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Oregon State University says a new study describes a "pattern of distrust" in the relationship between hospital physicians and midwives who transport their patients to hospitals due to complications during homebirths.
The study (led by OSU assistant professor and midwife Melissa Cheyney) looked at birth records in Oregon's Jackson County from 1998 through 2003 to determine whether a correlation existed between poor health outcomes and homebirths.
While the study didn't find a link between the two factors it did reveal ongoing conflicts between doctors and midwives with physicians asserting that only hospital births were safe. This finding is in line with a 2008 American Medical Association resolution (pdf), which stated:
The safest setting for labor, delivery and the immediate post-partum period is in the hospital, or a birthing center within a hospital complex.
Have you given birth in a hospital or with the help of a midwife? What was your experience? Did you experience tension between doctors and midwives?
Are you a doctor or a midwife? What conflict exists between the two professions?
Special thanks to moline543, who suggested a show about homebirths and midwifery a few months ago. We liked the pitch, but wanted to wait until the issue had gained some newsy prominence. Now it has.
GUESTS:
- Holly Scholles: Direct-entry midwife and president of the Oregon Midwifery Council
- Karen Adams: OBGYN and associate professor of obstetrics and gynecology at Oregon Health and Science University
- Gail Littlejohn: Director of Family Birth Place at Adventist Medical Center
Tagged as: births · doctor · home delivery · midwives
Photo credit: ThomasLife / Flickr / Creative Commons
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Having said that, though, it has been abundantly clear that the vast majority of physicians are very opposed to losing their power over women and birth. Under the guise of "safety,"
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I am a certified nurse-midwife who delivered babies both at home and in the hospital for more than 20 years. In my opinion, the hospital environment creates far more problems than it solves for low-risk birthing women and my strong preference is for birth outside of the hospital.
Having said that, though, it has been abundantly clear that the vast majority of physicians are very opposed to losing their power over women and birth. Under the guise of "safety," they oppose all attempts that women make to deliver anywhere besides the hospital and are often outright hostile to women who, because of complications that might arise during a labor at home, have to transfer to the hospital for high-risk care.
Obstetricians are trained surgeons who spend the majority of their medical education learning to deal with complex obstetrical complications while midwives learn how to take care of women experiencing normal pregnancies and births. Because not every pregnancy that starts normal stays normal, lines of care get blurred - but BOTH specialties are necessary to maintain balance in the maternity care system.
I fully advocate supporting midwives as independently functioning health-care professionals who care for low-risk women in the birth setting of their choice, providing that care within a system that allows for seamless transfer to hospitals and/or physician care if complications develop so that the level of care is always appropriate to the level of risk.
In my former homebirth practice, with careful screening and following protocols that provided parameters around risk-assessment, my outcomes (maternal and neonatal morbidity and mortality) were unmatched by anyone delivering babies inside the hospital, including physicians.
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Beautifully said.
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While this show is about home birth vs. hospital birth, I want to make sure people know that there is another option: a hospital-based birth with midwives. Here in Portland, OHSU, Legacy and Providence all have hospital-based nurse midwifery practices. (Links are directly to nurse-midwife practices.)
I had a C-section with my first baby, and a VBAC with the midwives at OHSU with the second. My experience being under the care of a midwife was vastly different and vastly better than my experience with an OB.
The main thing I wish I had known before my first birth is that an OB/GYN is a surgical specialist, trained to spot and treat gynecological and pregnancy-related problems. However, most women have normal, uncomplicated pregnancies, and don't need specialized medical care during their pregnancy.
Midwives and nurse midwives take a much more nurturing approach, treating pregnancy and birth not as medical events, but as emotional, physical and spiritual processes that may have a medical element in some cases.
Most importantly, women need to understand the implications of the care provider they choose. Books I found helpful in educating myself were:
- "The Thinking Woman's Guide to a Better Birth" by Henci Goer (Provides an overview of the philosophies, approaches and roles of OBs, OB nurses, nurse midwives, direct entry midwives, and doulas/labor assistants in birthing babies.)
"Ina May's Guide to Childbirth" by Ina May Gaskin (Provides a whole host of stories from women who have had positive birth experiences, as well as presents a birth philosophy outside the mainstream American cultural paradigm.)
Thanks for starting a conversation about this topic.
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Wonderful comments. Thank you for talking about the differences between midwife care and a surgical specialist care. It's wonderful that you had both a c-section and a VBAC, so you can talk about both experiences. Delivering a child doesn't have to be the extreme fight over home birth vs. hospital birth. It really is best with an educated decision, lots of options and trained people. Sometimes a c-section is necessary and we should thank the medical institute and sometimes there are normal deliveries where a natural approach should be welcomed. Wonderful book recommendations.
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I am currently 20 weeks pregnant with my second child. We are planning a home birth/ water birth. This will be my second water birth and my first birth at home. With my son I had planned a traditional hospital birth and was recieving prenatal care with an OB. At 30 weeks I switched to a birth center because it was becoming more apparent that it was MUCH more difficult to get the birth I wanted from a hospital. The difference in prenatal care was the first major difference I noticed. I hardly saw my OB, I was in and out and spent most of the time with the nurse. With each of my midwife appointments I felt like they wanted to know me as a whole person. They reassured me that birth and pregnancy were natural normal things and that pregnancy wasn't an illness.
As for emergencies and things that could go wrong, I know there are risks, the same risks (if not more) in a hospital. As I feel that some of the hospital "emergencies" are caused by the interventions doctors push on patients.
“The hospital doesn’t react quicker if you are giving birth there, it doesn’t influence mortality rates. In hospital, there is not a sterile team waiting in the operating room in anticipation of an emergency, it takes them about a half hour to be ready. In principle, if you are giving birth at home, it is the same. The moment the midwife calls to say a medical transfer is necessary, the gynecologist brings the appropriate team together.”(source)
Two recent studies, one conducted in the US with over 5,000 births and the other one in Europe with over 500,000, concluded that having a birth at home with a midwife was as safe as having birth in a hospital, and depending on your view of unnecessary interventions (that can often lead to birth trauma and interfere with breastfeeding) home births can be considered safer.
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I’m so glad you identified some sources here. Home birth is as safe or safer than hospital births. I completely agree that the medical intervention and drugs, cause the woman’s body to shut down and then a serious problem can arise. I recommend that everyone watch “The Business of Being Born” by Abby Epstein.
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I am a certified licenced midwife who has attended out-of-hospital birth in the Portland Metro area for 26 years. My understanding has been that there are only two major hospitals with on site OB's 24/7 : OHSU and Emanuel. Every place is different in protocol and response. Some hospitals will not call the OB in until a nurse has first assessed the need. In other cases, when we have requested a surgical team to be enroute immediately, the team was walking in the door at the same time we arrived. These are the very rare moments where respect between doctor and midwife are crucial to outcome as well as the experience of the birthing family.
I can say that the majority of my experiences with transfer to physicians have been very positive. The best transfers of care occur when both midwife and receiving physician refuse to view one another as an adversary, but accept the other as a co-helper for the laboring mom. The excellent midwife prepares her clients prenatally to view the hospital as a positive place, there to help them if the need arises. She will communicate openly with hospital staff and not take a defensive posture. The excellent physician will ask the midwife for her insights and ideas on how to help the birthing family. These wonderful doctors express empathy to the famiy, acknowledging that things didn't unfold as they had hoped. This respect assists the family in accepting needed medical interventions and generates a best outcome scenario both medically and emotionally.
In my experience, those rare hospital transports that are truly horrific are usually not due to physician disagreement with care decisions made by the midwife, but to the fact a home birth was planned in the first place. I have seen Doctors yell at parents, call them idiots, and actually cause serious medical harm, neglect patients, or refuse to provide care due to their anger and prejudice. Midwives can be just as wrong when they delay timely transport due to hospital prejudice. Fortunately, most Doctors and midwives are professional enough not to let their strong opinions compromise good care.
If we truly care about the mothers and babies we serve, both physicians and midwives would develop working relationships where they view one another as allies and work together for optimal outcomes and experiences.
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I planned to have a home birth until 38 weeks into my pregnancy when my blood pressure started to increase and it was decided that I was too high risk. I was subsequently transferred back into the conventional system, and at 41 weeks my labor was induced with Pitocin.
Having experienced both (at the same time!), I can definitely say that tension exists between the home birth and the hospital midwives. The home birth midwife came to my birth in the hospital, and though she and the hospital midwife were cordial to one another, it was clear that the hospital midwife felt as though the home birth midwife was stepping on her toes. At one point when I asked the hospital midwife to please just wait a minute for me to get through a contraction before asking me any more questions and demanding I make decisions, she snapped "do you want me to treat you?" I knew that outburst resulted more from the presence of the home birth midwife than from anything I said or did, but it was definitely not what I needed. -
The majority of low-risk women (by this I mean essentially healthy women, carrying one baby, without pregnancy complications) who are cared for by experienced and well-trained midwives are likely to have safe and positive births at home or in birth centers. There are several well conducted studies to support the safety of homebirth under these conditions. Problems emerge, however, with those few out of hospital midwives or "cowboy midwives" who agree to care for women with higher risk pregnancies or do not transport to the hospital in a timely manner when complications arise during birth, resulting in higher morbidity and mortality. The evidence to support homebirth as safe has only been established with low risk women.
