Nine Times Nothing is Still Nothing

Please welcome guest blogger Mrs. W! She is a a health economist, a mom and a modern feminist who lives in British Columbia and blogs at Quality Care for BC Mothers.

The Nine Statements of Consensus from the Home Birth Summit: Nine Times Nothing is Still Nothing

There are substantive and real issues confronting the home birth and obstetric communities in the United States.  Having a summit could have moved things forward, fairly substantially, if they actually took the 9 pre-determined agreed upon consensus statements and used them as starting points, instead of accomplishments – because nothing is accomplished as a result of the statements made.

  •  We uphold the autonomy of all childbearing women…
 Autonomy in the absence of complete and unbiased information is meaningless – there cannot be free informed choice when the information given to women on childbirth is incomplete or biased.  A woman must be informed of the risks and benefits of the choice she is making if she is to be empowered to make the choice that best meets her needs and the needs of her child.  If the autonomy of childbearing women is to be upheld, there must be a consensus on what the real facts of childbirth are, and a commitment to providing that information to women in an unbiased and accessible way.  
  • We believe that collaboration within an integrated maternity care system is essential for optimal mother-baby outcomes…

Again a really lovely idea, but, clearly there are substantial barriers to making this a reality in the current system.  In order to collaborate, midwives and OBGYNs need to speak the same language.  In order to collaborate, midwives and OBGYNs would need to hold each other in esteem and respect.  In order to collaborate, they need to facilitate the work of one another.  This means that when a woman who is at risk in labor is transferred to hospital for care, the hospital is prepared for her arrival before hand and the midwife is capable of giving full and appropriate information about the woman and her labor to the OBGYN upon arrival.

  • We are committed to an equitable maternity care system without disparities in access, delivery of care, or outcomes…

Homebirth as it exists in the US today does not ameliorate disparities in access, delivery of care, or outcomes – it accentuates them.

Women in the US are far more at risk accessing the homebirth system than the hospital birth system.  They are at risk of having a care provider who does not undertake standard and appropriate prenatal care (gestational diabetes testing, group B strep testing, weight and fundal height measurements, and pre-natal ultrasounds).  They are at risk of having a provider who does not have adequate and appropriate education and experience.  They and their babies are at greater risk of death or disability and they are at risk of having a provider who does not carry malpractice insurance and who would be held accountable to a lower standard of care in the event of death or disability.

There will continue to be disparities in access, delivery of care and outcomes seem unavoidable in the current context.

  • All health professionals who provide maternity care in home and birth center settings have a license that is based on national certification that includes defined competencies and standards for education and practice…
This begs the question what is the appropriate standard?  Furthermore, in the absence of legislation, what would be the consequence of failing to meet the standard?
  • We believe that increased participation by consumers … is essential to improving maternity care…
Is this the facilitation of informed joint decision making during the care delivery process?  If so, See number 1.  Or, perhaps more meaningfully, will this mean that consumers would have a way of voicing their concerns and having those concerns heard in much the same way that hospital patients can have a formal review of the care they received?
  • Effective communication and collaboration across all disciplines caring for mothers and babies are essential for optimal outcomes across all settings…
See #2.
  • We are committed to improving the current medical liability system …
Another starting point – what medical liability system currently applies to homebirth midwives?  Doesn’t a system need to be in place before it can be improved upon?  Is there an insurer that would take on the risk in the current environment?
  • We envision a compulsory process for the collection of patient … data on key … outcome measures in all birth settings….
So. Data is collected. MANA collects data. Does a $#!T load of good – unless you commit to releasing the data, it means nothing. Data existing does nothing without it being available to be analyzed, actually having it analyzed and releasing the results of that analysis.  Furthermore, there needs to consensus on what data elements are critical and the definitions of those elements – this is essential if the data across birth settings are to be comparable and the data is to be transformed into meaningful information.
  • We … affirm the value of physiologic birth … and the value of appropriate interventions based on the best available evidence to achieve optimal outcomes for mothers and babies… 

This seems at odds with valuing patient autonomy, particularly when not all pregnant women giving birth would choose physiologic birth if given complete information to make an informed choice.  Furthermore, valuing the particular process of birth (physiologic, a.k.a. “normal birth”) places form over function – shouldn’t the ultimate goal be healthy moms, healthy babies regardless of delivery method?



