The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS,
a homebirth midwife in Mountain View, CA
The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS,
a homebirth midwife in Mountain View, CA
|
A: When the baby is preterm or there is no midwife present. Birth Sense responds to the false implications from American OBs The investigators freely admit that planned home birth with a certified birth attendant did not have any greater risks than planned hospital birth. [More information] |
WARNING!!! If you have Aetna health insurance, you may want to change at the next opportunity, when your employer has their annual "open enrollment". Aetna doesn't cover homebirth, citing a single study based in rural Australia which shows that high-risk births far away from a hospital are high risk. They further cite the policies of the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists, both business competitors to homebirth providers. Their policy statement ignores a mountain of evidence that homebirth is as safe as or safer than hospital birth for normal, healthy pregnancies.. If their policymakers have any integrity, this logic will soon lead to cessation of coverage for planned VBAC's . . . there's no dearth of studies and AAP and ACOG policies proclaiming the danger of VBAC's . . . and then they'll stop coverage for any woman who declines standard ACOG/AAP recommendations regarding routine ultrasound, routine induction, routine IV's, routine use of continuous electronic fetal monitoring, routine administration of antibiotics for all GBS positive women (up to 40% of birthing women), and prompt cesareans for any woman who fails to progress in a timely fashion during labor and pushing. They may also stop coverage for children who are not vaccinated according to the full schedule of vaccinations recommended by the AAP, even though many intelligent parents decline the newborn hepatitis B vaccine and practice selective vaccination according to their child's own needs.
If this is troubling to you, as it should be, let them know. You
can easily send
e-mail to Aetna's National Media Relations Contacts and simply tell
them that they should not be in the business of denying coverage for reasonable
healthcare choices, such as homebirth, waterbirth and VBAC. They
will especially want to know if you are choosing another health insurance
provider because of this unreasonable policy. You might also suggest
that they expand their research beyond ACOG and AAP recommendations.
They could start at: http:
Note to Hospital-Based Practitioners: In many of my conversations
with hospital-based birth attendants, they'll inevitably recall labors
where things went very bad very quickly. However, in asking more
questions, it is almost always the case that dangerous hospital-only interventions
were being used, e.g. intrapartum pitocin and/or anesthesia. Yes,
artificially rupturing membranes can cause cord prolapse or rupture a velamentous
insertion, and babies can crash very quickly after that. Yes, women
with epidurals can have their blood pressure bottom out, and babies can
crash very quickly after that. Yes, women on pitocin can experience
uterine hyperstimulation, and babies can crash very quickly after that.
Yes, babies born under the influence of narcotics may have a lot of trouble
adjusting to breathing air, and they may require special drugs to reverse
the effects of the narcotics. However, these dangerous procedures
are not done at home, so these intervention-caused complications will not
be seen at home. This is part of the reason why homebirth is safer
than hospital birth.
Many hospital-based practitioners have never actually seen a normal,
physiological birth, where a woman is free to get into the position that
her body tells her is best for her baby, often upright during much of labor,
keeping baby off the cord, or sometimes on hands and knees for pushing,
helping to rotate baby anterior to prevent shoulder dystocia. If
you have no experience with homebirth, then it's going to be very difficult
to imagine how homebirth can be safer. However, this leaves exciting
potential for you to learn much from these pages. Enjoy!
Another confusing point for some hospital-based practitioners is that
they're not always sure about the difference between doulas (who may help
women labor at home for a while) and homebirth midwives (who are professional
birth attendants practicing in the home). A doctor may have a conversation
with a doula, thinking he's talking with a midwife, and he may understand
that she does not have a deep clinical knowledge, and he may jump to the
conclusion that all midwives are uneducated. Ahhhh, human nature!
These articles are written by Ronnie
Falcao, LM MS, the editor of the Midwife
Archives and owner of gentlebirth.org
Homebirth
Benefits - Why Homebirth Is Most Appropriate for Normal Birth
Dangers
of Hospital Birth - Why Birthing in a Hospital Causes More Problems
Than It Solves for Normal Birth
The Short and Long term Dangers of Hospital
Birth for low risk women by Judy Slome Cohain, CNM
Planned
Home Births - The College of Physicians and Surgeons of British Columbia
reversed their previous commitment to stamp out homebirth in the province
by threatening the license of any physician who supported or attended.
Wonder how ACOG will respond, as the CPSBC are hardly the folks from
a "cause celebre" that ACOG condescendingly asserts about those interested
in homebirth. The bibliography alone is worth keeping handy.
From Medscape Ob/Gyn & Women's Health [02/25/2010]
The
Birth Environment: How the place and people influence outcomes
- excellent slideshow from Penny Simkin.
Home Birth -
Excellent Patient Education from Kent Midwifery Practice in the UK (Kay
Hardie and Virginia Howes)
Dr Stuart Fischbein,
ob/gyn speaking on the benefits of midwifery care and hands-poised physiological
birth. Nine mins long.
Staying
Home to Give Birth: Why Women in the United States Choose Home Birth
Staying Home to Give Birth: Why Women in the United States Choose Home
Birth
Approximately 1% of American women give birth at home and face substantial
Who
is a Low-Risk Woman? The NICE Guidelines (page 13) list risk
factors: "Table 1 Medical conditions indicating increased risk suggesting
planned birth at an obstetric unit"
Where's my midwife? is a grassroots
organization seeking to increase access to midwives in hospitals, free-standing
birth centers and at home through education and advocacy.
Happy International Midwives Day
- a nice notice to celebrate the day - May 5.
Obstetricians in the United States continue to rely on intellectual
dishonesty to criticize homebirth and oppose midwives. Their meta-analysis
includes preterm births that take moms by surprise so that they end up
having an unplanned, unassisted, homebirth.
Birth Sense responds
to the false implications from American OBs - The investigators freely
admit that planned home birth with a certified birth attendant did not
have any greater risks than planned hospital birth.
MANA Press Release about
Meta-Analysis Regarding Home Birth in AJOG
ACNM
Expresses Concerns Regarding Recent AJOG Publication on Home Birth
- ACNM Press Release 7/7/10
It is important to note that the authors’ conclusion differs significantly
from findings of many recent high-quality studies on home birth outcomes
which found no significant differences in perinatal outcomes between planned
home and planned hospital births. We therefore caution against over-interpretation
of these findings until there has been an in-depth review of this analysis
which we will be conducting. In the meantime, we express several initial
methodological concerns.
New AJOG Home
Birth Study Political? from pushedbirth.com - Here’s what’s particularly
curious: Wax and coauthors acknowledge that some of the included studies
were not powered to report mortality rates, and when they analyzed the
data for mortality and excluded those studies, they found “no significant
differences between planned home and planned hospital births,” to quote
the study verbatim. But this is not the study’s banner finding. Instead,
the authors include the very studies they had excluded and report as their
conclusion that “less medical intervention during planned home birth is
associated with a tripling of the neonatal mortality rate.”
U.S.
analysis on home birth risks seen as deeply flawed - doctor who produced
some of the data calls the conclusion "sensationalist"
“We’re dealing with a politically motivated study,” said Dr. Klein,
who was a co-author with Dr. Janssen on the B.C. study.
A new meta-analysis
on the safety of home birth? by Amy Romano
International
Expert Calls Study Deeply Flawed and Politically Motivated from thebigpushformidwives.org
- 7/7/10
WASHINGTON, D.C. (July 7, 2010) – As New York and Massachusetts moved
to pass pro-midwife bills in the final weeks of their legislative sessions,
the American Journal of Obstetrics and Gynecology fast-tracked publicity
surrounding the results of an anti-home birth study that is not scheduled
for publication until September. Described as unscientific and politically
motivated, the study draws conclusions about home birth that stand in direct
contradiction to the large body of research establishing the safety of
home birth for low-risk women whose babies are delivered by professional
midwives.
“Many of the studies from which the author’s conclusions are drawn are
poor quality, out-of-date, and based on discredited methodology. Garbage
in, garbage out.” said Michael C. Klein, MD, a University of British Columbia
emeritus professor and senior scientist at The Child and Family Research
Institute. “The conclusion that this study somehow confirms an increased
risk for home birth is pure fiction. In fact, the study is so deeply flawed
that the only real conclusion to draw is that the motive behind its publication
has more to do with politics than with science.”