I disagree with xelakann's statement regarding the delay in receiving emergecy care in the hospital. The only time that response to an obstetric emergency would be delayed 30 minutes would be if you are receiving care in a rural hospital or one in which essential emergency staff (anesthesiologists, physicians) are not at the hospital at all times but take call from home. Large hospitals, like many in the Portland area, are set up to be able to respond very rapidly to an emergency. For the rare birth that results in a true, unforseeable emergency, large urban hospitals are exquisitely well prepared and are exactly where that laboring woman should be. The problem with in-hospital birth is not the rare emergency but involves the majority of normal laboring women who are birthing in an environment that can interfere with their normal process.
There is no escaping risk when pregnant or birthing or in being alive, for that matter. Birth is as safe as life gets. The question each pregnant woman must ask herself is if she feels more comfortable taking on the higher risk of cesarean section by birthing in a hospital or if she prefers taking on the higher risk of not having emergency care if needed at home. A woman can minimize her risk of unneccessary cesarean section by receiving care from a nurse-midwife in the hospital, and a woman can minimize her risk of poor care at a homebirth by verifying that her homebirth providers are well-trained and won't delay transporting to the hospital if there are problems in labor.
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The source I cited was from the website Orgasmic Birth. So admittedly I have no personal experience with how quickly a Portland area hospital staff can prep for a c-section, the OB on the show today said it takes about 30 mins and that they were working on getting that down to 15 mins. You can re-listen to episode or get the transcript to get her exact quote.
You have to keep in mind that a lot of the need for c-sections are caused by the interventions that interfere with normal birth and natural hormones. For example, pitocin interferes with oxytocin causing longer and more painful contractions (with can cause fetal distress) then with pit there is an increase need for epidurals which slow down labor, which leads to more pitocin, then forcing women to lie on their backs work agains the body's own ability to push out the baby. So quite often the baby gets in more distress the OB's then come and save the day with a c-section that was caused by their own procedures.
The OB on the show talked about having a natural beautiful birth in a hospital... but failed to mention how hospital procedures undermine a womens ability to birth naturally.
And in the example of the "OMG home birth gone totally bad-- BREECH baby!!" the midwife was right. The midwife saw a potenial risk in the birth and in a timely non-emergency manner transferred care to a hospital. Babies can turn breech at any point and the same thing could have happend in a hospital.
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My understanding is that if you have good labor support and your pregnancy is proceeding healthily, you may be safer giving birth at home because US hospital births are particularly heavy on routing medical interventions. Research shows that routine medical interventions during labor can cause harm, though in an unlikely emergency they can work wonders. Interventions can also interfere with early bonding between mom and baby as well as successfully starting to breastfeed. Our C-section rate is close to one third of all births, and should be closer to ten percent. If you labor at home you are a lot less likely to end up with an unnecessary C-section. Although I support home birth I did have a mid-wife attended hospital birth, because I had little available labor support, and my insurance coverage for other options was a bit iffy. I was pleased with my experience. I was very well prepared and had a non medicated birth in the hospital which is exactly what I wanted.
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I am a Naturopathic Family Physician and midwife and have been attending out of hospital births since 1993. Childbirth at home is family centered, peaceful, empowering to the mother, and dare I say- fun for all involved. Although my first choice for labor and delivery is at home, sometimes that is not possible or advisable.
In my practice, I have had to transport women to the hospital for complications on a number of occasions. There are various factors that affect how well received my patients are when they deliver at the hospital, including the prevailing recommendations of the American College of Obstetricians and Gynecologists. However, the most important is the attitude of the medical personnel that you work with. I have had far more positive experiences than negative ones. I find that arriving at the hospital with well documented charting of the pregnancy and labor helps my patient and myself gain the respect of the doctors and nurses caring for her.
Of course emergencies happen, but if one is an attentive caregiver, one can recognize a trend in the pregnancy or labor that can predict a possible emergent situation. I prefer to transport before the emergency, in plenty of time to avail the patient of all the hospital has to offer. I believe that the doctor who takes the case feels that they have time to assess the patient themselves and without rushing to emergency procedures, or feeling they have to deal with a patient who has not been cared for properly. I feel if I have done a competent job, the less the medical profession will be able to criticize our abilities, and that should go a long way toward building trust and mutual understanding between midwives and hospital staff.
Hopefully mothers will be able to choose where to give birth without conflict or strife between the caregivers. As a midwife, I am grateful for all the hospital can provide when the need arises, but I am also grateful for the wonderful experience that homebirth gives to the mothers, the babies, and their families.
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Thanks so much for having this discussion. I know it is a polarizing topic in many circles. We lived in a community where homebirth with lay midwives is the norm. However, due to a history of major post-partum hemorrhage, my husband and I agreed that homebirth was not a good option for our third child. We chose not to use the OBs in our coastal community, nor the local hospital, since they had a very high C-section rate and I had been warned by several nurses in the area to go elsewhere. We drove more than an hour up the coast to find a midwife with hospital privileges.
I gave birth to my first child in Missouri, where midwifery is illegal. My child and I had a horrendous experience, were manhandled and endured every intervention (and the resulting complications) one can have and still have a vaginal delivery. I gave birth to my second child at Southwest WA Med Center with Pacific Midwifery (a wonderful practice, btw). I was shocked when my nurse told me that it was the first natural childbirth she had ever attended!!
My third child was born at Samaritan North Hospital in Lincoln City, with the only practicing hospital midwife in north Lincoln County - JoAnne Kort, CNM. She was amazing, and I had a 10 1/2 lb baby boy with no complications, no interventions. Careful monitoring and medications after birth insured no repeat of the hemmorhage, despite the large size of my son. I felt I had the best of both worlds - the safety net of the hospital, and the ability to birth my child naturally, with my wishes and needs respected.
Anyway, the point I am trying to articulate is that while homebirth is a safe, viable option for many women, there needs to be a greater range of choices than homebirth with a DEM or lay midwife vs. intervention-filled hospital birth with an OB (who, as JPoundstone mentioned, is a surgical specialist, not a specialist is normal childbirth). For those of us who cannot choose a homebirth (because of insurance, medical conditions, etc), the option of a safe, natural, unmedicated vaginal delivery in a hospital attended by a CNM should be made available.
Thanks again for discussing this topic!
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I couldn't agree more. "Anyway, the point I am trying to articulate is that while homebirth is a safe, viable option for many women, there needs to be a greater range of choices than homebirth with a DEM or lay midwife vs. intervention-filled hospital birth with an OB (who, as JPoundstone mentioned, is a surgical specialist, not a specialist is normal childbirth)" There should be more options for woman.
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Angela you really touched on what this is all about FREEDOM OF CHOICE. It is interesting that in every instance but pregnancy and birth, individuals are encouraged and even expected to make autonomous decisions based on what is best for THAT individual. Why is it when it comes to womens reproductive rights and choices that expectation all of a sudden changes? Its as if it is believed that womens minds contract as their bellies expand. We need to protect our right as women to choose where and with whom we birth.
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I had two amazing home/water births, one just 7 month ago. I chose this option because I knew that if I were in the hospital, I would be subjected to more interventions than I would be able to fend off. I wanted a natural birth, but knew that I wouldn't be able to resist drugs if offered. After attending a hospital birth of a friend, and witnessing the cascade of unnecessary interventions that occurred, I knew that home birth would be a better option for me.
I also want to add that my midwives were infinitely more informative than the doctors I saw. Having an hour to get my questions answered instead of the 5 minutes usually alloted at the doctor's office, made my birth experience easier, more informed, and much more relaxed. My direct entry midwives never left my side for the many hours I was in labor and delivery. I believe I was more in control of my own experience and therefor had a calmer and safer birth.
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I just had a baby 6 weeks ago with a midwife in a hospital. She is part of a practice that has both OB's and Midwives. The partnership among them is awesome. The midwife provided almost all of my care except for once when she wanted a second opinion from the OB, he came in right away, checked me out and discussed the options with us. It was just perfect, I recieved the more holistic, non-medical centered care from the midwife with the security of backup, expert medical care if needed. This partnership was continued at the hospital as the hospital staff and midwife worked seamlessly as a team. I really think this is the best of both worlds and the kind of care that should be offered everywhere.
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My wife and I attempted to have both of our children, now four and one and a half, at home in the water. We received excellent care from midwives and really loved our relationship with them.
We had to transport to the hospital both times, and both our children were born via C-section at OHSU. The complications that led to the need to transport in both cases were uncommon and unrelated -- just bad luck.
In both cases our midwives were excellent in clearly telling us when the time had come to go to the hospital and staying with us through the entire process of transporting, delivery, and recovery.
