the twins goes one further and insists that he was told by his daughter’s neurosurgeon that a hospital birth would have killed her. This is the moment when, reading these narratives, I mutter, “Yeah, right.”

 

Where does this idea come from, this certainty that what happened at home would have happened anywhere?  Why is it such a fixed idea?  As an obstetrician who has received many homebirth transports, I’ve had way too much time to ponder these questions.

 

Some of the blame lies in the rather fixed and rigid belief systems of homebirth adherents. Birth, they say, is inherently safe, and most birth complications and almost all cesareans are the result of unnecessary intervention, so nothing bad, nothing really bad, can happen at home.  When a birth goes awry, they simply accept the (to me) astonishing concept that it would have happened anywhere.

 

More blame can be placed at the feet of unscrupulous midwives, who have the ear and the trust of the mom, and are busily promoting the idea that the baby’s death was inevitable from the start of the transport all the way to the baby’s gravesite and beyond.    But it’s not just a lack of scruples that leads them to take this stance: many non-medical midwives (such as Certified Professional Midwives) are woefully undertrained and understand the mechanisms leading to intrapartum death poorly.

 

Sometimes this trope results from timing of the narrative. Particularly on Mothering, the posts are often made within days of the baby’s death.  When I read homebirth loss blogs I am particularly interested in the understanding that parents develop over time as they wrestle with their child’s death.  Many parents (and I am thinking in particular of Wren’s and Aquila’s and Mary’s) devastating realizations about the choices they made, but only after months have passed.

 

What about doctors, though?   What information given to parents leads them to report that “the doctor said this would have happened in the hospital?”
To understand what might be going on in the hospital, you have to understand what really happens at an emergency homebirth transport.  We usually get a call that a mother is coming, but very little detail.  Arrival is chaotic. Often the midwife has brought the mother separately from her family and support team. Frequently the records have been “forgotten” or are coming in a second car.  We encourage our local midwives to explain what is happening to us, but in emergencies we are doing this at the same time we are drawing blood, establishing IVs, placing fetal monitors, and performing ultrasound. One of the special challenges in these moments is that homebirth patients many times don’t trust doctors, so we need to establish rapport with them at the same time we are acting as quickly as possible. Since the mother is often exhausted and frightened, it’s a very tense situation.

 

Another challenge is that the midwife’s report of her patient’s labor is often not reliable. There is some outright lying, but most of the problem lies in concepts that are, to put it kindly, different from the model of care we use. A typical report is that “fetal heart tones were strong,”  that is, until they weren’t. Well, thanks, but no thanks. “Strong” has no meaning in the realm of fetal monitoring. Fetal heart tones are either fast or slow, present or absent. The details that I want from fetal monitoring, the ones that REALLY matter (accels, decels, variability) are not discernible without electronic fetal monitoring.  So “strong” is useless information.  Additionally, many midwives don’t recognize, or don’t recognize the seriousness of certain factors (meconium, prolonged rupture of membranes, post-datism), so these might be left out of their story altogether.  Sometimes these factors are present, but explained away, such as the time one of my own patients transferred to a homebirth midwife and then was transported back at 43+ weeks with a stalled labor AND meconium. Her far-past due date was airily brushed away as being an “unsure” due date, even though she’d had a six-week ultrasound.   Some (to us hospital providers) basic information is often missing: some midwives don’t believe in vaginal exams and will allow moms to push based on urge alone, many don’t check temperature or blood pressure regularly.

 

In short, in an emergency transport we generally operate as if the patient has walked in off the street, since what information we have from the midwife may be limited or unhelpful, and do an independent assessment.  It’s important to remember too that precious time has usually been lost by the time the family makes it to the hospital. Most of these mothers arrive by private car, and sometimes they get stuck in traffic.  A laboring woman, in pain and possibly ill, can be difficult to get dressed and into a vehicle.  Even if someone has dialed 911, sometimes the mother’s preferred birthing place is not easily accessible to the EMTs.

 

Remember that our focus at these times is NOT on the homebirth debate. We are simply trying to do the best by our patients. We are not political animals at these moments.  Most of us are not even ideologically opposed to alternative birthing practices (as long as they do not compromise our notions of safety), no matter what popular midwifery blogs might say.

 

Suppose then that the worst has happened, and that a baby dies. What then? I will never forget my first emergency homebirth transport. It followed what I would later learn was the usual pattern: the call came, mom arrived with two midwives and no records, midwife told a story that made no sense (she claimed the baby had been vertex and “heart tones strong,” but at eight centimeters, the baby had leapt out of the pelvis and turned breech, so she brought mom in).  With some difficulty I got the midwife to step out of the way (she had placed herself between me and “her” patient) and addressed the mother directly.  My ultrasound showed a breech baby.  No heart beat. Mom’s cervix was completely dilated.

