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.

19 thoughts on “Guest Post: What We Say to Loss Moms

  1. So much great information in this article. The info on fetal heart tones information is something that I think homebirth moms are NOT told. I wish I would have know before I had my son. The midwives were fine with his heart tones . . . until all the sudden they could not pick up any at all anymore. Even then they brushed it off, saying it must be in a weird position in the birth canal so it couldn’t be pick up. He was born not breathing and now has Cerebral Palsy from the lack of oxygen to his brain. Biggest regret of my life is taking the midwives at their word.

  2. The more interesting part is that the Midwifery community simultaneously derides MD’s and exalts them.

    “The MD’s are all liars…out for a buck…but the liars out for a buck said it would have happened in the hospital too….”

    How can this cognitive dissonance be? I scratch my head frantically just thinking about it.

    • The hilarious part is that the midwives make way more than the doctors do in the hospital, because it’s not like the money you pay at the hospital goes directly into the doctor’s pocket….there are security, janitors, and every other job in the hospital that needs to be paid for too.

  3. Thank you for this excellent post. In particular, I appreciate hearing the “other side” of the homebirth transfer picture.

  4. Loved this…this site has so many wonderful articles and info. I’m so sick of extremist putting down drs and licensed midwifes…guess what? People would still be dying of cancer soon after diagnosis if it weren’t for drs. I want to say to all you extreme ncb’ers…get your head out of your butts and stop being selfish and making the births all about you and playing with your babies lives…if you can’t stop putting your children lives at risks by ignoring the health risks then stop having kids.

  5. Very interesting to read. To be honest I am looking at homebirth for my third child. I two c sections in hospital both unplanned. My first was for ‘failure to progress’ as the induction drugs ‘Did not do the job’ (my OB’s words). My second was after labour and full dilation (I was due to have a planned c section as I was post dates but went into labour two days before, as it was late at night I was told I would have to wait till morning for my OB. After 6 hours of labour drug free (not my choice I was told nothing was available) I was in transition but something was stopping my son from coming all the way down. I was then told that because I had been pushing for more then an hour I had to have a c section as hospital policy did not let previous c section mothers push any longer.

    So why do I look at homebirth? My previous two experiences have left me at the point where I have a massive fear of hospitals. Both of my c sections were awful in that I was treated as less then human. I had students invited in to watch the births without my consent, my husband was barred from one even though he had been told he could be there. I had crude jokes made about me while I lay there, a needle was left inside me, both scars took a long time to heal and one needed to be repaired. There was much more that I don’t want to air in public but the the short end is that 2 years since the last one I am still seeing a psychologist. For me the risks associated with homebirth are starting to look worth it as the risk of being humiliated and degraded by an OB and other hospital staff is not one I can face again.

    In the support group I belong too I have seen over 40 previous c section mothers to go on and birth at home with no complications or transfers. They have ALL come back with great stories of being treated as a person and not a slab of meat. The midwife I would go with has been doing homebirths for 20 years and only 5 transfers in that time.
    I know too that in Australia our homebirth rate is slowly rising and from what Im reading many women are choosing it after poor hospital treatment.

    So I guess after all this the question I now feel entitled to ask is why should I trust an OB? My experience has taught me that OB’s are happy to take your money but will not treat you well. They will harm you, scar you and joke about it. My first son still bares a scar on his head from the OB’s scalpel. Im not able to be one of those people who can say that I would do it again for a healthy baby as both my boys and I were healthy before our treatment and left maimed because of it. I know homebirth can go wrong and be just as bad but I feel that only a fool would go back to an OB a third time after my experiences. And I admit I feel like a fool, I feel silly that Im so afraid and gutless because Im scared of being made to feel less then human again. Where should women like me go? I know Im not alone but for some reason stories like mine get lost or pushed aside and women like me just have to deal with it alone.

    • Jean,

      You were treated horribly by doctors and hospital staff. You shouldn’t have been. I am very sorry for what you have been through. When doctors mistreat their patients, they lower the quality of the entire medical community. Not all OBs are like that, even if you feel like they are because of them. It is unfortunate that you encountered bad OBs, but I do not think you should take that as a statement against all doctors. Come on. You can’t really believe ALL doctors and hospitals are like that. I am in no way trying to lessen the pain of your experiences. I am saying I hope you understand that your two bad experiences are not the be-all-and-end-all of obstetric care.