Characteristics
of planned and unplanned home births in 19 States.
OBJECTIVE: To estimate the differences in the characteristics of mothers
having planned and unplanned home births that occurred at home in a 19-state
reporting area in the United States in 2006.
METHODS: Data are from the 2006 U.S. vital statistics natality file.
Information on whether a home birth was planned or unplanned was available
from 19 states, representing 49% of all home births nationally. Data were
examined by maternal age, race or ethnicity, education, marital status,
live birth order, birthplace of mother, gestational age, prenatal care,
smoking status, state, population of county of residence, and birth attendant.
We could not identify planned home births that resulted in a transfer to
the hospital.
RESULTS: Of the 11,787 home births with planning status recorded in
the 19 states studied here, 9,810 (83.2%) were identified as planned home
births. The proportion of all births that occurred at home that were planned
varied from 54% to 98% across states. Unplanned home births are more likely
to involve mothers who are non-white, younger, unmarried, foreign-born,
smokers, not college-educated, and with no prenatal care. Unplanned home
births are also more likely to be preterm and to be attended by someone
who is neither a doctor nor a midwife and is listed as either "other" or
"unknown."
CONCLUSION: Planned and unplanned home births differ substantially in
characteristics, and distinctions need to be drawn between the two in subsequent
analyses. LEVEL OF EVIDENCE: III.
OB/GYN
Journal Fast Tracks Anti-Home Birth Study in Advance of Pro-Midwife Legislation
- International Expert Calls Study Deeply Flawed and Politically Motivated
“Many of the studies from which the author’s conclusions are drawn are
poor quality, out-of-date, and based on discredited methodology. Garbage
in, garbage out.” said Michael C. Klein, MD, a University of British Columbia
emeritus professor and senior scientist at The Child and Family Research
Institute. “The conclusion that this study somehow confirms an increased
risk for home birth is pure fiction. In fact, the study is so deeply flawed
that the only real conclusion to draw is that the motive behind its publication
has more to do with politics than with science.”
New
Study Identifies Need to Distinguish Planned from Unplanned Home Births
- The authors of a new study in the July 2010 issue of Obstetrics and Gynecology
found that in order for a successful analysis of home birth to be conducted
in the United States, a distinction needs to be made between planned and
unplanned home births. This study, titled Characteristics of Planned and
Unplanned Home Births in 19 States, by Eugene Declercq, PhD, Marian F.
MacDorman, PhD, Fay Menacker, DrPH, CPNP, and Naomi Stotland, MD has not
received any media coverage, while another home birth study scheduled to
be published in the American Journal of Obstetrics and Gynecology in September
2010 has generated international attention.
Students of rhetoric will notice the attempt to establish that there
must be a tradeoff between maternal benefits and neonatal benefits.
This is not true. Midwifery provides care for the mother-baby dyad
and optimizes outcomes for both.
letter to editor from Patti Jansen:
American Journal of Obstetrics and Gynecology
Standards for Validity in Home Birth Research
To the Editors:
The recent paper comparing maternal and newborn morbidity among births
at home, hospital and in birth centers by Wax et al, reported that babies
born at home more frequently experienced 5 minute Apgar scores below 7.1
The methodology employed brings into question the validity of this conclusion.
Secondly, ascertainment of the type of birth attendant is missing for
4801 women or 0.6% of the sample. It is possible that at least some of
these births were unattended. If this indeed the case, then these births,
which would be expected to have high rates of suboptimal outcomes, might
be over-represented in the home birth group, where the attendants are less
likely to arrive on time for a precipitous birth. In addition, some women
may have deliberately chosen to have an unattended birth and these would
of course take place outside of a hospital or birth centre.
Lastly, the authors acknowledge that births for which complications
necessitated transfer to hospital are attributed to hospital rather than
to home or birth centre births. In contrast to the above biases, this bias
would favor home births. They also acknowledge that perinatal mortality
is not measured, which eliminates deaths occurring during labour.
In view of these serous flaws, the statement that this study provides
a ³robust evaluation of maternal and newborn outcomes that is generalizable
and reflects actual practice² cannot be supported. Without internal
validity, placed in question by missing data and the inability to attribute
births to planned place of birth, the issue of external validity or generalizability
is irrelevant. Recent studies in Canada2, 3 and the Netherlands4 have used
population-based perinatal databases with mandated participation by midwives
and documentation of intended place of birth and attendant, as well as
relevant outcomes including intrapartum fetal death.
American studies of place of birth must meet this standard in order
to draw valid conclusions and allow international comparisons.
1. Wax J, Pinette M, Cartin A, Blackstone D. Maternal and newborn morbidity
by birth facility among selected United States 2006 low-risk births. Am
J Obstet Gynecol. 2009;202(2):152e151-e155.
I've seen this before. Instead of comparing apples to apples (e.g. homebirths
in the US or UK to hospital births in those countries), they cherrypick
the data to include countries where "homebirth" is done by lay midwives
who often have no medical training at all, carry no O2, and are located
in very remote areas.
Limitations
of Meta-Analyses from Improving
Medical Statistics and the Interpretation of Clinical Trials
"A meta-analysis is particularly subject to biased conclusions when
it is created by advocates of a controversial opinion regarding the same
topic the meta-analysis is addressing."
In Canada, it is not unusual for the same midwife to attend births in
the home as well as in the hospital, so you can eliminate qualification
biases in the research. This study compared the safety of homebirth
with the safety of hospital births attended by the same midwives.
HURRAY for truly useful research!
"The new Canadian study compares outcomes for planned midwife-attended
home births, planned midwife-attended hospital births (with the same cohort
of midwives), and planned physician-attended hospital births. The
women in all three groups all met the requirements to be eligible for a
home birth, so the study groups are as comparable as possible.
The study used data from one health region in British Columbia. Canadian
midwives practice in both home and hospital settings, which allowed a comparison
of midwife-attended home and midwife attended hospital birth where ONLY
the setting was different. "
Home
birth with midwife as safe as hospital birth [8/31/09]
Outcomes
of planned home birth with registered midwife versus planned hospital birth
with midwife or physician [Full
Text]
Results: The rate of perinatal death per 1000 births was 0.35
(95% confidence interval [CI] 0.00–1.03) in the group of planned home births;
the rate in the group of planned hospital births was 0.57 (95% CI 0.00–1.43)
among women attended by a midwife and 0.64 (95% CI 0.00–1.56) among those
attended by a physician. Women in the planned home-birth group were significantly
less likely than those who planned a midwife-attended hospital birth to
have obstetric interventions (e.g., electronic fetal monitoring, relative
risk [RR] 0.32, 95% CI 0.29–0.36; assisted vaginal delivery, RR 0.41, 95%
0.33–0.52) or adverse maternal outcomes (e.g., third- or fourth-degree
perineal tear, RR 0.41, 95% CI 0.28–0.59; postpartum hemorrhage, RR 0.62,
95% CI 0.49–0.77). The findings were similar in the comparison with physician-assisted
hospital births. Newborns in the home-birth group were less likely than
those in the midwife- attended hospital-birth group to require resuscitation
at birth (RR 0.23, 95% CI 0.14–0.37) or oxygen therapy beyond 24 hours
(RR 0.37, 95% CI 0.24–0.59). The findings were similar in the comparison
with newborns in the physician-assisted hospital births; in addition, newborns
in the home-birth group were less likely to have meconium aspiration (RR
0.45, 95% CI 0.21–0.93) and more likely to be admitted to hospital or readmitted
if born in hospital (RR 1.39, 95% CI 1.09–1.85).
Interpretation: Planned home birth attended by a registered midwife
was associated with very low and comparable rates of perinatal death and
reduced rates of obstetric interventions and other adverse perinatal outcomes
compared with planned hospital birth attended by a midwife or physician.