 

I’ll leave for another narrative how I had to dissuade the midwife from taking charge of the delivery of what turned out to be a perfect baby girl, who was easily delivered as a vaginal breech, and how I finally had to remove her from the room on the mom’s request (she was “normalizing” the baby’s death by coaching the mom to “join in spirit with the many mothers who have lost their babies in birth, and draw strength from them”), and move on to the topic at hand: what did I say to the mother?

 

What would YOU say?  To this day, I am not certain why that baby died.  I don’t have enough information to go on, really. She certainly was dead on arrival at the hospital, and mom certainly had been laboring at home.  I got calls from people I’d never met who told me the midwife had lied about the due date, that the mother was diabetic and untreated, and so forth.  Why might she have died?  Cord entanglement is common enough with breeches, and this might have been the fault.  Or if she was truly post-dates, the placenta may not have been adequate to support the baby in labor. She was not, by any available measure, diabetic.   Who knows exactly why this baby died?  I surely don’t.  Do I believe this birth was preventable?   Yes, that I do believe. If this baby had been monitored properly, and had been in a place where the changes in her heart rate could be responded to appropriately, she would have made it.

 

Here’s the important thing: the question of whether the baby would have died in the hospital never came up between the mom and me. Then or later. This mother has kept in touch with me over the years, and she came to her own conclusion, that her daughter would be alive today if she’d been in the hospital, and possibly if she’d chosen a different midwife.  I agree.

 

Parents, all parents, want desperately to do right by their children. I have NEVER met a parent who wasn’t trying, to the best of their abilities, to provide what their children need. Mothers always blame themselves when something bad happens to their baby.  In the moments of new grief, when the loss is fresh, I would never add to their burden by blaming them or their choices. My actions are not politically oriented;  I would never be answering their questions with an eye to what might wind up on Mothering or Birth Without Fear.

 

So where does “the doctor said this would have happened in the hospital too” come from?  If a patient asked me why her baby died, I would answer to the best of my knowledge, but my answers would be focused on scientific answers: infection, abruption, meconium aspiration, etc. Keep in mind, “home birth” is not a cause of death.  What causes death is failure to intervene soon enough when bad things are happening.  Three factors make this more likely to lead to death at home:  midwives not well-trained enough to recognize a problem in time to intervene, difficulty and delays in transport, and the tendency to view transport as failure.  While they will never show up on the death certificate, these are the things that kill babies.  The truth is, parents have never phrased their question to me as “If I delivered in the hospital, would this have happened?”  at the time of first hospitalization.  These questions come much later, and the parents usually know the answer by then.

WHAT?? You would still VBAC with 99% chance of uterine rupture?

 

Oh, and before I get all the comments about how I’m shoving all NCBers in the same box…she may be the only one who would VBAC unassisted with a 99% chance of uterine rupture, but she sure isn’t the only one who thinks scientific evidence is bunk.

The good folk at Unhindered Living

Birth Without Fear

 Jette Clausen

 

All over the forums at MDC 

 

 

 

 

 

 

 

 

What’s My Agenda?

Forced c-sections for all!! Muahahahahahahahahahaha!

That was a joke for those of you who are humor impaired. What is true is that I have an agenda. Top of the list? Safer mamas and babies.

I’m writing about this for two reasons. First of all, someone in the Fed Up Facebook group posted one of the ACNM Objectives for Healthy People 2020 and asked the Skeptical OB to write a blog post about how we can increase physiologic birth in hospitals:

 

 

I think that the goal of hospitals, doctors, midwives, and nurses should be improved outcomes and not necessarily less intervention. If there is evidence that less intervention improves outcomes, then, sure, we should strive for that. In some cases, such as elective induction before 39 weeks, I think that is the case. Overall, however, I think many of the poor outcomes in the US are unrelated to levels of intervention. It is true that the US has poorer outcomes than some countries in Europe. However, some of those European nations have both lower mortality rates AND higher rates of intervention *cough* Italy *cough*, so I’m not sure there’s even a correlation with rate of intervention and better outcomes. I do think that, in any case, experience should come after outcome on the importance scale.