      My question for you is, does it have to be home birth? You have had two previous c-sections. The safest place for you is a hospital. But can you find a midwife who can be your primary in the hospital? If your greatest problem is a fear of mistreatment, then your greatest ally is communication with care providers beforehand.

      Are there any birthing centers attached/neighboring the hospital? Do you have a choice to go to a different hospital than your previous births? Can you find a new OB and explain your fears and concerns to them?

      Like I said before, the safest place for someone with your medical history is a hospital. However, your fear is understandable. No one should be treated the way you were treated. But poor treatment does not mean you should risk your health and safety, and those of your child. At the risk of throwing out a ‘cliche’, how would you feel if you are treated like a queen next time, but get a dead baby out of it?

    • Jean, I am so sorry for how you have been treated. I understand where you are coming from to a large degree because in my community, we truly do not have good hospital options. We don’t. And it is a large part of why I am planning my 4th home birth. So, please do not think that I am against home birth.

      Here is what has me concerned:

      1. I’m really, really concerned about a midwife who has been practicing for 20 years and only transferred 5 times. That’s not a good transfer rate assuming she’s done more than about 3 births a year. I know it seems counterintuitive, but honestly if your midwife doesn’t have a *high* enough transfer rate, I guarantee there are moms with under treated anemia after post partum hemorrhage. I guarantee there were near misses with health issues to the baby. I guarantee that you have under diagnosed tachypnea of the newborn, which can be normal or can be a sign of a massive infection that can be treated effectively most of the time *as long as it is caught in time.* 20 years matters far less than the total number of births.

      2. I don’t think it is unreasonable to want to be able to attempt a VBA2C. But *how* you attempt that is going to be a game changer in terms of the likelihood of having something that could cause serious danger to you and your baby. The first sign of rupture is normally heart tone problems with the baby, and you really really really need to be on constant monitoring for that. And once again, I’m supportive of VBA2C. But you are not going to be able to know that the choice you’re making is safe and you’re good to keep going without that reassurance from the monitors.

      And I think that uterine rupture is really not the only thing you should be worried about. There’s a lot of other stuff that can become an issue. A friend was making a VBA2C attempt and she had a full placental previa and her placenta actually grew *through* the scar tissue and was wrapping around other organs. It’s called placenta percreta and it is fatal I think 1 in 12 times even with the best care.

      I am so sorry that things are so scary for you, but honey… this isn’t an issue of it being sometimes “just as bad at home.” You being irreparably harmed and your baby being harmed or killed by a delay in treatment is far worse than even the most abusive caregivers. And I’m sorry that you’d have to make this choice, and second the poster who asked if there was another hospital you could go to, but if it is choosing between abusive caregivers and having your baby that far away from emergency help when you truly *do* stand a much higher than average chance of needing it, you do need to choose the few days of trauma for you versus the unfortunately much higher than average chance of injury or death if you do not have access to immediate surgery if needed.

      I wish there was something else I could say, but you’re not low risk. You’re not, and it would be cruel and deceptive to say that you were low risk and bank on luck being on your side. Best wishes for your birth and *hugs.*

      • You said this so well. I’d have to agree 😀 Also, we have a great article written by a homebirth midwife on how to find a good homebirth midwife, complete with insurance and a regestry on the State Board of Health 😀

    • “In the support group I belong too I have seen over 40 previous c section mothers to go on and birth at home with no complications or transfers”

      I just wanted to comment on this….I’m not sure what kind of support group it is (c-section, maybe?), but personally if I lost a baby I wouldn’t be in a support group full of people with healthy VBAC babies. *shrug*

      Honestly, I’d try giving birth in a birthing center that is en suite to a hospital (if you have that option). Then you get a licensed midwife who has hospital access and if anything goes wrong, expert medical care is right next door.