The care we received from the doctors and nurses at OHSU was also excellent, and saved the lives of both mother and baby in both cases.
The interactions between the two teams -- midwives and hospital -- were professional, if not full of love and mutual admiration.
We still wish we had been able to deliver our children at home; should we get pregnant again, we will try to have the third baby at home, and we remain strong supporters of home birth for healthy moms and babies. Our care and the depth of the relationship we got to have with them was amazing. We would recommend our midwives and a home birth to anyone who is contemplating it.
That doesn't mean we don't appreciate and understand that hospital birthing is also the necessary option in some situations, are we will always be grateful that that option was available to us when we needed it. We will always be thankful for the skill and dedication of the doctors and nurses who delivered our babies, even though we wish we hadn't needed it.
It's sad and distressing to see the animosity between the two communities. Home birth with a trained midwife should be the standard of care for all healthy mothers and babies, and doctors and policy makers should respect and encourage it. At the same time, we need doctors and hospitals to care for mothers and babies whose birth experience becomes a medical problem, and the home birth community needs to respect and acknowledge their vital role too.
Thanks to everyone who helped us bring our beautiful children into the world.
--JT
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Last October I delivered my first baby. My pregnancy was normal and healthy. I was not high risk and there was no reason to think that anything would go wrong. The delivery went fairly smoothly, but upon delivery, my daughter suffered a sudden and unexpected lung collapse. Thankfully I delivered in the hospital and trained medical professionals were immediately on hand. Even with their quick attention, we almost lost our little girl. I can't even bring myself to think what might have happened if I had tried to deliver at home.
For me, it's very likely that a home birth would have ended in the death of my daughter or at least serious brain damage. How does the home-birth movement address situations like mine?
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I am sorry you had such a scary experience. As a mother who had a child at home that also has some breathing difficulties, my midwives were able to take most of the identical steps a neonatal resusitation team would have taken at the hospital. He recovered nicely and we did not need to transport.
A collapsed lung is indeed a medical emergency in a newborn that would be difficult handling at home. I think my answer (not as a midwife) as to how it would be addressed is that rare things happen rarely. There are risks with every choice we make, and as a parent i looked at the odds of something this rare happening and decided it was safe. A certain number of healthy women die during c-sections. This also is a rare occurance. I don't think that should ever stop a necessary c-section if that's what's needed. I know it's difficult to step back and look at it from this perspective when it's YOU that it happens to but there are risks with all choices.
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A CPM does not come to a birth unaided, but with an entire emergency medical kit including fluids, oxygen, and pitocin, among other things. I would certainly imagine she could handle a collapsed lung without a problem.
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I wrote in earlier about having been transferred into the conventional system due to high blood pressure. I added up the costs of hospital vs. home birth. The hospital "experience", pre-natal care included, cost $15,331 (I had an uncomplicated vaginal birth with a very lose dose of Pitocin and no pain medication). In contrast, the home birth midwife charged me $3,000 for pre-natal and postpartum care for me and my baby. In my opinion, in addition to being significantly less expensive, the home birth midwife's care was much more thorough. My pre-natal visits with her each lasted about 45 minutes, and she came to my home nearly every day after the baby was born to weigh the baby and make sure everything was going well.
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I'm disturbed by a value system among some in Portland that places medication-free home births as somehow 'better' than hospital births. This leaves some of my friends feeling defeated and regretful if they have to do something that deviates from the perceived 'better' path - despite a positive collaborative hospital birth experience.
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I have several friends who have had a traditional hospital birth, with schedule inductions and epidurals and the whole sha-bang. They had WONDERFUL birth experiences. They Loved how they brought their babies into this world and I would never discredit their experience. But for MANY women who want to have a natural birth, who believe that the interventions aren't necessary and only interfere with the birth process hospital births arent' a safe or comfortable place.
I am pregnant with my second child and the hospital is my last choice on where to have a baby. However I am not a home-birther-at-all-costs. If there was a medical reason or situation that warrented a hospital birth I'd be there with bells on. I think hospital are wonderful places for sick people and medical emergencies and I am grateful for all the advancements in technology we have.
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I don't think most people are saying that women who chose hospital births are less. It is that those who want natural births have to fight for that right.
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Ms. Scholles needs to understand that the reason Ms. Adams breach story was a disaster is that the "clients" failed to understand that if a physcian hadn't stepped in there child probably wouldn't have made it. Also her statement that the "clients" are capable of making decisions is quite disturbing. There is a reason the infant mortality rate is lower today than it has been thorough-out history, DOCTORS & SCIENCE. Midwives are dangerous.
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The earlier discussion about the "breech" baby transferred to the hospital being a disaster... First, I’m delivering at home and my midwife will not deliver a breech baby. I’ve already been told if the baby is breech we would start at the hospital. I can’t speak for all midwives but I’m not sure if delivering a breech baby at home is common. In fact, I’m sure it’s uncommon. Most midwives would have identified this situation early and insured the right steps to inform an ob/gyn way ahead of time. Second, Karen Adams experience was one incident. 11,000 babies are born every day. Third, the transfer rate of clients to hospitals for most midwives is very low. As pointed out earlier there are hundreds of successful home births.
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First off I have to say that there is plenty of research out there that confirms that the US has the 2nd highest infant and maternal death rate among civilized countries. The infant mortality rate is not lower. And for being one of the most "technologically advanced" countries that says a lot. As far as clients being able to make their own educated decisions.... Do you not believe that you have the brains to research and make an educated decision that would be best for YOU? Why do you just trust so easily that everyone has your best interest at heart?
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Please do some research on your statements, or don't, you most likely won't like the results.
We have some of the WORST infant mortality rates in the world.
I highly recommend anyone wanting to further educate yourself to watch this short (web-based) video. Birth By the Numbers
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There is a reason mortality rates are lower, but it is not because of doctors and science in the way you state. Historically, the highest mortality rates were due to doctors perfoming vaginal exams from patient to patient and from cadaver to patient without washing his hands and thus spreading childbed fever.
And historically, homebirths attended by trained midwives has always had a lower mortality rate than hospital births attended by a physicians. So I could argue that doctors are dangerous!
Please, don't show your ingnorance- check the facts and do the research before you make claims you can't back up.
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I had both my children at home with a midwife. My first birth was a very "textbook" labor, about 16 hours long. I labored in a birth tub and birthed on my bed. He weighed 8 pounds and was 21 inches long and very healthy.
The birth of my second son was somewhat different. He was 9 lbs 12 oz and had shoulder dystocia (he was STUCK!). My midwife has "caught" nearly 500 babies and her skill was obvious. She knew how to change my position to help the baby out without the use of forceps, episiotomy or other interventions. She took good care of my body to ensure I didn't tear or have other trauma to my body.
After the birth of my second son, I hemmorhaged badly, losing about 8 cups of blood. My midwife (as all Oregon midwives) carries anti-hemmorhage medications. She administed two of them to me to curb the bleeding and ultimately I was fine. There was brief discussion as to whether I needed to be transported and it was clear that the midwife was able to control the situation.
My husband and I wouldn't hesitate to birth at home again!
Ultimately the most important thing is to preserve a birthing mother's right to choose where to birth and what the environment of birth should be! Forcing midwives into expensive licensure will ultimately limit the birth choices of women.
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A home birth is like riding your bike without a helmet, or riding in a car without a seabelt. You may get away with it a 100 or a 1,000 times, but at some point disaster will strike. Why take the chance with a human life? It seems a selfish act, bordering on child abuse or child endangerment.
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I couldn't agree more.
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It is ridiculous to call someone's decision to birth their child normally at home "selfish, bordering on child abuse or endangerment". Disaster strikes every day in hospitals due to unnecessary medical interventions. Why is the infant mortality rate so high in the U.S.? Hint: it's not because women are choosing to birth their babies at home.
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Actually home birth is the safest place to have a baby, check the statistics. Hospitals is where most maternal and infant deaths occur. Of developed countries the USA as the worst rates. Other developed countries in Europe that have 1/3 to 2/3 of home births have better outcomes.
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good point. especially since babies and mamas NEVER die or have long lasting harm (physical or mental) when birth happens in a hospital.
with this argument you are effectively saying that we should never ride a bike or drive in a car because accidents do happen. its going to take a little more to convince me.
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As it was pointed out in the discussion about malpractice rates, there is no way to guarantee a perfect child every time. I have seen home births AND hospital births, and seen things go wrong with both and bad outcomes with BOTH- and being in a hospital did nothing to change tham, in fact a few were caused by the physician's actions.
You are stating this as if chosing a home bith over a hospital birth carries a much higher morbidity and mortality rate- which it doesn't. Please don't make parents who chose homebirth out to be selfish and dangerous when there is no factual basis to your claims.
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and I think you are sadly misinformed. a midwife is not an untrained loony with no materials at hand and zero experience in handling emergency situations.