 

The other reason I’m writing this is that I came across a comment from an older post on this blog, to which I’d neglected to reply:

 

 

I hope that my response to her makes my agenda when it comes to homebirth a little more clear:

 

First of all, it is true that I am *STILL* using the wonder database. It would be great if there were only RCTs regarding birth outcomes, but it’s impossible to do and get the numbers needed to show anything real. You have to have tens of thousands of births in order to show a pattern — anything less and the death numbers could be a fluke.

It is also true that many of the women who post here have been harmed because of an out-of-hospital birth with a CPM and they have not only been censored and shouted down by the natural birth community, but also ridiculed because of their experience. This blog does serve as an outlet for them in some ways.

I not against homebirth with a CNM. I believe that in certain situations (truly low risk woman, proper screening and precautions taken, location close to hospital in case of transfer), the risk approaches that of a hospital birth with an OB.

As far as what I hope to achieve…

I don’t necessarily want to have the CPM credential abolished, as many of my readers do, but I do think it’s redundant with the existence of the CM (A CM is a direct entry midwife with the same midwifery training and examination as a CNM but no nursing, currently only legal in New York and Rhode Island). If it’s going to stick around, it needs to require a minimum of a Bachelor’s degree from an actual accredited university (i.e., not Birthingway, Aviva Institute, National College of Midwifery, etc.), with the same science courses BSNs are required to take and pass with a B or better. If every CPM had the education that graduates from Bastyr have, I might be satisfied. I also want the NARM to reflect the same level of difficulty and accuracy as the AMCB exam (that CNMs and CMs take). If the requirements for a CPM aren’t changed/made more stringent, then I do want the credential abolished and would be happy to make the Certified Midwife (CM) a national certification.

Other things I’m working for:

  1.  Mandatory Licensure. Those practicing midwifery without a license should be subject to criminal and civil liability and actively prosecuted. No turning a blind eye as is currently happening, even in states where lay midwifery is illegal.
  2. Adoption of something similar to the Netherlands Obstetric Protocols for Antepartum, Intrapartum, and Maternal Postpartum Risk Assessment for homebirth in the US. While the Netherlands numbers aren’t the best, their homebirth numbers are certainly better than ours. Adopting their protocols will give homebirth midwives a solid guideline to safely serve women and families and restrict them to the low risk births in which they are trained and specialize. Those who choose to attend high risk births in violation of these regulations should be subject to supervision and/or suspension and if appropriate (ie in the case of a death as a result of their violation), civil and criminal liability.
  3. Adoption of an Infant Postpartum Risk Assessment Tool. The Netherlands protocols do not include comprehensive risk assessment for neonates, so such a tool could be composed by a team of GPs, OB/GYNs, pediatricians, and neonatal nurse practitioners.
  4. Disclosure…of training level, numbers of births attended, numbers and percentages of poor outcomes with comparison to national rates, complaints filed, malpractice lawsuits filed and settled — for all maternity care providers
  5. Immediate Suspension of the license or required supervision of any CPM involved in a maternal or infant death or major injury, pending investigation. Midwives involved in fatalities and major morbidity must be investigated and must stop practicing until it is determined that they are safe practitioners.
  6. Permanent Revocation of any CPM license after a second fatality or major injury if it has not already been revoked. A midwife might have one unlucky accident in the number of births that homebirth midwives typically attend, but a pattern of incompetence, recklessness, or negligence must not be tolerated. Once a practitioner has reached 750 births, the number of deaths allowed before suspension could be increased.
  7. Publicly Available Information about each maternity care provider’s record in a reliable online search tool. Patients must be able to see if their provider has had malpractice suits, complaints in the last 10 years, disciplinary actions, suspensions, or other indicators of poor performance.
  8. Malpractice Insurance for all CPMs and Birth Centers. Malpractice insurance is simply part of the cost of doing business as a healthcare provider. It protects consumers and the State from shouldering the costs of mistakes.
  9. Better Tracking and Public Availability of mortality and morbidity statistics.  If CPM is going to be a legitimate credential, it needs to be listed as a choice on birth certificate data. There must also be a spot for “planned homebirth” so that hospitals don’t get the blame for transfers that end in a death they could not have prevented by the time it arrived. Morbidity data is not currently collected and it needs to be.
So there you have it. My agenda is not to make homebirth illegal.  I have no naive illusions that if all I hope for comes to pass, the Gloria LeMay’s of the world will suddenly stop taking on risky clients and hiding in the closet when the sh*t hits the fan. If you spend enough time on MDC, it is pretty clear that there is no shortage of lay midwives willing to deliver footling breech post-dates twins being carried by over-40 moms in states where they are currently illegal. I do not support prosecuting parents for making risky choices that end in disaster. I do, however, support the prosecution of those who call themselves midwives and do the same. My desire is that women have the information they need to make the appropriate decisions for themselves and their babies, and that midwives are held accountable for their actions.