Meanwhile, instead of acknowledging actual research already done, ACOG
is collecting "anecdotes", which are individual stories taken out of context
with no containing statistics and nothing to compare with. If your
OB/GYN is a member of ACOG, let them know that you'd like them to write
a letter to ACOG.
Outcomes of planned
home birth with registered midwife versus planned hospital birth with midwife
or physician.
A new era
of home birth research - August 31st, 2009 by Amy Romano
Finally, ACOG is showing signs that they are floundering and will soon
founder under the weight of their own pomposity.
After the 2009 Canadian study came out, ACOG
did something very strange. Instead of acknowledging actual, scientific
research already done, ACOG started collecting "anecdotes", which are individual
stories taken out of context with no containing statistics and nothing
to compare with. (If your OB/GYN is a member of ACOG, let them know
that you'd like them to write a letter to ACOG expressing their concern
about ACOG's lack of scientific rigor on this subject.)
ACOG
requests unsourced anecdotal home birth "data"
Instead of trying to badmouth their competition, why don't they keep
their own house in order and collect stories about mothers and babies who
are killed by aggressive treatments (Cytotec, decapitation with vacuum
extractors) or by hospital infections? Apparently the need for large
numbers disappears when they are the ones collecting the data. Really
. . . anecdotes? As doctors say about any studies that show homebirth
to be safe, they like to say that the studies weren't large enough. Problems
are infrequent in childbirth, no matter where it takes place, so only "really
large numbers" could reveal whether the home truly is as safe as the hospital,
says Tracy, an OB/GYN at Boston's Massachusetts General Hospital.
So I guess they'll solve the problem by trying to collect just the stories
where problems occurred in a case where the woman was even thinking about
a homebirth. Honestly, I've heard of OBs who have blamed Down Syndrome
on a homebirth. Sheesh!
Meanwhile, on Sept. 11, 2009, The Today Show ran a segment called "The
Perils of Home Births", in which they aired the opinions of OBs that homebirths
are dangerous. No studies were cited, no midwives were interviewed.
We just saw doctors who had strong opinions about homebirth, and reporters
who parroted what the doctors said. Apparently not one of them knows how
to use the internet to find actual scientific studies about the safety
of homebirth.
They quoted a doctor as saying, "homebirth had become almost the equivalent
of a spa treatment for women, that it was this sort of hedonistic
concept of birthing."
The ACOG rep. quoted in the segment points out that if an emergency
arises and we can't intervene within minutes, the life of the mother and
the life of the baby could be endangered. She appears not to understand
that midwives are trained and equipped to handle these emergencies or to
get to the hospital for brewing problems. And she has no concept of the
additional dangers that are introduced at the hospital.
In a stunning display of ignorance about homebirth safety, Erin Tracy,
ACOG's delegate to the AMA, is quoted in USA
TODAY [9/13/09] as saying, "low-risk pregnancies can become high-risk
in minutes: A baby's shoulder might get stuck in the birth canal, or heavy
bleeding could necessitate a blood transfusion for the mother." She
actually chooses a really poor example when she cites shoulder dystocia,
the situation when the baby's shoulder gets stuck. The remedies for
shoulder dystocia are non-surgical . . . there is nothing that an OB can
do for this in the hospital that a midwife cannot do at home. In
fact, because women at home are unmedicated, they can change positions
more easily, getting on hands and knees (the Gaskin maneuver), which is
the solution for shoulder dystocia which is least likely to cause a serious
tear in the woman's perineal tissues. And there is nothing magical
about the hospital building to prevent too much bleeding after the birth.
Many midwives employ techniques (delayed clamping of the cord) which appear
to reduce maternal bleeding. And if the mother does bleed too much,
they can use the same anti-hemorrhagic pharmaceutical medications as are
used in the hospital.
Doctors say it's impossible to compare home and hospital because hospitals
deal with so many more high-risk cases. Apparently, both the reporters
and the doctors interviewed missed or forgot the 2009 Canadian safety study
of midwives who practice in both the home and the hospital, and with matched
population comparisons between midwife and OB for low-risk women.
You can read this excellent
response from wheresmymidwife.org
Numerous birth advocacy organizations signed on to the excellent CIMS
Letter to the Today Show. There are 16 references at the bottom.
By the way, if you enjoy irony, you'll particularly enjoy the end of
the TODAY show piece, where the OB suggests questions to ask the midwife:
Does the midwife have malpractice insurance?
Does she have physician backup?
In the United States, the answer to this question is mostly going to
be no because the MD-controlled malpractice insurance companies refuse
to offer malpractice insurance to homebirth midwives. And the very
same MD-controlled malpractice insurance companies do not allow physicians
to backup homebirth midwives.
Given the level of hostility that ACOG and the AMA routinely display
towards midwives, it is beyond ludicrous that MDs are still the ones regulating
the licenses of homebirth midwives in California.
The Cochrane Collaboration's international OB/GYN committee writes,
"The change to planned hospital birth for low-risk pregnant women in many
countries during this century was not supported by good evidence."
(See http:
such as the 2005 BMJ Retrospective North American Study and the 2009 Canadian
"Same Midwife" and Matched Population Study duplicate results of historical
comparisons of homebirth safety with hospital birth. The findings:
home is as safe or safer than hospital, but women and baby experience more
trauma in the hospital. When is ACOG going to learn to read the research?
Erin Tracy, ACOG's delegate to the AMA, is quoted in USA TODAY [9/13/09]
as saying, "low-risk pregnancies can become high-risk in minutes: A baby's
shoulder might get stuck in the birth canal, or heavy bleeding could necessitate
a blood transfusion for the mother." She actually chooses a really
poor example when she cites shoulder dystocia, the situation when the baby's
shoulder gets stuck. The remedies for shoulder dystocia are non-surgical
. . . there is nothing that an OB can do for this in the hospital that
a midwife cannot do at home. In fact, because women at home are unmedicated,
they can change positions more easily, getting on hands and knees (the
Gaskin maneuver), which is the solution for shoulder dystocia that is least
likely to harm the woman or baby. And there is nothing magical about
the hospital building to prevent too much bleeding after the birth.
Many midwives employ techniques which appear to reduce maternal bleeding.
And if the mother does bleed too much, they can use the same anti-hemorrhagic
pharmaceutical medications as are used in the hospital, while transporting
to the hospital if long-term, surgical remedies are necessary. Why
is home safer than the hospital? Reduced maternal stress supports
reduced fetal distress, and you can't get hospital-acquired infections
in the home! For much more information, see http:
Little do they realize that every time they come out on some high-profile
TV show to badmouth midwives and homebirths, I get an onslaught of phone
calls from women who say they didn't know that there were still midwives
out there and that women could still have their babies at home.
Keep up the good work, ACOG!
And if you want to enjoy a lot of chuckles, thanks to ACOG, check out
My
OB said WHAT?!? - read and contribute to this hilarious web page.
Resources
Science and Sensibility:
Choice of Birth Place in the United States
Saraswathi Vedam, CNM, MSN, SciD(hc); Patricia A. Janssen, RN, BSN,
MPH, PhD; Ronnie Lichtman, CNM, PhD
Debora Boucher, Catherine Bennett, Barbara McFarlin, Rixa Freeze
pages 119-126
Abstract | Full Text | Full-Text PDF (374 KB)
Journal of Midwifery & Womens Health
Volume 54 Issue 2. Pages 119-126 (March 2009)
obstacles when they make this choice. This study describes the reasons
that women in the United States choose home birth. A qualitative descriptive
secondary analysis was conducted in a previously collected dataset obtained
via an online survey. The sample consisted of 160 women who were US residents
and planned a home birth at least once. Content analysis was used to study
the responses from women to one essay question: "Why did you choose home
birth?" Women who participated in the study were mostly married (91%) and
white (87%). The majority (62%) had a college education. Our analysis revealed
508 separate statements about why these women chose home birth. Responses
were coded and categorized into 26 common themes. The most common reasons
given for wanting to birth at home were: 1) safety (n = 38); 2) avoidance
of unnecessary medical interventions common in hospital births (n = 38);
3) previous negative hospital experience (n = 37); 4) more control (n =
35); and 5) comfortable, familiar environment (n = 30). Another dominant
theme was women's trust in the birth process (n = 25). Women equated
medical intervention with reduced safety and trusted their bodies' inherent
ability to give birth without interference.