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My mother almost died in the hospital when I was born because the OB-GYN had never seen a non-medicated birth and wanted the placenta to come out on his timetable. He massage my mother's abdomen and she hemoraged and almost died. My younger siblings were both born at home with a nurse midwife in a healthy non-traumatic way.
I am looking to have my first child in the next few years and I only hope that I can find a midwife and a conventional practitioner (who fundamentally and meaningfully respect each other's practices) to support the birth of my child. I still feel insensed that my mother was treated in this way, and even with the most liberal conventionally trained practitioners, like your guest, there is still a tone of standardization and right and wrong and no really meaningful engagement with the individual mother's/family's/baby's needs. We are just statistics and patients. I want to be a mother.
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"The safest setting for labor, delivery and the immediate post-partum period is in the hospital, or a birthing center within a hospital complex."
Maybe safest, but I'd bet that most women in the world don't have either the money or the access to that.
Mankind, er, make that Womankind, evolved to give birth without doctors, and then for many thousands of years were assisted by midwives. I would think that doctors and midwives could build a better partnership so that doctors would recognize that midwives can take care of normal births and just take care of the emergency types themselves.
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I strongly disagree with the option of home births; if you choose to give birth naturally, do it in a hospital where professionals can treat you and your child in the case of an emergency. I had an extremely difficult birth with my first child that resulted in an emergency c-section; if I had chosen to give birth at home it is likely that either me or my child would have died. Losing the valuable minutes in transport can be the difference between life and death.
And, the discussion regarding the money saved as a result of a home birth is absolutely disgusting! If you cannot afford to give birth to your child in a hospital, you cannot afford to have the child period. Stop putting your unborn child's future on the line because you failed to adequately plan for the financial implications!
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First off, Midwives are professionals that can perform emergency life-saving techniques. There is always a plan in place in case of an emergency that transports the mom to the hospital in as much time it takes for a staff of people to prepare for a C-section.
I had a very difficult birth at home, and if I had been in a hospital, they most likely would have performed a c-section, simply to avoid any risks of suit against them, whatever the likelihood.
Most of the procedures are unnecessary and coslty and increase th cost of birth overall.
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The debate over cost of home birth vs. hospital birth is a complex issue. It’s not about people being able to “afford” a child. The issues that come into play are; over inflated doctors salaries, big pay offs for drug companies and insurance. Next time you go to the hospital you are costing everyone in America a big bill for unnecessary procedures. Also, midwives have a very difficult time getting insurance companies to corporate with them, this should change in this country so women have options.
Giving birth doesn’t have to be about a life and death situation. Hospitals breed fear. Actually of developed countries the USA has a horrible maternal death rate and infant mortality rate, but this in hospitals. So I would think twice about delivering a baby in a US hospital. A woman’s body is completely capable of delivering a baby. All the medical intervention and drugs, cause the woman’s body to shut down and then a serious problem can arise.
Sources: CBS news report
Maternal Mortality Rate In U.S. Highest In Decades
documentary: The Business of Being Born
CNN Health report
Parent Dish
"the U.S. has the highest rate of obstetrician-attended birth in the world, and among the highest rates of hospital birth and C-section (if not the highest). We are the richest country in the world by just about anyone’s estimation, yet our maternal mortality rate is worse than Australia, Austria, Belgium, Bosnia, Canada, Croatia, Czech Republic, Denmark, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Israel, Italy, Japan, Kuwait, Latvia, Malta, Netherlands, New Zealand, Norway, Poland, Slovakia, Slovenia, Spain, Sweden, Switzerland, and the former Yugoslav Republic of Macedonia." source.
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Giving birth doesn’t have to be about a life and death situation. Hospitals breed fear. Actually of developed countries the USA has a horrible maternal death rate and infant mortality rate, but this in hospitals. So I would think twice about delivering a baby in a US hospital. A woman’s body is completely capable of delivering a baby. All the medical intervention and drugs, cause the woman’s body to shut down and then a serious problem can arise.
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"And, the discussion regarding the money saved as a result of a home birth is absolutely disgusting! If you cannot afford to give birth to your child in a hospital, you cannot afford to have the child period."
It seems like another way to say that is "only the wealthy and well-to-do should have children, because the poor are obviously ill-equipped to raise children properly".
I don't think I can put much stock in a point of view like that...
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In construction, all sites have to have a poster-map of the nearest hospital with phone numbers.
How about having the midwife required to know the nearest hospital and call and tell them that a birth is currently in progress and tell them how it is progressing? Then if it goes badly the hospital is forewarned and if it goes well the hospital is also notified and can relax about it.
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Good idea. That's what my midwives said they do in those cases. During the pregnancy, the midwives clarify that with the client.
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My first pregnancy was normal and I planned to have my baby at the hospital. I had no expectations re: natural birthing. I figured I'd just take things as they came. 10 days late, my water broke but I was not in labor and had to be induced. 19 hours of labor and 4 hours of pushing later, all at the hospital on a pitocin drip, it was determined that the baby was in distress and I would need a C-section.
Despite what I'm hearing from the expert on the show, there's no button you push to get a pediatrician, a surgeon, or an anesthesiologist. I am still shocked when I remember that it was well over an hour (closer to two) after it was determined that I needed a C-section, before a surgeon and an anesthesiologist could be found to perform the emergency C-section. Meanwhile, the pitocin was still dripping and I was told to just deal with the labor pain. It was until I thought to request that they remove the pitocin and they give me something to stop the labor that I experienced any kind of relief.
I wasn't as upset about having to have a C-section as much as the incompetent way the hospital handled my particular situation. Very disappointing.
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Hugs Mary, that had to be really stressful.
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For the birth of my son I planned a home birth. My opinion was that I was pregnant, not sick so I wanted my child born in the warmth of my home. My son dictated other path although. After 24 hours of labor my midwife recognized early signs of distress and we transported to a nearby hospital that my midwife had a relationship with. My transport was calm and relaxed, not frenzied or with the attitude that something is "wrong". My son was born after another 24 hours by cesarean. This is not the path I would have chosen, but my son is healthy and I give my midwife all the credit for her early identification of a potential problem. Also her diligence in establishing a relationship with a hospital and OB/GYN made my son's birth in a hospital more bearable.
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The US ranks 28th in infant mortaliy. It's safer to have a baby in Thialand or Cuba. Why? Where's all this science to back up the claim that it's safer to give birth in a hospital? Is it coming from the doctors or the women giving birth? The assumption that women are not informed enough about their own bodies to make their own decisions regarding their own health care is ridiculous. Dismissing responsibilities for our own bodies and letting all of that rest in the healthcare industry is what got us in the messed up health care situation in the first place. Doctors perform a C-Section instead of vaginally birthing a breech baby is one great example of the fear factor taking over. The reason for that is- they are no longer TRAINED to birth a breech baby. They don't know what to do unless it's making a cut- and that's less safe for everyone. Where are the facts people? Read, read, read and be informed!
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I am a 37 year old mom of 14 month old home-birthed baby. When I became pregnant I owned a small baking business and was uninsured. I was able to get onto the Oregon Health Plan and was given the choice of a midwife home birth. This would be my choice in any case. I would not have had that choice under my previous health insurance provided through my employer.
I think it should be illegal not to offer coverage for any choice of legally obtainable childbirthing options. Additionally, the Oregon Health Plan offered all forms of birth control at no cost to me, where my company-provided insurance does not cover any form of women's contraceptives, but will cover a vasectomy.
I had a difficult birth, but I still didn't want to be in a hospital. Instead I had my partner, my mom, my sister and three wonderful competent midwives assisting my 72 hour birth in the comfort of my home.
Lastly, I'd like to add that about choice, I think our society is not very educated or experienced with homebirth, in general, which fosters a lot of fear. I needed to seek the company of people who were supportive of my choice of a home birth. The midwives provided a community of supportive people. But I received criticism from people and members of my family. Had I not been fully researched and knowledgeable about my choices about all of the different optional procedures that can be done during a pregnancy, I may have easily folded under the pressure to go with a hospital birth for a perfectly normal pregancy. I trusted my midwives and I did a lot of my own research on the safety of home birth.
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I think lasonadr below is misinformed:
There may be higher rates of ceseareans in women with diabetes or preeclampsia but that the majority of women who develop these common complications have vaginal births. It is absolutely not the standard of care for hospital midwives, ob gyns or family doctors to automatically perform a cesarean when these complicatoins develop.
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I had my daughter at the hospital with a certified nurse midwife (backed up by an ob-gyn) because of the more personal care the midwife provided and because I knew there was a chance I may end up having a c-section (which did happen) so I wanted to be in the hospital and prepared. That said, I feel strongly that birth has been made in to a medical procedure and that hospital births can create a disconnect between the mother and the procedure/experience. I am hoping that we will move away from that and bring the woman back into the experience, bring the community back into it and move away from a preconceived fear based outlook since for many people it is a wonderful, yes painful, but great experience. I feel that certain hospitals and doctors create unnecessary stress and fear. I understand that they are coming at it from a worst case scenario but there needs to be a balance so it is not made worse with no reason. Let the doula's in, let the midwife's in, work to change the culture of the birth experience. I do feel that home birth's should be allowed and many of my friends have had home births and say that they were more relaxed and the birth went better than in a hosptial because of the environment. Home births should be supported by the medical community and all involved should work to improve relations and to break down misconceived notions of each other. This will make for healthier births for all.