What changes do YOU think will make childbirth safer?

Why There is No Excuse for Midwives to Work Without Insurance

Jade Jymson, who does a little blogging over at the Mama Tao, has written today’s guest post for us.

Since I started writing about the state of midwifery in the US, I have come across many reasons why Natural Childbirth Advocates ™ feel that midwives should not have to or are not able to carry insurance. A few of the main reasons are as follows:

  • Why should midwives have to carry insurance when it just means that you want to sue them? Or: We are too litigation happy when all we think about is money when something goes wrong. Or: Money is not going to bring your baby back.

 

 

Let’s start at the beginning, shall we?

Why should midwives have to carry insurance when it just means that you want to sue them? Or: We are too litigation happy when all we think about is money when something goes wrong. Or: Money is not going to bring your baby back.

 We all have to carry insurance. I have insurance on both of my cars. Even though I have never been in a wreck, if I should hit someone, I know I would never be able to pay to have their car fixed out of my own pocket. I buy insurance so that I know I can afford to pay for repairs done to others property. If you break something that belongs to someone else, you should have to pay.

In cases like Zen’s we see that the midwives have done serious damage to these people and their lives. Zen’s mother was told to push for over 6 hours because the midwife was sure she could see the baby’s head. It turned out to be a blood clot on her bladder. His mother still needs serious surgery to repair the damage done to her body, but the midwife was not insured. Why should Zen’s mother have to pay to repair the damage herself?

But then again, why should I care? It’s not like I have to pay for it. But hold on a second…what about Sam’s parents? What if Sam’s parents were not able to pay his hospital bills? In such cases almost all children qualify for Medicaid.  And what is Medicaid? Why it’s a free insurance paid for by tax payers. When the midwife is not able to pay for her mistakes, we all end up paying for them.

There are no companies willing to offer insurance to CPMs

This is simply not true. Contemporary Insurance Services specifically offers insurance to CPMs and CNMs who attend homebirths. In the past week, we requested a quote for a midwife in California with 3 years of experience and a clean record, and they were perfectly willing to insure her. Not only that, but they’ll insure her even if she has previous claims against her practice at a rate only 10% higher. And this isn’t the only company, either. It was just the first one that came up after 20 seconds of making sweet love to Google.

Midwives don’t make enough money to pay out the insurance premiums.

While I have to admit, my first thought is to say, “Who cares?” The first rule you learn in freshman economics in high school is that to have a successful business you have to make more money than you spend on whatever is necessary to keep your business running . And running safely, I might add. You don’t get to run a restaurant without being able to afford the supplies to keep your kitchen clean or own a climbing gym if you can’t afford harnesses for your climbers.

Considering that many states allow midwives to work uninsured because of this issue, let’s take a deeper look and see exactly what a midwife’s  finances must look like.

Faith Beltz, the infamous midwife to the Paperella’s, made $4,200 off of Aquila’s tragic birth. That’s right, she made a mistake that led to their daughter’s death and she was still paid for the job. Let’s pretend that all midwives make as much as Beltz does and take only one birth a month.

$4,200(12)=$50,400

Yep. IF a midwife charging what Beltz does only takes 1 birth a month she makes $50,400 a year. But most midwives have more business than that, right? So let’s look at what she would make if she took only two births a month:

$4,200(2)(12)=$100,800

Wow! That is more than most people I know make in a year. Pretty impressive. So how much does this insurance cost anyway? Some of the commenters in the last post keep throwing out numbers like $60,000. If that is true then a midwife might have a problem paying her bills if she only takes one client a month.

To make sure that this $60,000 a year number was correct, we contacted the company mentioned earlier as a CPM who had been working for 3 years and had never made a mistake that resulted in the death or harm of a patient.  This is what they quoted us:

 

Wait? Huh? The payments start out at $13,000 and then rise to $22,132 after 5 years. For then on after the rates stay the same to be insured. The policy pays out $200,000 to $600,000. If we are using Faith Beltz and her $4,200 with one birth a month, she still has $28,268 to live on in the fifth year and beyond. Most midwives don’t have a birth center or an office or a secretary to pay – they have little to no overhead. They don’t even buy the materials they use at your birth; that is part of the homebirth kit you purchase yourself.

$28,000 is not a whole lot of money, but it’s also not chump change. If she did two births a month she’d have $78,668 left over.

But $4,200 only one number and most midwives take more than one birth a month.  If they only take one client a month and can’t pay their insurance, they need to find more clients.