American OBs Make Another Desperate Attempt to Slander
Homebirth, 2010
. . .
We are puzzled by the authors’ inclusion of older studies and studies
that have been discredited because they did not sufficiently distinguish
between planned and unplanned home births — a critical factor in predicting
outcomes.
Declercq E, Macdorman MF, Menacker F, Stotland N.
Obstet Gynecol. 2010 Jul;116(1):93-9.
Re: Wax J, Pinette M, Cartin A, Blackstone J. Maternal and newborn
morbidity by birth facility among selected United States 2006 low-risk
births.
February 2010, Vol 202, Issue 2 152e1-152e5.
This retrospective study utilized 2006 US Standard Certificates of
Live Birth, used by 19 states in the US. To establish a low obstetrical
risk population, multiple exclusions were applied to the data with the
result that only 36.0% (745, 690/2,073,368) of women in participating states
were included. Inclusion of only slightly more than one third of the potentially
eligible population raises questions about the ability of birth certificates
to identify women at low risk and consequently the generalizability of
study findings.
Since only 75% of the births studies were recorded as attended by a
physician or midwife, fully one quarter may have been unplanned home births.
Unplanned home births are well known to be at higher risk for adverse
outcomes.
2. Janssen P, Saxell L, Page L, Klein M, LIston R, Lee S.
Outcomes of planned home birth with registered midwife versus planned
hospital birth with midwife or physician. Can Med Assoc J. 2009;181:277-383.
3. Hutton K, Reitsma A, Kaufman K. Outcomes associated with planned
home and planned hospital births in low-risk women attended by midwives
in Ontario, Canada, 2003-2006: A retrospective cohort study. BIRTH.
2009;36(3):180-189.
4. de Jonge A, van der Goes B, Ravelli A, et al. Perinatal mortality
and morbidity in a nationalwide cohort of 529, 688 low-risk planned home
and hospital births. BJOG. 2009;116:1177-1184.
Homebirth Safety References - Canadian "Same Midwife"
and Matched Population Study, 2009
Giving birth at home with a midwife present is as safe as a hospital
delivery accompanied by a doctor, suggests a new Canadian study, which
found home births were associated with fewer adverse outcomes for both
mother and baby.
Instead of trying to badmouth their competition, why don't they keep
their own house in order and collect stories about mothers and babies who
are killed by aggressive treatments (Cytotec, decapitation with vacuum
extractors) or by hospital infections?
Janssen PA, Saxell L, Page LA, Klein MC, Liston RM, Lee SK.
CMAJ. 2009 Sep 15;181(6-7):377-83
For a great analysis of the new Canadian home birth study, go to www.scienceandsensibility.org.
You might want to sign up to receive notice of posts on this great Lamaze-sponsored
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ACOG's Last Stand - Anecdotes, Smoke and Mirrors
"Et tu, Medscape?"
Home
Birth Gone Awry: Is This Typical?
In the past, Medscape has been reliable for sharing good, unbiased information. I'm not sure why this has changed so drastically around the issue of homebirth, other than that ACOG and the AMA appear to be on the warpath against homebirth and midwifery.
In response to the article, "Home Birth Gone Awry":
The author describes a direct-entry midwife as a midwife who enters the profession of midwifery directly without earning a nursing degree, implying that this represents a lack of beneficial training. Yet this is just like a "direct entry" obstetrician, who enters the profession of obstetrics directly without earning a nursing degree. Are you concerned about their lack of appropriate skills and training because they specialized in medicine and obstetrics without first studying nursing?
A more accurate and less-biased definition of a direct-entry midwife is that she is a mid-level healthcare practitioner specializing in midwifery. Anyone who knows the kind of care that is provided at a homebirth by direct-entry midwives knows that there is plenty of nursing care provided. California Licensed Midwives are almost all direct-entry midwives, and we are trained and licensed to perform all of the nursing skills of a maternity/newborn nurse in addition to all the skills of a CNM, including IV and catheter insertion, although these are typically not necessary.
One significant difference between direct-entry midwives and CNMs is that we're typically trained in an out-of-hospital setting, where we also do the newborn resuscitation and provide newborn care as well as maternity care, both as the primary healthcare provider and as the nurse. So, you see, the joke is that direct-entry midwives who specialize as midwives without studying nursing as a separate specialty actually do lots more nursing than Certified-Nurse-Midwives. The world's a funny place sometimes. And, of course, CNMs are midwives who typically aren't skilled in newborn resuscitation and newborn care, which are considered essential midwifery skills in most of the world. And the same could be said of OBs.
So you could state that CNMs are nurses who are also primary birth attendents without specializing in newborn resuscitation or normal newborn care and that OBs are surgical specialists with little or no training in normal birth.
It seems kind of silly for ACOG to complain about a "lack of collaborative work with hospital-based providers" when they actively reject and alienate direct-entry midwives. In general, direct-entry midwives are specialists in out-of-hospital birth and more qualified to attend unmedicated births than OBs and CNMs, who are trained in medicated and interventive births.
It would have been helpful if you had pointed out that the Washington State Study was not well designed. In fact, it wasn't really designed as all, as it was a retrospective statistical analysis of records in a state that does not distinguish between unassisted homebirths and homebirths attended by a trained professional. If you want to compare unassisted homebirths with unassisted hospital births, I would be happy to refer you to a local mother whose baby was born at our local hospital without anybody assisting her because nobody was paying attention to her. She happened to be standing at the time, so the baby simply fell to the floor, snapping the umbilical cord. Thank goodness, the baby is still alive and is believed not to have suffered permanent damage from the lack of proper care.
Or if you would like a well-documented and publicized case of an under-assisted birth in the hospital, I refer you to the very sad case at Beth Israel where a baby died because of communicatoin problems among the staff.
It is truly specious of ACOG to support free-standing birth centers as being somehow safer than a homebirth. In my practice, a homebirth is simply a birth center birth where I take all the birth center equipment to their home. A birth center building does not offer any special safety, in and of itself. And there is no kind of equipment in a free-standing birth center that I cannot take into a home.
This article also missed a very important point regarding the clientele who choose homebirth. There are large homebirth communities among the religious communities in the Pennsylvania and Ohio areas--the Amish and Mennonite. I would assume that most of the breech births occurred among those populations, as most DEMs I know refer breech to hospital-based providers, who then tell them they must have a c-section because they (the OBs) don't have the good breech skills of the European OB communities. (This policy is devastating to the religious communities who plan on large families, where a c-section has drastic effects on their childbearing plans.) It is intellectualy dishonest to avoid this issue if you're aware of it. The Amish and Mennonite communities will typically stay at home to have their babies, whether or not a midwife will serve them. Statistically, we would expect more of the breech babies to have died if there had not been a midwife present to assist. Those midwives deserve respect for their willingness to learn the skills necessary for responsible attendance of breech births and to use those skills in the service of these religious communities.
And these same populations typically decline ultrasound screening, as they would not consider terminating a pregnancy under any circumstances. Thus they are going to have higher neontal mortality rates, as the babies born with anomalies incompatible with life will die at a homebirth just as they would have died at a hospital birth.
The article shines in the discussion of the importance of facilitating a rapid transfer of care to a hospital-based provider when necessary. Thank you for this.
The concluding paragraph is very touching, but it perpetuates that myth that women who choose hospital births will always have good outcomes. It denies the reality that there are babies who are born healthy in the hospital and then die from a hospital-acquired infection. It denies the reality that hospital interventions sometimes kill babies. (Do you need references regarding the babies who have been decapitated from overly aggressive use of vacuum extractors?) It denies the reality that seemingly unavoidable hospital procedures that routinely separate mothers and babies result in breastfeeding failure, which accounts for 20% of infant mortality.
Ronnie Falcao, LM MS
***************************************
Note that Medscape also highlighted the Malloy article.