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I take serious offense as Karen Adams states that she believes a MOTHER is incapable of making an educated decision about her own care and her pregnancy.
We all know that there are risks that come with pregnancy and childbirth. WHY can't a mother, knowing her own medical history, paying very careful attention to her test results and taking the initiative to follow up on all necessary care, be allowed to make her own decisions?
Perhaps some patients do not take this initiative. But that should not limit us, as the patient, from being allowed to make the choice that we feel is best for us and our families.
The C-section rate is above 34% in the US, while the NEED for C-sections is 2.8% according to the AMA.
C-sections rates go up with the use of Pitocin, Epidurals, and laboring on one's back, when the pelvic structure collapses and is 1/3 smaller than in an upright or squatting position.
And once other conditions show up, gestational diabetes, preeclampsia, breech, etc, the only option the OB has is surgery. It may be convenient for the OB to do C-sections, but besides the physical scar on the mother and her uterus, you also have an increased risk of infection, bleeding, post-partum depression, difficulties in bonding with your child and difficulties in nursing your child.
Many mothers will do whatever their doctor wants. And many mothers, even wanting a homebirth will look at the risks and decide that it isn't worth it to them.
But for those who know the risks, why should we not be allowed to make our own decision. After all, if something does go wrong, who lives or dies with this decision? Not the OBGYN.
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I have to disagree with Karen Adams comment on being able to have a beautiful, natural birth in a hospital setting.
I'm a physician who grew up with midwives and chose to have my child at home, because after years of working in various Labor and Delivery wards in the Portland area (prior to medical school) I knew that having a natural birth in a hospital is almost impossible. Even if you have an OB who is supportive, the hospital's protocols will not allow a minimal interference approach. Everyone gets a saline lock IV, everyone gets TOCO monitoring- which absolutely ties you to staying still in bed (about the worst thing you can do for labor). Nurses are swamped with paperwork and only come in and out of your room to check your progress periodically. You are in an alien environment and forced to work against an artificial time table or pitocin will be administered to speed things up. It's no coincidence that most unplanned c-sections occur around shift change.
Of course, having a cesarean section saves some babies in some situations. I've seen many absolutely necessary c-sections and thank the gods they were done! However, subjecting so many healthy women to this unnecessary and major surgery as a side effect of how our Birth Culture exists in this country is like summarily giving mastectomies to all women because some will develop breast cancer. If the rate truly reflected saved lives, why is our infant mortality rate so much higher than Europe, and their c-section rate so much lower?
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Let’s do protect the public.
Each year, 195,000 people die from hospital/doctor mistakes, says HealthGrades, the healthcare quality company.
http://www.medicalnewstoday.com/printerfriendlynews.php?newsid=11856
Each year, 99,000 die from infections caught in hospitals, says the CDC (others say more).
http://www.cdc.gov/ncidod/dhqp/hai.html
Complete story at
http://pajamasmedia.com/phyllischesler/2008/11/13/death-by-hospital-is-it-avoidable-part-two-of-a-series/
BTW, 300,000 deaths make doctors/hospitals the third leading killer, after cancer and heart disease, in America.
If government can deliver protection, and stand up to the AMA concerned mainly about its monopoly and income, then make conventional medicine safe.
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licensure does NOT guarantee quality of practice with midwives anymore than it does any practioner or professional, a point i believe Karen Adams made herself. Peer review amongst OBGYN's has not lowered the incidence of cesarean or increased the occurence of evidence based practices.
A better relationship between medical personel and independant midwives will happen when OB's number one priority becomes the pregnant/birthing mama in front of them. Karen Adams comments left no doubt as to the superiority of the Obstetrician's thinking mind compared to the ignorant mamas out there who "don't know the difference" when it comes to midwifery credentials. This "god-complex" among medical professionals is a giant barrier to constructive communication between the medical and midwifery community.
When mamas and babies become the center of birthing practices in America and insurance companies and golf schedules are pushed to the background, then we will see a merging of caregivers and a new normal for childbirth. It can't happen soon enough.
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We had both of our children at home with no problems. We had a WONDERFUL naturopathic midwife for both births. Before we had our first child, most of the people we knew with children (relatively few at that time) had birthed their children at home. Now that we know many more people with children I am continually shocked by how few considered a home birth -- or even having a doula at the hospital. It bothers me when people tell me or my husband that we were so brave to have had a home birth. It was such an obvious choice once we read up on it. But when birth is considered something scary and is witnessed by most people many more times dramatized on TV and in movies than in real life, I can kind of understand why people think hospital births are the only option.
The real challenge for us was that our insurance did not cover either birth. In the first case we knew that it wasn't covered and planned ahead. In the second case, with a different insurer, we were told our home birth was covered several times before being told it wasn't covered at the last minute. That was very difficult. In Washington there is a law that insurance companies must cover services provided by a licensed provider (i.e., an ND, LMT, etc., not just for births), and I wish that was true in Oregon as well.
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I am a family physician (MD) who does maternity care including birth and newborn care. My practice philosopy is to provide women with excellent and wide ranging information in order to allow them to make well informed choices. I have read good quality studies on home birth as it is practiced in other countries such as the UK and the Netherlands where there tends to be a more seamless relationship and transition between in hospital care and birth center and home care for laboring and birthing women. Women who are candidates for home birth in these settings are low risk and they are appropriately screened during their pregnancies for common complications. These studies show that home birth can be very safe. It also seems like an ideal situation for pregnant women as they are less likely to have a traumatic experience during transport, they have increased continuity of care, and a functioning health care team that communicates well together and is generally on the same page about goals of care.
I am the primary care physician for women who choose to have home births. I will often continue to see them during their pregnancies for issues that come up that are either out of the scope of practice of their midwifes or unrelated to pregnancy. In discussions with my patients it is clear that they ARE having informed consent conversations with their maternity care providers but the risks and benefits discussed are VERY different than what I am familiar with. I'm not always confident that my patients are given all the information they need in order to make choices that are right for them. For me its not about not wanting to "give up my power over women"- if a patient of mine would prefer no interventions at 2-3 weeks past her due date I would be a worried about some increase in risk for her (the main risk being a risk of cesarean with a small increase in sudden fetal death...) but if I felt that she really understood how the risks/benefits balanced out in such a situation and was making a clear minded choice, I would support that. I worry that some home birth clients have the risks minimized or the risks are not well explained or well understood by their providers.
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you make excellent points. my hope is that there will be more physicians like you to make out of hospital birth even safer and an option for more women and their families.
informed consent is such a slippery slope - definatly a matter of training and perspective
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Thank you for posting OHSUfamilydoctor. More doctors need to be as educated as you are on birth. :)
I wish others in your same practice felt the same way. I mentioned my homebirth plans to an aquaintence that I later found out to be an OHSU Family practice doctor and I was bombarded with all sorts of horror stories about all that can go wrong (not necessarily home birth related).
Over all I have a great impression of OHSU and STRONGLY considered using their midwives for this birth.
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I'm pregnant with my first, and I am trying to decide currently between certified professional midwife care, nurse midwife care, and obstetrics. I have found that in interviewing doctors and nurses, the varying opinions on risk are so different, even among doctors in the same practice, that making the decision is absolutely maddening.
I have been by three different obstetricians from the same practice that, as a generally low-risk patient, my risk of c-section with could be 10%, 15%, or 25%, respectively. The doctor who put the risk at 25% estimated that as many as 90% c-section calls he makes from fetal monitoring may have been fine naturally, but refused to take the risk.
Meanwhile, the CPM I spoke with put my risk closer to 2 or 3%, as that was the c-section rate of her entire practice. The c-section rate of my obstetricians office is 40%.
The nurse midwife I met seemed so overworked that she had trouble putting sentences together, and though her care may be more caring and attentive, her statistics varied little from the obstetricians I spoke with.
Furthermore, if I go to the hospital, I have been told by a nurse that I should have a safe word with my husband to avoid an epidural. It seems that without protecting myself ahead of time, if I do so little as cry out the word 'epidural' when I am in the throws of labor pain, they are required to administer one, and with hospitals automatically giving mothers an IV upon admission, it is no surprise then that the epidural rate for my OB's patients is nearly 80%.
What's more, regarding breech births, my mother was extremely surprised to hear that breeches aren't even attempted anymore. One of my cousins was natural breech in the '70s and was absolutely fine, and she shared with me another breech birth anecdote with the same result. I talked to my CPM about breech, and she claims that the problems with statistics that doctors see is that they do not differentiate between the breech birth performed by someone with direct experience with breech births, who can call a breech requiring c-section, and those breech deliveries performed with no option for c-section by an inexperienced provider. Additionally, the obstetrician who actually has had any experience with a natural breech delivery is a nearly extinct creature.