$2000(2)(12)=$48,000=$25,868 Leftover

$3000(2)(12)=$72,000=$49,868 Leftover

Finally , one of our readers  said that the average midwife makes $60,000 per year.  If this is the case then she’d still have $37,868 leftover at the end of the year. Not too shabby.

Again, if midwives have issues making this payment then clearly they have two options, just like every other business in the world. Take more clients or charge more.

If the insurance companies were involved then midwives would no longer be able to take women with VBAC, Breech, GD, GBS and a number of other issues.

I’m going to do something I thought I’d never do. I’m going to talk about something that was said in The Business of Being Born. If I recall, the entire movie they were raving about homebirth and midwife care, but they were always saying one thing I feel is important. Midwifery care should be the norm for LOW RISK WOMEN. You can rant and rave all you want to about how normal breech is and how GD is a myth made up by the man, but in every first world country that uses midwives there is a list of things that risk them out of homebirth. Breech, multiples, large babies, transverse…it goes on and on.

There are situations that should risk people out of homebirth. That does not stop midwives from taking these clients, but they should not be taking them—whatsoever.  If having insurance stops midwives from taking high risk clients, then GOOD —  it makes midwifery and birth safer for all of us.

I am sorry that this means some of you will make the choice to give birth in a hospital because you want a birth attendant, but we’ll never have the true numbers about the safety of homebirth until midwives stop seeing clients that should never have been homebirth candidates to begin with.

Friday Fallacy: The US Infant Mortality Rate is Worse than that of the “Third World”

A favorite argument in the anti-hospital contingent is that the US infant mortality rate is SO BAD, that it is worse than “third world” countries.

There are many things wrong with the above argument, not the least of which is that the US “has more infant mortality than most other countries, including 3rd world.” You’d think maybe this was one lone internet warrior, but the argument is everywhere.

My favorite part is that both of these women claim that anyone who doesn’t accept what they say just hasn’t done the research. Anyone want a drink?

Before I say anything else, let me mention that “third world” is an outdated term, and we now use “developing countries” to describe, well, developing countries. But, as I often do on this blog, I digress.

There are two things wrong with this argument. First, it simply isn’t true. The US infant mortality rate, while higher than it should be, in my opinion, is nowhere near the rates of developing nations. Let’s have a look at this map:

Huh. Would you look at that. We’re in the same basic category as all of Europe, Japan, South Korea, Australia…

A graph is a little more your style? Well, here you go:

Again, there is always improvement to be made when it comes to any kind of mortality, and the US rate is higher than many developed nations (The WHO says the American rate is a 5, and countries like Canada, the UK, New Zealand, and Ireland, are a 4 and many Scandinavian countries are a 3. Countries like Poland and Hungary are a 6.), but the United States is nothing like a “third world” country when it comes to infant mortality. We’re far lower than the world average.

The other  — larger — problem with this argument, is that infant mortality is not a measure of maternity care, it is a measure of pediatric care. It covers babies from birth through a year of age. The correct statistic to use is perinatal mortality, which is through 27 days of life. So how does US perinatal mortality measure up?

Have a gander. I used the data from the list of countries that the World Bank considers “high income or developed” to make my graph (I left out Trinidad and Tobago, as the World Bank has given them an asterisk and their PMR is significantly higher than all other nations on the list including, of course, the United States):

The US has numbers equal to or better than 18 of the 31 nations, including Great Britain, France, Finland, Denmark, the Netherlands, etc. In the category of perinatal mortality, the US does much better in comparison to the rest of the developed world than they do with infant mortality. Again, there is always room for improvement when it comes to death rates, but it is a flat out lie that the United States is on par with developing nations in this regard.

No Matter How You Run The Numbers, The Result Remains the Same:

Homebirth, with or without a non-CNM midwife, is more dangerous than giving birth in the hospital.

Keeping in mind that homebirth midwives all claim to work with only low-risk women, lets look at the numbers I posted Friday:

“This Must Be a Joke” rants and raves in the comments of the previous post, calls me biased and stupid, and claims I shouldn’t have used the numbers from 32 weeks on. Other than the insults, she has a point. (I assume she is a she. If not, I apologize profoundly.) So I re-ran the numbers. Several times. Keep in mind that homebirth midwives all claim to work only with low-risk women. If women are having footling breech babies at home, it is only because some CPMs and DEMs lack the education and skill to diagnose the problem ahead of time and are shocked to see feet coming out first down the birth canal.  Or they believe that breech is just a “variation of normal” and low risk enough for birth at home. But I digress. We’ll compare the “other midwife” category (Notice this is midwives who are not CNMs we’re talking about here. There are no women in this category who intended to give birth with their OB at the hospital and somehow ended up giving birth with a midwife in their car on the way instead) with both the hospital numbers that include high risk hospital births — those attended by all hospital caregivers — and those that are only low risk, which are the births attended by CNMs.