For a more thorough discussion of overall homebirth safety and hospital dangers, please see:
Homebirth Benefits - Why Homebirth Is Most Appropriate for Normal Birth by Ronnie Falcao, LM MS
Dangers
of Hospital Birth - Why Birthing in a Hospital Causes More Problems
Than It Solves for Normal Birth by Ronnie
Falcao, LM MS
This study is not to be confused with the Australian
Outback Study, which showed that twin and breech births are safer when
done with reasonable access to surgical facilities, as opposed to remote
locations in the Australian outback, multiple hours away from a surgical
facility.
Planned
home and hospital births in South Australia, 1991-2006: differences in
outcomes. [full
text]
Kennare RM, Keirse MJ, Tucker GR, Chan AC.
Med J Aust. 2010 Jan 18;192(2):76-80.
Epidemiology Branch, SA Health, Adelaide, SA, Australia. marc.keirse@flinders.edu.au.
[from Susan Hodges at Citizens for Midwifery]
A new home birth study based on data from South Australia has just been published. Of course, an editorial on the topic in the same issue of the journal, penned by the President of the Australian Medical Association (“which is opposed to home birth in Australia”) helped to “spin” the findings to show that home birth is much more dangerous than hospital birth, even though the actual data show no such thing.
You can read the whole article at < http:
> : “Planned home and hospital births in South Australia, 1991-2006: differences
in outcomes” (Robyn Kennare, Marc Keirse, Graeme Tucker and Annabelle Chan,
MJA 192(2), 18 January 2009).
You can also find some great analysis of what the study actually tells
us. If you are interested in reading research critically and understanding
how data and results can be twisted (on purpose or by not thinking about
what they mean), these analyses are worth your time:
“That Homebirth Study in South Australia”
“More critique of the homebirth study and its reporting by the media"
The AMA wants to make birth centers illegal, along with homebirths,
even though hospital births are causing more mothers
and babies to die and suffer lifelong
injury.
Ricki
Lake Attacked by the AMA
Well, all I can say is that they're getting really desperate, and they
apparently have very little respect for the intelligence of American women.
I don't think they've realized that the world has changed with the invention
of the Internet. Women can now access PubMed and read BMJ articles,
and they can easily discover that ACOG continues to attack midwives and
homebirth without any evidence to support them. Sigh. Fortunately,
this is one old-boys' network that is dying a quick death.
The
Authorities Resolve Against Home Birth from JOGNN by Nancy K. Lowe,
published in the recent Journal of Obstetric, Gynecologic, Neonatal
Nursing, the official journal of the Association of Women’s Health, Obstetric
and Neonatal Nurses (AWHONN).
‘‘Whereas, there has been much attention in the media by celebrities
having home deliveries, with recent ‘Today Show’ headings such as
‘Ricki Lake takes on baby birthing industry.’’’
The
heat gets turned up..on home birth - response from the Lamaze Institute
for Normal Birth.
Big
Medicine's blowback on home births - Why do U.S. doctors strong-arm
women into our standard maternity care system? By Jennifer Block
President’s
Editorial: Doctors Ignore Evidence, AMA Seeks to Deny Women Choices in
Childbirth from The Midwives Alliance of North America; this includes
excellent information as well as references.
Read more about the ACOG 2008 Press Release from The
Big Push for Midwives and Childbirth
Connections
Midwives Remain Committed
to Women’s Birth Choices, Despite AMA Resolution that Aims to Restrict
Them from The Maine Association of Certified Professional Midwives
The American College of Nurse Midwives has responded to recent AMA Resolutions
(regarding home birth and regarding doctor supervision of midwives) with
a letter to the AMA and addenda. While these are understandably written
from ACNM’s viewpoint and interests in the CNM and CM credentials, overall
the documents are excellent, and do a good job of affirming home birth
and pointing out the outrageousness of ACOG/AMA behavior regarding these
issues. The addenda are organized by topic and the statements are well-documented.
In my opinion the ACNM has done an outstanding job of refuting all the
main issues raised by the AMA’s Resolutions, especially the anti-home birth
resolution 205 (see Grassroots messages 806032, 806033, 806037 and 807038).
The addenda in particular should prove to be excellent resources (including
all the references) for supporting the option of planned home birth.
You can read (and download) these documents at:
http:
http:
Parenting
Group Denounces AMA Resolution Against Homebirth: Members of the Holistic
Moms Network Say Homebirth is a Safe Choice And Must Remain a Legal Right
from the Holistic Moms Network
Physician Group
Seeks to Outlaw Home Birth—Is Jail for Moms Next? - from th International
Chiropractic Pediatric Association in collaboration with the Holistic Pediatric
Association.
Maria
Iorillo's Response - Her blog is great reading anyway!
Midwife-Attended
Home Births Less Safe Than In-Hospital Deliveries By Jill Stein
"The risk of neonatal mortality among infants delivered by a certified
nurse midwife (CNMW) in the home is considerably greater than among in-hospital
CNMW deliveries, according to data released here at Pediatric Academic
Societies (PAS) 2009."
Actually, this "study" shows a deep lack of understanding about what
statistics show.
At least he had the intellectual honesty to admit that he was just talking
about his assumptions here, because he actually made quite a few different
assumptions. For example, he assumed that the pool of women choosing
to birth at home with a CNM started out with the same risk factors as the
women choosing to birth in the hospital with a CNM. This is nothing
more than an assumption. In fact, we know that many of the homebirth
populations (Amish, Mennonite) decline prenatal ultrasound and specifically
refuse to terminate a pregnancy that might result in the baby's death.
If these same women chose to birth in the hospital, they would probably
be risked out of the midwife practice and would end up in the pool of higher-risk
women with higher mortality rates attended by OBs. It's also important
to think about the fact that a study of Licensed Midwives attending homebirth
showed homebirth to be safer than hospital
birth. Is it possible that CNMs are safer in the hospital because
they are trained in the hospital, and Licensed Midwives are safer at home
because they are trained in out-of-hospital birth? These are important
issues that aren't addressed by Dr. Malloy's opinion piece.
Safety
of midwife-attended home births questioned
I poked around a little bit online and found this related article in
PubMed:
Current issues in
Texas neonatology.
"Since almost 10% of the births in the United States occur in Texas,
issues that affect neonatal care in Texas are important for both the state
and the nation. Although overall statistics are similar for the state and
nation, closer examination reveals a need for improvement in specific areas,
namely prenatal care, black and Hispanic mortality, and low birth-weight
rates. Lay midwifery regulation has been an important concern in Texas."
I think this may be another factor in the difference found in Dr. Malloy's
study: there are higher mortality rates among black and Hispanic populations
in Texas, and these are the same populations that are more likely to use
real lay midwives, i.e. the curanderas of the immigrant Hispanic population.
Apparently, Dr. Malloy also has a long-standing issue with homebirth
and "lay midwifery". Right away, the phrase "lay midwifery" instead
of "direct entry midwifery" belies a bias towards tight control by the
medical establishment. A "lay midwife" has no formal training.
A "direct-entry midwife" has formal training in the midwifery model instead
of in the medical model; this is what puts a bee in the bonnet of MD-centric
healthcare providers.
Dr. Malloy's "research" is a shining example of why reputable research
must look at matched populations, such as the 2009
Canadian Same Provider / Matched Population Study, 2005
BMJ homebirth safety study.
"Overall, the results demonstrate that the safest setting for a delivery
is in hospital attended by a certified nurse midwife. Women who decide
to deliver in the home "need to recognize the greater risk associated with
that choice," Malloy said." [Ed. I do appreciate good strategy, and
the divide-and-conquer approach to midwives might have worked before ACOG
showed their true colors about midwives in general.]
Can anybody guess why Dr. Malloy doesn't continue with "Women who decide
to deliver with an MD need to recognize the greater risk associated with
that choice."
Do you feel comfortable with the idea of giving birth at your local
hospital with a midwife attending the birth?
Do you feel comfortable with the idea of giving birth at your local
hospital with a family practice doctor attending the birth?
Do you feel comfortable with the idea of giving birth at your local
free-standing birth center?