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Just remember that the CPM will ultimately be caring for the lowest risk women so the cesarean rate is lower because of a pre-selected population.
Also- there is NO hospital setting I'm aware of that would give a woman an epidural without an informed consent. If a woman asks for an epidural she then goes through a process that takes a while where she discusses her choice with an anesthesiologist. If she "blurts out" epidural but then reconsiders there is no way that she would be forced to have one: that would legally be considered assault.
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An OB's office takes all the elective cesarians and also handles the cesarians for midwives, so they have a much higher rate.
And although the CPM handles primarily low risk women, she also handles multiples, breeches, and VBACs, so there is that to consider.
In the 1980s, the risk of a cesarian was only 5% altogether in the United States. That is in general, in hospital births. I wish I could have that, even in a hospital, but due to the way healthcare has evolved in this country, I cannot.
Regarding epidurals, I was not left with the impression that I would be drugged against my will. I was left with the impression that the administration would be so rapid upon my suggestion of it that there would be little time or room for discussion or clarification with my husband. Again, this is the impression I was given by a nurse who practices in a hospital birthing center who suggested that I share a safe word with my husband. I did not make this up.
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Almost everyone who attempts a home birth has a safe successful delivery. However, for most women, delivering a baby is the most dangerous thing they have ever done in their lives. The risk of a mother in the U.S of dying during pregnancy (11 per 10,000) is higher than the risk of dying during one year of driving a motorcycle, driving an ATV recreationally, or having HIV, and most people would consider these to be risky conditions where certain safety practices should be considered.
Most women think that an amniocentesis is a risky procedure. However the danger of having a baby die around time of delivery (1% in the U.S.) is at least 2x as dangerous as the chance of miscarriage after an amniocentesis.
Most patients want to do what is safest for their babies. Without question, this means delivering in a hospital, delivering in a birth center next to a hospital, or at least delivering with a provider who has expertise and training. I support patient autonomy and the right of mothers to make their own choices, but in reality, home delivery with a direct entry midwife is a sensible choice only for those mothers who put their personal birth experience above the safety of their children.
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"Without question, this means delivering in a hospital or delivering in a birth center next to a hospital. Home delivery is sensible choice only for those mothers who put their personal birth experience above the safety of their children."
Without question? Based on what statistics and/or studies?
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if you dig a little deeper into the reason why the US has such a high infant mortality rate you may be surprised to find that the most agreed upon cause of infant death is prematurity caused by lack of prenatal care. Additionally it may be shocking to know that the highest rates of infant mortality are found among the poor and non-white women among us.
If insurance companies and care providers were truly worried about the rate of death among infants, prenatal care would be available to all women at low or no cost.
As for the danger of childbirth, you may as well go to the hospital every time you need to poop as it is a similar physiological process during which people sometimes die.
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"As for the danger of childbirth, you may as well go to the hospital every time you need to poop as it is a similar physiological process during which people sometimes die."
- i really hope you are joking.
the physiology of labor & delivery is extremely dynamic and presents significant stress to mother and baby. as most laboring women are young and healthy, they are able to tolerate these changes without difficulty. however, for those mothers or babies with certain baseline medical problems or compromised organ systems, the physiologic stress of labor and delivery can be profoundly dangerous.
not at all like taking a dump.
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"Home delivery with a direct entry midwife is a sensible choice only for those mothers who put their personal birth experience above the safety of their children"
Even if you had some statistical data to back up the idea that the hospital setting is safest for baby, there would still be no support for this statement. You have no insight into the motivations of a mother who is looking for a safe home delivery. A home delivery is one without narcotics that will interfere with her child's breathing, one that avoids unnecessary c-sections that can damage the reproductive system, endangering future children and causing breathing difficulty for baby, one that places significant weight on the imprinting period at the end of birth that is missed in cesarians, when natural childbirth causes a cocktail of hormones to be administered to baby. There is absolutely no doubt in my mind that mothers are choosing home births for their children, not selfishly for their own benefit as you suggest.
Perhaps you need to believe that they are being selfish in order to overcome some anguish associated from a terrible hospital birth you had experience with?
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in my mind, the most important outcome is a healthy mom and a healthy baby at the end of labor and delivery.
prioritizing a preconceived birth plan over the health of mom & baby seems foolish and shortsighted. i understand that people want a birthing experience that is as non-interventional as possible. who wouldn't want that? however, those who desire a "natural" birth despite significant risk factors (medical problems, VBAC, breech, multiples) must be prepared to accept 18th century outcomes for 18th century practices.
to assume that an urgent/emergent transport of a home-birth gone bad results in no significant delay compared to an emergency occurring while birthing in the hospital shows poor understanding of hospital practice. a true emergency c-section (crash section) can occur within minutes....and when dealing with a hemorrhaging and unstable mother or baby in serious distress, minutes can make all the difference between maternal/infant death or disability.
everyone has their own threshold of risk acceptance. for me, i would prefer a calm, peaceful, supportive birthing experience, but the absolute safety of mother and child will ALWAYS come first. sure, breech babies can be delivered vaginally. VBACs can occur without complication. but, is the significantly increased risk of maternal and infant DEATH worth the home birthing experience?
i want a pediatrician, obstetrician and anesthesiologist immediately available to respond to any anticipated or unanticipated emergency.
no question.
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This is not the 18th century. Midwives have emergency supplies on hand, such as oxygen and fluids. What's more, the most significant risk to mom and baby in the 18th century was secondary infection, and we have antibiotics for that now.
It's great that you know what you want, but the increased risk of maternal and infant death you are imagining isn't what you think it is.
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Thank you for holding this show. I hope the sense of the online comments was conveyed during the show--I couldn't listen to all of it--but our experience strongly supports the value of qualified midwives. Both of our boys were born at home in the 1980s with the midwife who wrote the first midwifery licensing exam for the state of Washington.
In the late 1980s (dated but it is what I know), the lowest rate of infant mortality in the world was in a Scandanavian country. Their most common birth method was at home, with a licensed midwife, and an aide car available. To be fair to MDs, their schooling, nor our lawsuit-happy culture, nor the time allowed per patient, allow them to provide the best care that most deliveries need: specialized, attentive, sustained, in-tune, centered and client-supportive.
A good midwife's attention can assist a mother to turn her baby to avoid a breach or complicated birth.
I think there is room for another show on this topic with greater exploration of the mis-perceptions held by both sides.
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I was honored to be invited to speak as an expert on this important topic on today's show. I do have a degree of expertise stemming from my 17+ years as an obstetrician, and having delivered thousands of babies. But each woman is the expert about her own experience.
I want to respond to lasonador, who says that I believe "a MOTHER is incapable of making an educated decision about her own care and her pregnancy." Not at all! My comment on the show related to the fact that some women may see an unlicensed, unregulated direct entry midwife (DEM) as the same thing as a licensed, certified DEM or nurse midwife, and without specific knowledge regarding the difference, may find herself in a situation not of her choosing.
Bottom line, the question is: what degree of risk do you find acceptable? Everyone will answer that question differently. In the hospital there is indeed the red button on the wall, and the csection room down the hall. An emergency csection in a well-staffed hospital with immediate anesthesia availability should happen in much less than 30 minutes, or even 15. We can have that baby out in minutes. Although those kind of "drop and run" emergencies happen very rarely, immediate surgery can be the difference between life and death.
As I said on the show today, home birth can be safe (meaning, can carry with it an acceptably low level of risk) in carefully chosen women with a competent provider who has good judgment and a backup plan for hospital transport. But some situations are simply not appropriate for home birth: vaginal breech (risk of head entrapment), vaginal birth after csection (risk of uterine rupture), twins (risk of cord prolapse), etc.
This isn't a "god complex," as ani calls it, but the best recommendations we can come up with based on medical science. If the science changes, then the recommendations will change. Those sorts of guidelines are why you seek medical advice for in the first place, and why your doctor's opinion should carry some weight.
Such an important discussion--thanks for the opportunity to weigh in.
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Thank you for doing this show!
We haven't had a chance to listen to it yet but are glad to see that the comments are well-thought out and don't actually make this issue an "us vs. them" battle as the show title suggests.
We had both of our children at home. It was the right fit for us and both births were beautiful in their own ways.
Our choice to go with homebirth was far from uninformed. As such, we do not "push" our choice on other folks as being "right". However, because of our experience, we get numerous requests for mid-wife recommendations.
We loved our midwives and they were the "right" fit for us but that doesn't mean they are the right choice for everyone. So rather than pointing folks solely to our choice, we pulled together some thoughts a while back on "mid-wife shopping" in general.