3 thoughts on “Nine Times Nothing is Still Nothing

  1. For #2, the midwife must be compelled under threat of loss of credential to provide FULL information. I’ve seen too many sad stories where incomplete information costs lives, and saving the OOH provider’s skin is placed above care for the patient.

  2. “Furthermore, valuing the particular process of birth (physiologic, a.k.a. “normal birth”) places form over function – shouldn’t the ultimate goal be healthy moms, healthy babies regardless of delivery method?”

    Yes. But with the caveat that it’s very easy to over emphasize how much technology can do to achieve those goals. Modern Western medicine is based both on public health and the medical needs of warfare. It should come as no surprise that what it excels at is surgery and drugs.

    I’m grateful for the safe surgeries and drugs we do have. However, in other areas of my health, I have repeatedly experienced that simple changes to diet and lifestyle improved my health in ways that no Doctor has been able to supply via pill.

    And when I have sought out medical treatment it was because the simpler, more direct approach (nutrition, rest, etc) wasn’t working well. In other words, medical invention was clearly very required, an unambiguous need, and I was grateful to have the option.

    If I had to list the major birth miracles of the 20th century, it would in this order:
    -Improved nutrition
    -Improved nutrition (yes, I said it twice)
    -Understanding of germ theory->worrying about general cleanliness
    -Safe blood transfusions
    -Bottled oxygen
    -Modern antibiotics

    Note that C-sections make it to the bottom of the list. The simple stuff: better food, cleaner birth conditions, blood transfusions and antibiotics make giving birth now safer than at any time in history. Safe c-sections are the proverbial icing on the cake.

    At the turn of the 20th century some doctors would run from the morgue, hands unwashed, to catch the babies of poor women in hospitals (an extension of poor houses at the time). Not surprisingly both the babies and women didn’t fare so well. In other words, hospitals didn’t always have the track record they do today with safety. No woman with means would have been caught giving birth in one in 1900.

    From what I’ve read, the remarkable increase of hospital births in the 20th century had far less to do with safety than with the availability of improved pain medication only at the hospital. The narratives I’ve read of Doctors attending homebirths through in the 1920-1940s, they encouraged mothers to go to the hospital not because it was safer, but because they could offer pain relief they would be unable to do at home.

    I’m keenly aware that most of my ramble above is opinion, personal experience, and some history interpretation. What I’m suggesting are possibilities. Maybe for all the unfortunate new-age who-ha surround homebirth community, they are onto something. Maybe it does makes more sense to look at simple things first: nutrition, better emotional support of women through the birth process (a point that modern American hospitals sorely lack), etc before looking at advanced technology in improving outcomes.

    It’s possible that MDs and modern hospitals are in fact getting loads credit for some rather simple advances in technology and nutrition achieved decades ago, available to most women in any birth setting.

    And it’s just possible that women initially turned to hospitals because not because they were perceived as safer, but because it was a more attractive option in terms of pain relief. Hospitals = safer is a narrative of modern times. It may well be true today, but my other experiences with modern medicine have led me to believe it’s best not to make a blind assumption.

  3. The difficulty with birth is that it is impossible to know before hand if you are a woman who would be better off without intervention versus one who would be better off with intervention. Only hindsight enables a woman to know whether or not her choice was a good choice or a bad choice – and we owe it to women to minimize the risk that the choice made was a bad choice.

    Based on the information that I’ve seen on this topic – currently in the US, homebirth is a much riskier option (in terms of death and disability) than hospital birth.

    I also note that hospital birth may carry a higher risk of having interventions during labour and delivery – however, it would be wrong to assume that those interventions are without value.

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