Do you feel comfortable with the idea of giving birth at home, attended
by a qualified birth attendant?
Homebirth with a well-trained and equipped midwife is safer than every
one of the other options listed above.
Family practice doctors and midwives working in hospitals and free-standing
birth centers typically attend the births without the immediate presence
of their backup obstetrician. Years of experience have confirmed
that birth emergencies requiring cesarean birth tend to develop slowly
and that there is a safety margin of 75 minutes between
the signs of a serious development requiring a cesarean and the actual
cesarean birth. I have seen obstetricians taking their time even
with placental abruptions because the safety margin is so generous.
Midwives and family practice doctors are trained to handle the emergencies
that may occur within a few minutes of the birth, i.e. shoulder dystocia,
postpartum hemorrhage, placental problems. And, in fact, every one
of these emergencies occurs at a time when cesarean section is no longer
an option.
Homebirth midwives are further trained also to perform neonatal resuscitation
as necessary. In the most extreme case, they can continue to perform
resuscitation measures while a baby is transported to the hospital, where
these functions can be taken over by mechanical ventilators.
So, women giving birth at home have the same safety net as all the above
scenarios. In addition, they are not exposed to antibiotic-resistant
and hospital-acquired infections, which can be so deadly to newborns because
of their immature immune systems.
[NOTE - The one exception to the above is a situation where a baby who
is experiencing fetal distress has passed meconium, in which case the baby
is better off born at the hospital, where a special intubation team can
be waiting in case the baby is not vigorous at birth. For this reason,
I personally transport such clients to the hospital in time for the birth
so that the baby's lungs can be washed out immediately after the birth.
The likelihood of this is well below the likelihood that the baby will
become sick from a hospital-acquired infection.]
Homebirth is also safer than giving birth at your local hospital with
an obstetrician, but this is more difficult to understand intuitively.
However, most women intuitively understand that it is better NOT to have
someone cut their perineum with a scissors!
In England, they have a national healthcare system which values the
health of a child throughout the child's entire lifetime. They understand
the additional benefits of homebirth that might not show up in a birth-focused
study. For example, they understand that babies born at home are
more likely to breastfeed better and for many months longer than babies
born in the hospital. They understand that babies born at home are
not going to be colonized with hospital germs such as antibiotic-resistant
infections. They understand that a mother who is happy and proud
of her birth experience is going to be a happier mother and will have happier
children. All of this is good for their health as well as their happiness.
Here's an excerpt from the British
Joint statement No. 2, April, 2007 on Home Births:
"The Royal College of Midwives (RCM) and the Royal College of Obstetricians
and Gynaecologists (RCOG) support home birth for women with uncomplicated
pregnancies. There is no reason why home birth should not be offered
to women at low risk of complications and it may confer considerable benefits
for them and their families. There is ample evidence showing that labouring
at home increases a woman's likelihood of a birth that is both satisfying
and safe, with implications for her health and that of her baby."
Fact Sheet Summary
of the New Landmark Study Showing that Planned Home Births Are Safe
Outcomes
of planned home births with certified professional midwives: large prospective
study in North America [Full-text
article]
Conclusions: Planned home birth for low risk women in North America
using certified professional midwives was associated with lower rates of
medical intervention but similar intrapartum and neonatal mortality to
that of low risk hospital births in the United States. [NOTE - CPMs
are equivalent to Licensed Midwives in some states.]
Answers
to Questions About “Outcomes of planned home births with certified professional
midwives: large prospective study in North America” from the
authors, Kenneth C. Johnson, Betty-Anne Daviss
Understanding
Birth Better addresses the concerns Dr. Amy has written about.
Here are press releases from midwifery organizations:
Landmark
Study Reports Planned Home Births Are Safe from Citizens for Midwifery;
they also published another
overview and the BMJ press release.
And some OB/GYN newsletters:
Home
superior to hospital birth - "Among low-risk women, home births assisted
by certified midwives achieve similar rates of intrapartum and neonatal
mortality as hospital births, with lower rates of medical intervention,
reveal Canadian researchers." [from obgynworld.com]
Here's the popular press on the homebirth safety study:
Home
birth safe for low-risk pregnancies from Reuter
Giving
Birth at Home Is Safe, Study Show from foxnews.com or another
version from WebMD. This one happens to quote Ronnie
Falcao, LM, MS, the non-nurse editor of these web pages, who has also
written her own comments
about the article.
Bringing
Out Baby ... at Home - Home Delivery also from WebMD - "You're bringing
a baby into a home full of love rather than a hospital full of germs."
On Reuter's website: “Home birth as safe as hospital delivery for low-risk
pregnancies”
On Fox News website: “Giving Birth at Home Is Safe, Study Shows”
On MSNBC website: “Home births Safe for low-risk women”
On CNN website MedPage: “Study: Low-risk home births safe”
On the CBC.CA (Canadian) Betty-Anne was on the national television news
Friday, the 17th:
On Yahoo! News: “Home Birth safe for low-risk pregnancies”
On Forbes: “Childbirth at Home as Safe as Hospital Delivery: Study”
On KOMO 4 News & ABC News: “Midwives a Safe Alternative to Hospital
On eMediaWire: “Study Shows Home Birth Lowers Cesarean Risk”
I was starting to think that the OB/GYN online journals were just going
to ignore the most recent study about homebirth safety.
Then, what to my wondering eyes did appear, but the following heading
from www.obgynworld.com:
The largest prospective study of planned home births to date evaluates
the safety of such births supported by direct entry midwives.
Among low-risk women, home births assisted by certified midwives achieve
similar rates of intrapartum and neonatal mortality as hospital births,
with lower rates of medical intervention, reveal Canadian researchers.
"Despite a wealth of evidence supporting planned home birth as a safe
option for women with low risk pregnancies, the setting remains controversial
in most high resource settings," note Kenneth Johnson (Public Health Agency
of Canada) and Betty-Anne Daviss (International Federation of Gynecology
and Obstetrics, Ottawa).
To examine its safety further, the team compared perinatal outcomes
for all planned home births (n = 5418) supported by the North American
Registry of Midwives in 2000, with those previously reported for low-risk
hospital births in the USA.
Overall, 12.1 percent of women were transferred to hospital for delivery.
The incidence of neonatal mortality among those who remained at home was
similar to that documented for low-risk hospital births, with no maternal
deaths. Medical intervention, however, was substantially less common among
home, versus hospital, births, with epidural, episiotomy, forceps, vacuum
extraction, and cesarean section rates of 4.7 percent, 2.1 percent, 1.9
percent, 0.6 percent, and 3.7 percent, respectively.
"Our study of certified professional midwives suggests that they achieve
good outcomes among low-risk women without routine use of expensive hospital
interventions," conclude Johnson and Daviss.
Posted: 23 June 2005
I thought this reporting was remarkably favorable, considering some
of the knee-jerk interpretations that have come out of other sources.
Study Shows Homebirth Superior to Hospital
Birth - A summary of the 2005 BMJ Homebirth Safety Study suitable for
publication in chiropractor newsletters.
Outcomes
of planned home births in Washington State: 1989-1996.
"This study suggests that planned home births in Washington State during
1989-1996 had greater infant and maternal risks than did hospital births."
Obstetricians Use
Dubious Method in Attempt to Discredit Homebirth from MANA, 2/11/03
4.
Why does the Washington home birth study have different conclusions than
almost all other articles on home birth? from Kenneth C. Johnson, Betty-Anne
Daviss, the authors of the North American
Prospective Study, 2005.
When
Research is Flawed: The Safety of Home Birth by Henci Goer
Press Release from
Midwives Alliance of North America (MANA)
Homebirth:
Is it really a safe option? from ivillage.com
A
Comprehensive Review & Critique on the Pang-Benedetti Study on Home-based
Birth from Faith Gibson's
site
"The Pang-Benedetti study appears to have been designed to mislead and
to artificially create a media "event" to generate flattering publicity
for obstetricians and hospital birth by making home-based birth care appear
dangerous. Perhaps this is a misguided effort to neutralize the extensive
media coverage of deaths in hospital patients as a result of medical mistakes,
antibiotic-resistant infections and adverse drug reactions. Why we put
healthy women and babies into such a bio-hazardous environment is a source
of wonderment. However, two wrongs do not make a right. "
Homebirth
Research and Resources from the Seattle Midwifery School contains a
number of rebuttals to the Pang study.