So it may be a little off-topic but we wanted to share that information here since it may inform expectant parents who are considering a mid-wife assisted birth (in any setting):
http://milagrosboutique.com/2007/04/18/midwife-shopping/
All the best,
Tony and Jennifer Fuentes
Milagros Boutique
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The question of cost came up during the show and I wanted to add this tidbit. This is not a comparison of hospital vs. home birth, this is an example of how health care cost have spiraled upward over time. I was born in 1946, before health care insurance and have before me my parents hospital bill for an uncomplicated vaginal delivery. It was a grand total of $60.70 which included 5 days/4 nights stay in the hospital. In today's dollars that would be $701.09 !! A 1946 dollar= $11.55 in 2009.
1946 2009
DELIVERY SERVICE $15.00 $173.25
DRUGS 16236 $ 2.00 $ 23.10
DRUGS 16290 $ 1.00 $ 11.55
XRAY $12.00 $138.60
DRUGS 16373 $ .70 $ 8.09
ROOM RENT MOM 15TH-19TH $24.00 $277.20
ROOM RENT BABY 15TH-19TH $ 6.00 $ 69.30
P.S. As I look at the submitted copy I see that the price columns are not straight. It's easier to read comparisons across (and is, after all the point) than to read down the columns. I don't have time at the moment to go back and set up columns. So I offer my apologies instead.
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wow! thanks for that neat comparison.
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in my great grandmothers journal, she recorded the cost of the birth of her first of 12 children at home (late 1800's early 1900's). $12.00 for the doctor to come and have a smoke in the front room with dad... pretty amazing how far we have come
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Thanks for hosting a discussion on this topic. I just wanted to add my personal story to the long line of personal accounts appearing here, especially because I suspect my experiences are representative - where pregnancy and delivery are low risk, normal, and satisfying experiences.
I have given birth twice. The first time was at Portland Providence and the second was at Adventist Medical Center. I had a different doctor for each one as well. However, both were family practice/ ob-gyn physicians from Portland Family Practice that provided prenatal care as well as attended delivery. Each birth was natural (save for a shot of fentanyl during transition at my second son's birth which I practically had to bribe the staff to get : )). I had a doula assist me during my first labor and delivery and would've hired one for my second as well if money weren't an issue. And each time I labored for as long as possible at home, trying to time my hospital admission to right before complete dilation.
In both pregnancies and deliveries I was well cared for, able to move into whatever position I needed to, never pressured or cajoled, my wishes were respected, my questions answered, and my babies lovingly attended to. Both my doctors were happy to work with a doula; both hospitals were fine with whatever family and friends I had in the room with me; I was given guidance and encouragement by the nurses; and by and large the hospital medical staff did a great job of helping me do what I needed to do.
I considered giving birth at home for my second but my husband was uncomfortable with it and, honestly, I figured that as long as the hospital nurses were compassionate, open-minded, and experienced, it would all work out just fine.
I was fortunate in many ways. If I lived in a different era or place, it's likely that my births would've gone about the same. I didn't have perfect information or the perfect doctor/midwife/doula/hospital/etc. What made a difference is that I always felt like I had choices and that if something unfortunate were to happen, my baby and I were going to get the care we needed, whether that was in a hospital, taxi cab, or my bedroom.
I believe there are as many ways to experience labor and delivery as there are babies in this world and that the best thing we can do is ensure our medical and insurance systems - both in practice and philosphy - support this diversity in values and medical situations.
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The OB who was interviewed said that the American College of Obstetricians and Gynecologists (ACOG’s) bans OBs from delivering breech-presenting babies vaginally. It doesn’t
A 2001 study concluded that cesarean deliveries are safer than vaginal births for babies in breech position based on short-term assessment of the babies. When the babies were reassessed at age three, there was no significant difference in their neurological status based on how they were delivered. In 2006 ACOG revised it policy on Mode of Term Singleton Breech Delivery: "In light of recent studies that further clarify the long-term risks of vaginal breech delivery, the American College of Obstetricians and Gynecologists recommends that the decision regarding mode of delivery should depend on the experience of the health care provider. Cesarean delivery will be the preferred mode for most physicians because of the diminishing expertise in vaginal breech delivery. Planned vaginal delivery of a term singleton breech fetus may be reasonable under hospital-specific protocol guidelines for both eligibility and labor management. Before a vaginal breech delivery is planned, women should be informed that the risk of perinatal or neonatal mortality or short-term serious neonatal morbidity may be higher than if a cesarean delivery is planned, and the patient's informed consent should be documented."
Many young OBs aren’t learning how to conduct safe vaginal births of twins or breech-presenting babies. As cesareans have gotten safer, OBs are more likely to suggest a cesarean as the best way to deliver a baby when complications are suspected, such as a "big" baby (hugely overestimated fetal weights are extremely common).
One–third of US babies are delivered surgically. Cesareans are safer than before but not safer than vaginal birth for a healthy mother and fetus. More cesareans have led to increases in preterm births, more babies in Neonatal Intensive Care Units, mothers readmitted to hospitals with infections or bleeding, and serious complications and deaths during the mother's subsequent births due to the big scar in her uterus. Pregnant women need full information on all risks associated with cesareans for the mother and baby during future pregnancies as well the current one. There are benefits and risks: if it wasn’t necessary, all you get is risks. -
I worked as an RN for 10 years, observed hospital practices which were invariably unclean and hyperactive, wrote a paper similar to this over 30 years ago, advocated breastfeeding, home birth, etc. Even noted in my paper the country variations in infant mortality rates. No one cared, no one listened, and they still won't. The medical megalopolis is immense and powerful. I had all 4 of my children at home with neither a midwife nor a physician present. I used logic and remained upright as much as much as possible and avoided all drugs. I had amazingly blissful (despite the pain) births (I do not believe in the Indian Princess theory, I screamed and it was very stress relieving) and they were short, quick births. Compared to what I see women experience in the hospital, even realizing that a lot of women are prima donnas and more interested in pain relief than child health, I consider myself one of the lucky ones to have escaped the societal pressure to do it the mechanical, controlled, humiliating, and spiritless hospital delivery. Having a hospital delivery does not guarantee safety or health of the child and sometimes is even counter to those concepts.
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I am a Labor and Delivery nurse with 20 years experience and a Mama who had 2 home births. I must point out how fortunate we are to have articulate, thoughtful, and compassionate OB/GYNs like Karen Adams in our midst who support home birth for true low risk, term candidates. Likewise, Holly Sholles strongly represents her community of DEMs, being a well spoken passionate and intelligent provider. In Oregon, we have the components to lead the country in the creation of a strong, safe home birth culture with seamless and safe transport to hospital care when merited.
Here is the obstacle to this perfect comprehensive birth culture from my perspective. Currently, licensed DEMs are able within their written scope of practice to deliver breech, twins, and VBAC at home. There are no clear guidelines for them to establish fetal well being (how often they must listen to babe's heart beat), limit length of time for safe second stage (time spent pushing), length of time for bag of waters to be ruptured. In the hospital, I have personally witnessed sad and devastating outcomes transferred in from attempted home birth related to these vague and wide open Standards of Practice. Sadly, despite years of controversy, the DEM community has not established MANDATORY data collection to support their claims that high risk practice within home birth is safe. What we know is that there have been term losses of infants due to these practices documented in the complaints to their State Board of Licensure.
The latest research strongly establishing safety of home birth comes from the Netherlands. Almost one third of Dutch women deliver at home. It must be noted, though, that the Dutch midwives function with strict and clearly spelled out Standards of Practice prohibiting breech, twin, and VBAC delivery at home.
I have met many competent, compassionate, skilled DEMs in our state. Sadly, relations between hospital and home birth culture will continue to be fractured as long as we are on the receiving end of bad outcomes related to these high risk practices attempted at home.
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i understand where you are coming from. However, i disagree that there should be mandates limiting what kinds of births midwives are allowed to attend (breech, multiple, vbac etc.). Women who are considering birthing at home with a higher risk pregnancy do so with an understanding that they are, in the end, responsible for their choices and their birth outcomes. These women also understand that their chance to birth vaginally within an institution will be greatly reduced b/c of a practitioners lack of knowledge or an insurance companies rules. Instead of aquiescing to the system - these women ,in many cases, are choosing to give birth without any kind of practitioner in attendance. While i fully support a woman's right to choose an unassisted birth, she should also retain the right to have a knowledgable birth attendant present to help if necessary. While no one likes a bad outcome in birth, least of all midwives, it should not be up to governmennt to say what choices a woman can and cannot make in regards to her body. As well, a midwife should not have to go against these mandates thereby risking her status and livelihood to do the job that she has been well-trained to do. Mandatory licensure or regulation of midwifery in oregon will, in my opinion, lead to worse outcomes for mamas and babies.
Midwives are highly trained professionals, as i am sure you know, who do not take their responsibility lightly and work alongside thier clients to make the best choices for everyone involved, especially in regard to safety of mama and baby.
Instead of taking rights away from women, why not train doctors in the art of breech, multiple and vbac birth. Why not make birth as safe as possible by taking the decisions out of insurers hands and giving responsibility back to the individual.