  6. Jean – first of all, let me say that I am sorry that you had such terrible hospital experiences. Medical students should never be allowed in unless the patient explicitly consents to it, and you should never have been made to feel sub-human. I hope that you made formal complaints, because this should NOT have happened. I don’t think that anyone here would deny that malpractice can and does happen in the hospital, and that there is room for improvement in hospital care.

    Having said that, please, please, please reconsider a home VBAC! Uterine rupture is a rare complication, but when it does happen, minutes count. Since you have already had 2 c-sections, you’re at higher risk of having a rupture to begin with. I have read about other women who have had disastrous complications from home VBAC attempts, including death of the baby, loss of the uterus, and even death of the mother.

    I don’t know where you live, but do you have more than one hospital available? Is a large hospital system within driving distance? Many small hospitals still do not routinely perform VBACs simply because they do not have the resources available to ensure the safety of the mother and her baby (they need to have 24 hour anesthesia, the OB must be in the hospital for the duration of the mother’s labor, and there must be a dedicated OR for crash c-sections).

    I really hope that you can find an OB and hospital that you are comfortable with. Given how poorly trained the majority of homebirth midwives are, I can’t help but feel afraid for you should you decide to give birth at home. I have delivered with a CNM in the hospital (they don’t do homebirths), and I know that there are CNM practices that do hospital VBACs.

  7. I had a home VBAC. I had a pph that you would not believe. It freaked my husband out. Thankfully, the midwives stopped it in time, but I was unable to even sit up afterwards without passing out. I couldn’t pee (too potty trained to pee in a bedpan/tupperware). I had to transfer to the hospital because I had lost so much blood.
    I asked the midwife what would have happened if my baby had been in trouble too (because it took the the midwife and her student both to stop the bleeding), and she said it had never happened to her (so, my take, SOL on that one).
    I thought that having a vbac would be a magical, womanly, empowering experience. It wasn’t. It wasn’t bad, but it wasn’t this amazing thing. Recovering from the anemia of the blood loss (‘crit went down to the high 20s, barely avoided a transfusion) was about as hard as recovering from the c-section.
    Thinking back on it all these years later, I am spooked by my decision to attempt a vbac at home. It all worked out okay in the end, but it was a close thing.

    • D – I had a massive pph too. It was during my first, totally unmedicated birth. There were three people tending to me, plus the pediatrics team that was checking on my son who was not crying robustly. If I had been at home, I would have died, because the bleeding was being caused by a cervical laceration. Even with a prompt trip to the OR for surgery, I still just missed having a blood transfusion. I still clearly remember waking up in the middle of the night and feeling that I had been duped. My birth was not an empowering experience. In fact, I don’t ever remember feeling more frightened, because I knew that I could have died. I am currently expecting baby no. 2, and I am frankly terrified about giving birth again. I am excited about having another child, but any naivete that I had about childbirth is gone.

  8. I wish so much that women who are thinking of homebirth could understand the situation clearly. That delays in transport are time they can’t afford when their baby is in distress. That continuous fetal monitoring, and not just listening with a doppler, is critical in recognizing when a baby is going into distress, and that homebirth midwives tend to be so biased towards natural birth that they tend to downplay emergencies and obscure facts (like post dates) because it doesn’t fit it with their philosophy. So no matter how appealing homebirth might look on paper, in reality its very risky business, and its just not worth it.

  9. I want to thank you for this lovely guest post. As my handle indicates I am a student midwife who is learning the ins and outs of what makes a safe, expedient, responsible transport. Midwives are a *huge* mixed bag. Especially when it comes to the “is it time to transport” question. I agree so strongly with PrecipMom that a super low transport rate is a red flag. (I will make the exception for midwives who work with extraordinarily healthy and particular populations, such as the Amish, but no one else.)

    Martha, I’m really glad to note that you are aware that the midwives coming in are scared. This is a *huge* problem. I am very very fortunate to work with midwives who are reasonably conservative with their transports and have an excellent relationship with the local hospital. There is a double edged sword happening where many doctors feel that all midwives cannot be trusted, and many midwives feel like all doctors are out to end midwifery. Neither of these statements are true, but there are *some* midwives who make the wrong call more often and *some* doctors who would like to see midwifery irradiated. Without some really really intense communication, there is an atmosphere of distrust at transports that serves no one well.