Homebirth
Under Fire - What the Headlines Don't Say - by Jill MacCorkle - Mothering
Magazine, March/April, 2003, p. 38
Key points:
"We know, too, that hospital birth can be made safer by adopting the
midwifery model of care, which has been shown to result in lower rates
of intervention and better outcomes, regardless of setting. We already
have a comprehensive blueprint for how to achieve better hospital birth:
the Mother-Friendly Childbirth
Initiative from the Coalition
for Improving Maternity Services. (www.motherfriendly.org)."
Aetna bases their anti-choice policy on the single Australian study
that shows that high-risk births (twins, breeches, etc.) are safer in the
hospital than in rural areas without ready access to emergency hospital
transport. Lesson for American parents: Don't plan to give birth
in the Australian outback if you have a high risk birth. Dhuh.
full
text]
Michael
Coory has written a commentary that points out that for the period
cited, "the perinatal mortality rate for Australian home births (7.1 per
1000 births) was much higher than that for home births in other industrialised
countries." This was presumably because many of the births included
in the study occurred in rural areas with no emergency transport to hospitals
for problems that arose during labor. This is irrelevant to home
birth in the United States, where many homebirth midwives discourage planning
to
give birth in locations that are remote, where transport to the hospital
would take more than the 30 minutes recommended by ACOG.
Irene Shaw has written an
excellent discussion of the study with some very useful quotes from
the study itself:
Australian home births carried a high death rate compared with both
all Australian births and home births elsewhere. The two largest contributors
to the excess mortality were underestimation of the risks associated with
post-term birth, twin pregnancy and breech presentation, and a lack of
response to fetal distress. Marsden Wagner, MD MSPH, an internationally recognized authority on
childbirth and public health issues, addresses the issue in his article,
"Fish
Can't See Water: The need to humanize birth in Australia".
Pro-homebirth editorial in British Medical Journal, Home
birth
It basically says that for low and moderate risk mothers the safety
of home-based midwifery care for both mothers and babies is equal or superior
to hospital-based obstetrician care. If anything, homebirth has become
even safer as portable technologies allow homebirth midwives to perform
continuous electronic fetal monitoring, if necessary.
The following articles are referenced and available via hot links from
the Home Birth editorial:
Prospective
regional study of planned home births [full
text]
The
Northern Region's Perinatal Mortality Survey Coordinating Group. Collaborative
survey of perinatal loss in planned and unplanned home births [full
text]
Outcome
of planned home and planned hospital births in low risk pregnancies: prospective
study in midwifery practices in the Netherlands. [full
text]
Home
versus hospital deliveries: follow up study of matched pairs for procedures
and outcome. [full
text]
Outcomes
for births booked under an independent midwife and births in NHS maternity
units: matched comparison study. [full
text]
CONCLUSIONS: Healthcare policy tries to direct patient choice towards
clinically appropriate and practicable options; nevertheless, pregnant
women are free to make decisions about birth preferences, including place
of delivery and staff in attendance. While clinical outcomes across a range
of variables were significantly better for women accessing an independent
midwife, the significantly higher perinatal mortality rates for high
risk cases in this group indicate an urgent need for a review of these
cases. The significantly higher prematurity and admission rates to intensive
care in the NHS cohort also indicate an urgent need for review.
Editor: This study shows results similar to the "Australian Outback"
study, i.e. high risk cases have higher mortality rates at home.
This shouldn't be a surprise to anyone, as high risk cases are more likely
to benefit from the technology available in hospitals. It is incumbent
on midwives to make it very clear to high-risk women that there is a chance
that there could be significantly worse outcomes at home. The families
must then balance this information with the other important factors in
their home life. Some families choose homebirth for high-risk cases
for religious reasons. Others believe that the mother could be so
seriously re-traumatized by a repeat of a previously traumatic hospital
birth that they consider that the overall risk to the mother/baby dyad
of a homebirth is still less than of a hospital birth, although statisticians
have not yet figured out how to account for these other factors.
The language of this study is to be commended for re-affirming a woman's
right to birth in the circumstances of her choice, and a family's right
to shape the way in which their family lives, including the birth experience
of their babies.
And it is also to be commended for making it clear that the study confirms
other studies showing that homebirth is as safe or safer than hospital
birth for low-risk cases.
Outcomes
of intended home births in nurse-midwifery practice: a prospective descriptive
study.
Place of
birth
"No evidence exists to support the claim that a hospital is the safest
place for women to have normal births "
Meta-analysis
of the safety of home birth
Outcomes
of planned home births versus planned hospital births after regulation
of midwifery in British Columbia [full-text
article]
According to Janssen, "In a home birth you have the focused and undivided
attention of an experienced practitioner who may be able to pick up complications
very early as opposed to being in a crowded hospital where there's a mix
of both experienced and new practitioners who have other responsibilities."
Are home births
safe?
Do
obstetric intranatal interventions make birth safer?
Impartial analyses of the evidence from official statistics, national
surveys and specific studies consistently find that perinatal mortality
is much higher when obstetric intranatal interventions are used, as in
consultant hospitals, than when they are little used, as in unattached
general practitioner maternity units and at home. The conclusion holds
even after allowance has been made for the higher pre-delivery risk status
of hospital births as a result of the booking and transfer policies. It
holds even more strongly for births at high than at low predicted risk.
It follows that the increased use of interventions, implied by increased
hospitalization, could not have been the cause of the decline in the national
perinatal mortality rate over the last 50 years and analysis of results
by different methods confirms that the latter would have declined more
in the absence of the former. Data are presented which point to the deleterious
effect of interventions on the incidence of low birthweight and short gestation
and their associated mortality. Also presented are data supporting the
alternative explanation of the decline in perinatal mortality, namely the
improvement in the health status of mothers built up over several generations.
The organization of the maternity service stands indicted by the evidence.
Despite the beliefs of those responsible, it has not promoted, and cannot
promote, the objective of reducing perinatal mortality.
Is Homebirth
For You? 6 Myths About Childbirth Exposed
Home versus
hospital birth (Cochrane Review) "The change to planned hospital birth
for low risk pregnant women in many countries during this century was not
supported by good evidence."
Excerpt from the World Health Organization's Summary
of Research on Place of Birth from Care
in Normal Birth: A Practical Guide Report
Collection
of Homebirth Safety Information On the Web
Collection
of Homebirth Safety Information - Illinois Midwives' Pages
Angela Horn's
Home Birth Reference Page from England, including a short article,
"What
if your doctor advises against home birth?"
Bibliography
of Midwifery - Home Birth Literature Review
Physician and Midwife Attended Home Births
I highly recommend the fourth edition of Five Standards for Safe
Childbearing by David Stewart, Ph.D.
The homebirth section has a lot of research:
Since the founding of NAPSAC in 1975, we have searched for the data,
if it exists, that supports 100% hospitalization for birth. We have not
found it. We have formally requested all of the major medical associations
(ACOG, AMA, AAP, AAFP) and any other professional organization who supports
100% hospitalization to share, with us, their data. To date, they have
not. We have asked them to write chapters for the NAPSAC books. We have
offered to publish their documentation. We have given them the opportunities
to speak before large audiences at NAPSAC Conferences in order that their
valid statistics, if they have any, can be made known. To date, they have
failed to produce even one study in support of their contention. The Midwifery chapter now has 157 references, and the Home Birth chapter
has 218. This documentation can no longer be ignored. The Midwifery chapter
and the Homebirth chapter will also be available as reprints.
The new, fourth edition costs $16.95, plus $3.00 shipping. The Midwifery
Reprint costs $4.95, plus $1.50 shipping, and the Home Birth Chapter costs
$3.95, plus $1.50 shipping. Quantity prices are available for these two
reprints.