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There have been many studies that show home birth for low-risk pregnant women to be just as safe as (if not safer than) hospital birth.
http://news.bbc.co.uk/2/hi/health/7998417.stm
http://www.smh.com.au/lifestyle/lifematters/midwife-home-birth-as-safe-as-hospital-says-study-20090416-a8wu.html
The ideal scenario is for low-risk pregnancies to be with a midwife either at home or at a free standing birth center and for high-risk pregnancies to be with an OB. This is the way it is done in many other developed countries and it is obviously working well due to the fact that their infant and maternal mortality rates are much lower than the United States.
http://show.mappingworlds.com/world/?subject=MORTALITYMATERNAL
There are also studies that would suggest that hospital protocols and interventions endager pregnant women. One of these interventions is the Cesarian Section which has a recomended rate by the World Health Organization at 15%. The United States has a C-section rate at over twice that and climbing. Complications arising from a C-section is the number one cause of maternal death. A low-risk pregnant woman is many times more likely to end up with an unnecessary C-section if she gives birth at a hospital.
http://www.medicalnewstoday.com/articles/80743.php
At the hospital, a low-risk pregnant woman is also more likely to be injured from episiotomy, forceps, vaccume, even epidurals can cause lifelong back pain and headaches.
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That being said, I personally believe that while it may be possible, it is highly unlikely to have a natural birth in a hospital. Hospital protocols make that almost impossible.
My sister lived in Chicago and had a very low-risk, uncomplicated pregancy until a few weeks before she was due. She was found to have group B strep (a very common bacteria which can in rare cases cause respiratory problems in the newborn). She had been planning a natural birth with a midwife at the hospital and she wanted no interventions.
When she arrived at the hospital in labor, they immediately started her on IV antibiotics. Because of the IV, the nurses would not let her walk around, not even to use the bathroom! If they saw her walking around they would literally grab her by the arm and lead her back to the bed. My sister was still coping with her contractions without medication so she did not have the concentration to argue with them. As a result of not being able to empty her bladder, it became distended and her baby couldn't decend all the way.
After pushing for three and a half hours, the midwife called a doctor in to assist with a vaccume. Her recovery was horrendous and her bonding time was greatly inhibited by pain. She refers to her daughter's birthday as the most traumatic day of her life.
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The most traumatic day of my life was when I gave birth to my son at a hospital. No one explained (or even mentioned) the risks associated with pitocin, episiotomy, or manged third stage. I received all three and developed complications with them all. The nurses had the pitocin at a higher dose than my doctor had prescribed which caused my uterus to become exhausted and unable to clamp down after the birth. I was loosing too much blood from my episiotomy, and while my doctor was trying to rush the delivery of my placenta, my exhausted uterus would not clamp down and I hemmorrhaged. I was unconscious for the better part of a day and unable to hold, nurse, or bond with my son.
Was I going to go through that again? No way in hell. When I was pregnant with my daughter I found a midwife and eight months later gave birth to her in a kiddie pool in my own house. My midwife was very experienced, very competent, and (gasp!) uncertified. I had an amazing, healing experience supported by two women who had gotten to know me and care about me as a person, not a patient. Although my second labor was longer (17 hrs as opposed to 5 hrs) than my first, I was able to walk around, eat and drink to keep my strength up (what a concept!) and (gasp again!) use the toilet! I felt safe and calm, loved and cared for.
I am now pregnant again, due in December and you can guarantee I'll be taking my "chances" at home again!
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I had my first child a year ago. We were a planned home birth, that ended in a hospital transfer and C-section.
At 20 weeks, I transferred care from a hospital OB to a local midwife team. With the OB I would wait an hour to see her and then get 10 minutes of her time. I did not feel like an individual person. Rather I was measured, studied and quickly hurried out of the room. With the midwives I felt that their treatment was superior and holistic. I had hour long appts that looked at all aspects of my pregnancy (mental health, diet, excercise, interpersonal relations). My partner and I felt respected and we were able to develop trusting and rich relations with my midwife team over the course of the pregnancy.
The pregnancy was uncomplicated and I carried to term.
During my labor at home, I felt confident and relaxed with my midwife team. I was an active participant in the decisions and efforts to birth my son at home. I never feared for my health nor did I have any concerns about my son. We were diligently monitored and assessed and at no time did my son show signs of distress. We were calm, thoughtful and aware every step of the way.
When I transferred to the hospital, my midwife team joined us. Upon entering the hospital setting my shift in care changed dramatically. I was disrespected as an individual, belittled, and made to feel like a bad person because I had not come in sooner and threatened the life of my child. I was offered inflated and inflammatory medical advice "you would have died" and my midwife team was disrepsected and dismissed on several occassions.
My son was born at 11am on Wednesday. He was healthy, robust, quick to latch and perfect! It was a journey and we were both elated and exhausted.
As I reflect back, a year later, I am thankful that I had access to skilled OB's trained in ceasarean delivery. However, I am still extremely disappointed in the transition of care and the inability of the hospital team to treat myself and my midwife team with equal respect for their reputable skills and our decision to attempt a home birth.
I feel that it will be important work for both communities (midwife and hospital) to begin to build bridges and communications that ultimately support and foster the needs of their patients in a positive and constructive manner.
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TO DR. KAREN ADAMS FROM THE LICENSED MIDWIFE OF THE BREECH BIRTH TRANSPORT
As you know because of our communication through email, I was listening to the show when you started to talk about an example of a "homebirth gone bad." I recognized that the scenario was a transport for which I was the midwife. I was surprised by the vast discrepancy between the story you told on the radio, and my perception of the events that I witnessed. For example, you stated that the mother's blood pressure had been taken once in the prior month. The chart reflects that her BP had been taken 4 times in the month preceding the transport (and was normal on every occasion).
You have indicated to me that you do not think women should have the right to choose a vaginal breech birth. I believe in a woman's right to choose where and how to have her baby. I recognize that vaginal breech is outside the scope of practice for most hospital based providers now. My understanding from the obstetricians and CNMs who have taken the time to talk to me about such important issues, is that this is partly the result of malpractice insurance restrictions (as are many non-evidence based hospital practices), partly the result of the Term Breech Trial study (the conclusions of which have been retracted: see my post script below), and partly due to a snowball effect: As fewer doctors do these births, fewer doctors are able to train new doctors on how to do them, resulting in even fewer doctors with the knowledge, training, and experience to handle breech vaginal birth. There are still a significant number of informed consumers who demand this option.
(part 1 of 2) -
(part 2 of 2)
My client was an informed consumer who sought out a midwife once she discovered she could not have a vaginal breech birth at the hospital, where she had been receiving her care throughout pregnancy. At our initial interview, I was impressed with the vast amount of research that her and her partner had done on the safety analysis of vaginal breech birth vs. planned Cesarean. Had she been able to find a qualified provider at the hospital to provide her with a trial of labor for a vaginal breech birth, I doubt she would have sought out other options.
We transferred from home to hospital appropriately and in a timely manner. She had a healthy baby via cesarean. This is not a "homebirth gone bad" but an appropriate homebirth transport.
In my opinion, here is what a homebirth gone bad is: A situation where transport IS needed, but doesn't happen because the midwife and/or the family are fearful of the treatment they will receive upon arrival to the hospital. I'd like to work together to ensure that true homebirths gone bad don't become a reality here in Oregon, as they have in other states. I know that the midwifery community as a whole has been meeting and striving to find ways to bridge these relationships with hospitals. We are eager to work toward the same goal of effective and appropriate transfer of care.
I again would like to invite you to meet with me to review the case of this transport. If you would be willing to proceed with a conversation regarding these issues, you have my contact information.Jesica Dolin, BSM, LDM
PS. The conclusions of the Term Breech Trials (cited by most doctors as a major study showing breech birth is not safe vaginally) were retracted because the study was found to be so flawed. Please google "Five years to the term breech trial: the rise and fall of a randomized controlled trial" for more information. -
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I had two hospital births - having developed preeclampsia during my first pregnancy, my ob said, "once high risk, always high risk." Both births were induced (despite the fact that my blood pressure was great during my 2nd pregnancy) and the births were very disappointing. I had wanted natural child births and ended up getting epidurals because the pain of the pitocin combined with being strapped in my bed was so intense. With my 3rd pregnancy, I switched to a midwife halfway through because my ob said I would have no choice but to go down the same path again. No thanks. My blood pressure was controlled by my midwife with proper nutrition, something my dr was never concerned about. The birth was at home, in a birth pool and was so incredible. It was calm and at my own pace and it was so nice not to have a bunch of nurses run in at the end like they were suprised a baby was actually coming out.
I had a few experiences with local doctors who were amazed that I had a home birth and had nothing but positive things to say about it. But my old ob found out about it from a friend and was quick to voice his disappointment. My midwife had actually worked for him in the past and he cornered her once and asked how she could possibly have a home birth.
I am now pregnant with my 4th and there was no question in my mind when I found out that I was going to have this one at home, too. Thanks for the show!