    Like I said, I am lucky enough to be working with midwives who regularly have meetings with the local hospital to discuss how transports can be handled well, and when transport should be initiated. It’s fabulous collaboration and it makes for really excellent care for our moms and babies.

    I can also guarantee that most midwives are more likely to transport sooner (making for more non-emergent transports and fewer emergency transports) if they think their client will be well received, not, for example, told she was killing her baby for trying a homebirth at all as happened to my sister when she transported for an acynclitic babe with good heart tones. I wish this wasn’t the case, but it’s true.

    • I think what you are taking about, meetings and conversation, as well as midwives who are willing to drop at the first sign of trouble is absolutly nessessary if we are to have safe homebirth. Teh “mixed-nag” has just got to go. Might I ask if you are a CNM or a CPM in training.

      • Yup, those meetings and conversations are vital. Both “sides” need to let go of some major preconceptions and find out what is actually going on for the other party/parties.

        I am a CPM student, I’ve already completed three and a half years at one of the MEAC schools and am 1/3 of the way through my clinical training. I thought about doing a CNM, but I knew how hard it can be for a CNM to get malpractice coverage in my area if she is doing homebirths and I knew I would be miserable working in a hospital I went and sought out midwifery education elsewhere.

        It breaks my heart when politics, policy, and ego get in the way of helping families. I’ve see it in midwives (CPM and CNM alike) and I’ve seen it in doctors. Divisiveness will get us nowhere.

  10. I had my first baby at home,, thank goodness my son was born healthy. I had a PPH and needed to be transported to the hospital. The doctor at that hospital was a monster. My second baby was born at a wonderful hospital that supported midwives,, I had a perfect birth, no complications. Baby number three was 10 lbs and 2 weeks over due at a hospital,,, this hospital was awful,, I hated everything about it. Baby number 4 was at same hospital as baby 3,, was induced 2 weeks over,, baby was sideways, 11 lbs, and I needed a c-section. My baby was fine and healthy,,, hospital sucked. I hated everything about the hospital stay. I was a surrogate for the 5th baby I delivered (not mine genetically) she was 6 lbs,, I had an induced VBAC, awesome experience,, great hospital great staff,, this was the same hospital as baby # 2, in *******, Alberta Canada. Baby number 6 was born at the same hospital as baby 3 and four,,, needed an emergency c-section due to dropping heart rate,, hated the hospital and everything about the way they did things,,, in the end my son was born with lungs full of meconium, had he been born at home he would have died,,,,, Thank God he is alive and healthy today,,, I would gladly put up with the crap I got from that crappy hospital to take home a healthy baby in the end. Birth number 7, I was determined to have my daughter in a different hospital,, I would have loved a home birth,,, but was not willing to risk my baby’s life to have her at home. So I drove the extra hour to another midwife friendly hospital. My baby was breech,, they attempted to turn her at 41.5 weeks. My wonderful baby girls heart rate dropped as they turned her,, and she bounced back,, however the water had broke and we were committed to a birth that day. My doctor said we could try a breech VBAC, as I had delivered large babies in the past and they figured this baby was going to be smaller. I declined and requested a c-section,, I wanted a healthy baby more then I wanted to avoid a section. The cord was wrapped several times around my baby girls neck,, it took three doctors and 30 minutes to deliver her by section….. Thank GOD I opted for a section,,, I am convinced she would not be here if I had opted for a home birth,,, And I am convinced she would have been born with severe brain damage had I insisted on a breech VBAC. The doctor said to me after,, “God must have been looking out for you,, because if you had opted for a VBAC your baby might not have made it.” This was an awesome hospital,, awesome nurses and a doctor that listened to a mom to be. Thank you ******* Hospital! . … Please….. please focus on the baby,,, not the romance of a great birth. A birth only lasts a few hours and your stay at a hospital a few days,,, A baby’s life is forever,,,, This comes from a person who would much,, much prefer a home birth as doctors and hospital staff can be huge jerks, that treat people as morons. I would gladly be a treated as a moron and come home with a baby then treated wonderfully and end up with aching arms. . DAMN it WHY!

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