Here are the numbers from 37 weeks on:

 hmmm. Looks like homebirth midwives are doing even worse in comparison to the hospital than they were in the 32 weeks-and-beyond numbers. How could that be? Because the 32 week numbers were increasing the hospital death rates! Once the pregnancy approaches term, hospital numbers improve, but it sure looks like the homebirth midwives don’t. Keep in mind, homebirth midwives claim to work only with low-risk women. But wait! These numbers include those babies born before 39 weeks. We all know those are slightly more dangerous than those born after 40 weeks. What happens if you throw out weeks 37 through 39?

 

Even WORSE numbers for homebirth! The homebirth death rate with an other-than-CNM midwife is now virtually TWO TIMES the higher risk hospital numbers, and more than three times the lower-risk CNM numbers. Keep in mind that homebirth midwives claim they work only with low-risk women. But wait, that 42nd week can get dicey! Totally ignoring the fact that most homebirth midwives claim there’s no expiration date on pregnancy, lets just take that out of the numbers. SURELY that must be the problem for homebirth midwives.

 

 

Hmmmm…nope!  While in all three cases above — while their numbers are slightly higher than CNMs working in the hospital — homebirth CNMs have a much more reasonable rate of death than other homebirth midwife death rates, which are yet again twice as high as higher risk hospital rates and more than three times as high as lower risk hospital rates.

Ahhh, but then we have another commentor, NaturalMamaNZ, who takes issue with my numbers. She complains that I have not properly accounted for confounding factors. Fair enough, she could be right. However, a confounding variable in this case would be high risk situations- but it’s quite an anomaly because midwives themselves accept high risk patients — all the while claiming to accept only low risk patients — and create high risk situations (remember, there’s no expiration date on pregnancy…) so there is really no way to seperate that from the data because that would be “cherry picking” good numbers, just like Johnson and Daviss did in NaturalmamaNZ’s favorite study. The data shows what it shows because of the current unregulation of midwifery and the carelessness in their want to accept patients of all levels of risk. Other confounding variables can easily be accounted for by changing the comparison groups to make them more alike. In this case, I changed the search criteria to include the same criteria Johnson and Daviss used – U.S. non-hispanic white neonates of 37 weeks + gestation. I further narrowed the criteria to women between the ages of 25 and 45 attended by the “other midwife” category, in order to remove any higher risk teen moms. I also only included those women with 12 years or more of education, meaning those who are, at a minimum, high school graduates.

 

 

 

WHAT? These numbers are even higher!!! Two times higher than the higher risk hospital births, the ones that include all caregivers, malpresentations, fatal birth defects, and so on,  and MORE THAN THREE times higher than those numbers for the low risk women who deliver with CNMs in the hospital.

But I can hear it now. “This must be a joke” will not stand for the fact that I left women up to age 45 in the group, because we all know they are higher risk. And those numbers include other potential confounders — single mothers, lack of prenatal care, twins, etc., etc. OK. Lets run these numbers, then: non-Hispanic white, singleton, 37 weeks + gestation neonates born to married women ages 25-39 with a minimum 12 years of schooling who started prenatal care before the 7th month of pregnancy. Surely these women — who are the epitome of the woman who hires a homebirth midwife in the US — will have stats that show that homebirth is safe!

 

I’m shocked. SHOCKED. (that’s sarcasm, for those of you who couldn’t tell. By the time I ran these numbers, I had ceased to find any of it shocking. I kept thinking I would be proven wrong with the next set, but alas, it wasn’t the case). These numbers are just as bad. Two times as high for the higher risk hospital births, and three times as high for the lower risk ones.

These numbers are sad. Yes, sad. They represent PREVENTABLE deaths.  Preventable by restricting the kinds of births that homebirth midwives can attend and requiring much higher standards for CPM/DEM education.  Or, better yet, doing away with CPMs and DEMs altogether and requiring a CNM to attend h0mebirths.

(Keep in mind that homebirth midwives claim they work only with low-risk women.)

Guest Post: How to Choose a Safer Homebirth Midwife — A CNM’s Perspective

Please welcome today’s guest blogger, Deb O’Connell CNM, MS. Deb has a private homebirth and well-woman gynecology practice in Carrboro, NC. She has been a midwife for 11 years and has attended over 800 births. Deb has experience teaching at the university level while managing low and high risk pregnancies, community hospital midwifery, gynecological clinics and homebirth.

While writing this for 10Centimeters, I am reminded of the intense debate that surrounds midwifery care for homebirth here in our country. While this is not an exhaustive list by any means, it is meant to give families an idea of some of the important questions to ask while interviewing a midwife for their homebirth.

I am a Certified Nurse Midwife and I personally feel that CNMs with experience managing high and low risk pregnancies are best equipped to attend a laboring woman who plans a homebirth. Why? CNMs are the only credentialed midwife legal in all 50 states. CNMs have been trained and have worked within the hospital setting – exposing them to both high/low risk pregnancies. Most hospital trained CNMs in practice will “catch” anywhere between 50-150 babies a year depending on the size/volume of their practice. CNMs have a master’s level education. CNMs have the lowest neonatal mortality rate of any other provider documented by the Center for Disease Control. Most CNMs are registered nurses that have then decided to move forward with their midwifery education. RNs have a vast knowledge of assessment skills, clinical skills and documented excellence of care. RNs are also licensed in all 50 states and a consumer can go to their state board of nursing to view complaints/grievances filed against their licensed CNM/RN. Finally, CNMs are credentialed to provide full scope midwifery which includes well woman care beyond pregnancy as well as contraception management and menopausal management.

However women will choose whom they want to attend them at birth – regardless of the midwives’ education level, training, experience, credential (or lack thereof) or even licensure.

Let the buyer beware.

Homebirth is not safe for every woman and any midwife who tells you that is grossly misinformed. Birth is not to be trusted – it is to be RESPECTED.

Homebirth is not as safe for baby as being born in a hospital – the NCB community can state it is (and in the past I have stated it as well) – however research has proven differently and parents need to be made aware that if the midwife they choose does not know how to recognize / anticipate when normal is turning into abnormal during the labor or birth, the results can be disasterous for mother and baby. A mother’s birth experience does not trump the safety of her fetus/newborn .

Parents who choose to have their birth at home should be sure their midwife has the following:

  1. Has experience in managing both low and high risk pregnancies.
  2. Licensed and credentialed to practice in your state.
  3. Carries malpractice insurance.
  4. Has a professional relationship with an OB/GYN or Maternal Fetal Medicine team for collaboration, consultation, referral, transfer and transport if needed.
  5. Has a well- organized transport system for her clients and reviews this with you during the pregnancy.
  6. Is willing to share her risk- out criteria, her practice guidelines, her stats and her professional license numbers with you (This should actually be a printed disclosure statement that accompanies the informed consent she has you sign).
  7. Asks you about the distance your home is from the hospital that has an OB Unit – ideally you should live no further than 30 minutes from your nearest hospital.
  8. Has another midwife or RN that attends each and every birth with her and they are both current in their BCLS and NRP certifications and have also had experience managing both low and high risk pregnancies.
  9. Follows you through your pregnancy to six weeks after birth.

Friday Fallacy: Babies Die in the Hospital, Too

So this Friday, we’re going to debunk 3 things.

1. The homebirther battle cry every time a homebirth death is mentioned, “But babies die in the hospital, too!”

 

2. The “fact”  that hospitals actually cause deaths.

 

 

3. and finally, that homebirth is “as safe or safer” than hospital birth.

 

 

So what does the data ACTUALLY say? I “did my research” using the CDC Wonder data sets for all births from 1998-2006.  In the search, I used the following parameters:

 

I used the ages from birth up through 27 days, which is the accepted definition of perinatal mortality. I searched using place of birth (either in hospital or out of hospital) and I searched for all care providers as well as searching only for CNM delivery data.
I also searched the most common causes of perinatal death: Respiratory issues, which includes things like birth asphyxia, neonatal hypoxia; Complications of labor and delivery, which covers everything from malpresentations (breech, etc.) and injuries from the use of forceps or a vacuum to complications of cesarean section andabnormal contractions; and complications of the placenta, cord, and membranes. In addition, I searched maternal (pregnancy) complications — high blood pressure, multiple gestations, etc. — complications of anesthesia during delivery, and infection. Because the argument I’ve often heard against using the CDC database numbers is, “It includes all those babies born in the car on the way to the hospital,” I did the complications of labor and delivery search twice, once with precipitate delivery removed as a cause of death. I also only included data from 32 weeks of gestation and beyond, because I imagine that even the most hardcore homebirthers would head for the hospital if they went into labor earlier than that.

 

This is what I found:

 


So here’s the thing. Technically, “Babies die in the hospital, too,” is true. However, the implication is that “Babies die in the hospital at the same rate and because of the same things as they do in homebirth.” And THAT is not true. Out of the hospital, babies die at a rate 2.5 times the hospital death rate. And with Certified Nurse Midwives? It’s better, but still one-and-a-half times the rate with CNMs in a hospital! So babies do not die at the same rate in the hospital as they do in homebirth.
Not only that, they don’t die of the same things.
  • Babies outside the hospital die at nearly 3 times the rate of in-hospital babies of complications of the placenta, cord, and membranes. That’s things like placental abruption, nuchal cords, true knots, and so on.
  • They die of respiratory issues (birth asphyxia, neonatal aspiration, hypoxia…) at four times the rate.
  • Infection causes death at nearly twice the rate outside of the hospital.

But the most shocking number of all is the number for complications of labor and delivery. It is nearly eleven times –ELEVEN TIMES!!! — as high for babies born outside the hospital. This is the category that contains breech birth and other malpresentations. These babies aren’t dying from congenital abnormalities; they’re dying preventable deaths. The only category where homebirth is better than the hospital is maternal pregnancy complications, and that’s nearly equal. Homebirth should be blowing hospital birth out of the water, here — they are all “low risk” women, whereas the hospital numbers include all risk levels.

As for hospitals causing deaths, look at the numbers.
  • Not a single death attributed to complications of anesthesia and analgesia, which can only be done in the hospital.
  • I hear lots of scare mongering going on about infection in the hospital, but the out-of-hospital numbers are more than TWICE as high!
  • Complications of delivery — the category with those awful c-sections that are slicing babies open and vacuums crushing babies’ skulls — are, best-case-scenario, more than eight times higher outside the hospital, and if you add in precipitous birth, it’s almost eleven times.

Now, I know what you’re thinking: “Those numbers include all births outside the hospital, even those which are unattended!” That’s right. Many births attended by midwives are not reported as such, simply because the midwife is illegal and hides in a closet before the EMTs arrive, telling her clients not to mention she was there when the you-know-what hit the fan. Not only that, many of the same people promoting homebirth are also promoting unassisted childbirth as safe. But I understand your great concern. That is why I ran some numbers for the “other midwife” category out of the hospital:

 

 The death rates are 1.3 times higher than hospital rates, but that is for all risk levels. The best comparison is to CNM’s in the hospital. Other midwives outside the hospital have a death rate almost THREE TIMES the rate of CNMs in the hospital. And in comparing respiratory related deaths with ALL hospital births (including those attending by doctors), the rate of death for out-of-hospital births is more than four times for other midwives, and is a shocking nine-and-a-half times higher than the rate for CNMs in the hospital.

These are the cold, hard numbers. Excel did all the math for me, so I’m pretty sure they’re correct! These clearly preventable deaths are the reason that I am so passionate about this. Please, the next time someone tells you that homebirth is “as safe or safer” than hospital birth, do me a favor and tell them they haven’t done their research.

If you’re gonna hate, please do it publicly!

Don’t be like “Bethany Morningside” and write nasty things using a fake profile where only I can see them. Not that it will do you any good. Also, I would like to extend my congratulations to Ms. Morningside  for proving my point so eloquently!

ETA:
Ahahahahahaha!! And after they were SO INDIGNANT that someone would come to their forum and “troll.” Pot, meet kettle.

Just to Clarify…

We here at 10centimeters aren’t against natural birth. Several of us have even had one. We’re not even against homebirth, given the right woman and the right midwife! We support women who choose to give birth without pain relief, women who choose c-sections, women who can’t have children, women who adopt children, and women who choose not to have children at all.  What we don’t support is the way the way the leaders of the natural birth movement try to shame women into having a very specific kind of birth using misinformation, half-truths, and occasionally outright lies. We also don’t support sanctimommies bashing women for their choices. We, however, DO NOT CARE how any individual chooses to give birth.

 

What are we for?

  • Better training and stricter clinical standards for homebirth midwives in the US
  • Mandatory malpractice insurance for all homebirth midwives
  • Mandatory reporting of outcomes and better recording (i.e., no planned homebirth transfers counted in hospital stats, no unintentional homebirths counted in planned homebirth stats)
  • Real evidence-based maternity care, with the understanding that science/medicine changes practices as the body of evidence changes
  • Open and honest discussion without stifling one viewpoint under the guise of not wanting to scare people or being “supportive”