Midwifery Care and Medical Complications: The Role of Risk Screening
by Eugene R. Declercq PhD, BIRTH Journal, 22:2 June 1995
Safest birth
attendants: recent Dutch evidence
"Analysis of national perinatal statistics from Holland, 1986, demonstrates
that for all births after 32 weeks' gestation mortality is much lower under
the non-interventionist care of midwives than under the interventionist
management of obstetricians at all levels of predicted risk. This finding
confirms with great authority the conclusions of all earlier impartial
analyses from Britain and other countries which agree in contradicting
the claims on which the organisation of maternity services in most developed
countries is now based, namely, that childbirth is made so much safer by
the application of high technology that only this option should be provided."
Here are some studies you all can look for to support homebirth as a
safe way to birth:)
"Outcomes of Elective Homebirths: A Series of 1,146 Cases" By Lewis
Mehl MD et al. Journal of Reproductive Medicine Nov 1977
"Neonatal Outcomes in Planned vs. Unplanned Out of Hospital Births in
Kentucky" by M Ward Hinds MD MPH et al. Journal of The American Medical
Hospital Association March 15th 1985
"Neonatal Mortality in Missouri Home Births 1978-1984" by Wayne F Schramm
MA et al. American Journal of Public Health August 1987
"Having Babies at Home: Is It Safe? Is It Ethical?" by Gerald Hoff MD
and Lawrence Schneiderman MD. Hastings Center Report December 1985
"Evaluation of Outcomes on Non Nurse Midwives. Matched Comparisons with
Physicians" by Lewis Mehl et al. Women and Health Vol5 1980
A really good book on this is "Safer Childbirth?" by Marjorie
Tew. She has a table contrasting the outcomes of similar risk group
women hospital vs. home. The perinatal mortality rate per 1,000 births
was:
for very low risk: hospital=8.0 home=3.9
To add to the resources for Homebirth statistics. There is a recent
Journal of Nurse Midwifery issue that is devoted to homebirth. One article
in particular deals with the statistical outcomes in homebirth in the US
of around 12,000 planned homebirths with CNMs. I was very impressed by
the outcomes and had been somewhat skeptical before about homebirth. This
particular version was published Nov/Dec 1995, Volume 40, Number 6.
From Sheila Kitzinger's Homebirth", 1986 stats in the Netherlands
OB attended hospital births, 83,351 births, 18.9/1000 infant deaths GP
attended home births, 21,653 births, 4.5/1000 infant deaths Midwife attended
hospital births, 34,874 births, 2.1/1000 infant deaths Midwife attended
home births, 44,676 births, 1.0/1000 infant deaths
These are the most recent stats. She also has charts of 1958 and 1970
home vs. hospital births in Britain, which show home birth very favorably.
You should read Safer Homebirth by
Physician-
and midwife-attended home births. Effects of breech, twin, and post-dates
outcome data on mortality rates. [full
text]
Adverse outcomes were similar for midwife-attended and physician-attended
births when twins, breech births, and postdates births were removed from
the samples.
Homebirth Safety
- The Farm Statistics
Isle of Man Study Shows Medical Interventions
Causes Problems
In contrast to the ACOG position, the
American Public Health Association passed a resolution in 2001 to increase
access to out-of-hospital birth attended by credentialed direct-entry midwives.
They based their decision on the weight of evidence about home birth demonstrated
in the home birth studies carried out with better methodologies than were
used in the Washington study.
Home
birth 'as safe as hospital' says RCM - 23/04/2004 - The Royal College
of Midwives (RCM) today (Thursday 22 April 2004) reassured parents-to-be
that home births are every bit as safe as hospital births.
References on Homebirth Prepared
by Ina May Gaskin, CPM
Misconceptions
Surrounding the Safety of Home Birth and Hospital Birth by Misty Dawn
Richard - a dissertation containing an excellent summary of midwifery history
and current issues.
Homebirth - Safety and Benefits
Britain's National
Childbirth Trust discusses homebirth:
"The National Birthday Trust survey of 6000 home births in 1994, published
in 1997 (see references) found that outcomes from planned home births were
just as good as from planned hospital births. They found that women's satisfaction
with home birth was greater than women's satisfaction with hospital birth."
The Heart and
Science of Homebirth - What are the facts about homebirth? Find out:
Order this collection of articles from Midwifery Today!
home
birth: what are the issues? by sara wickham - "There is no shortage
of evidence to support the fact that home birth is safe, satisfying and
empowering for women and their families. "
The
Homebirth Choice by Jill Cohen and Marti Dorsey
Homebirth section
from Sheila Kitzinger's site
with a nice extract
from her book, Homebirth.
Israel Gale's Homebirth Safety Information
Summary of Homebirth Debate from sci.med.obgyn
(October, 1996)
This "research" sounds suspiciously like the sensationalized stats that
were done in the early 80's from one state (Montana?, North Dakota?), that
showed a 2-3 times higher risk of infant mortality with home birth.
Upon closer inspection, it was found that these were "raw" statistics,
done without regard to choice in home birth, or caregiver. Some of
those births were late miscarriages, babies accidentally born at home or
a taxicab, in other words, anything out of the hospital was listed as a
"homebirth". Although this information was debunked, it still keeps
cropping back up now and again.
This is the way the stats were presented to our Legislative Study Council,
and even then mortality rates were the same. I could forward the figures
if anyone is interested. We had prepared the Study Council members for
possibly poor looking raw data, so I think they were pretty impressed when
the raw figures were presented and the outcomes were almost identical.
Doesn't say much for the so-called advantages of hospital birth in this
state though.
I strongly suspect that the leaking of this dubious statistics is intended
to lead to a knee-jerk response which leads to a change in clinical practice
or political view on home birth, without anyone ever bothering to produce
some reliable statistics.
This leak should not be regarded as credible nor as useful information
on which to make an informed choice.
Somehow I just felt that the article had to be based on dubious stats.
After all, the work (in the Lancet?) last year was so positive about the
outcomes for planned home births and seemed to show so clearly - along
with everything else - that it's when births happen outside hospital and
aren't planned that way that the outcomes are bad. At least in the UK anyway.
Everything that ECPC and WHO etc. etc. say confirms it.
But I couldn't help wondering..........................and thinking
that if it WERE the case, then what on earth are we all doing? I
wanted to follow it up and get hold of the article for starters. One of
the other antenatal teachers read it and said that there weren't any references
cited.
I do so hate to be a cynic - in fact I got told off by a really good
friend only last night for being too soft about all kinds of stuff - but
isn't this yet another example of scare mongering that happens all too
often? There were some similar articles written by obstetricians a few
years ago about water birth. No evidence, just hints as you say. The trouble
is that the damage is done. Everyone believes the doctor. "No way will
I have my baby at home -- ever!" Not that home is right for everyone;
I'm not saying that. Yet again it just underpins the idea that birth is
really dangerous and we shouldn't risk our babies' safety on mere whims.
I think the reason it has come out in this way is because the person
responsible for the leak knew that many obstetricians and others would
have jumped on it if it were in a medical journal and rubbished it! In
fact it would probably not even gotten through peer review.
There are homebirth midwives out there who do carry emergency IV equipment,
newborn resuscitation equipment, and meds. I can do almost anything at
home that I can do in the hospital within the 20 minutes that it might
take to transport a serious emergency from home. And, I have often seen
that with the constant attention of a midwife both during pregnancy and
labor, many potentially unfavorable situations are recognized early a nd
the course changed, something that often doesn't happen in the hospital
with sporadic nursing attention, even if you have a machine attached through
the whole labor. This is really an important issue in the safety of homebirth!
Home
Delivery By LIZ MITCHELL - from The Missourian - This article
really got it right as to the risks of doctors attending homebirth: "The
primary risk is the disapproval of colleagues, which could affect licensure
and hospital privileges."
Lamaze
blog response to ACOG anti out-of-hospital birth statement - a compilation
of from invited commenters.
Time
of birth and the risk of neonatal death.
"Neonatal mortality was 1.88 for daytime births, increasing to 2.37
for early night and 2.31 for late night births. . . . The increased risk
was identified in hospitals that provide intermediate, community, and regional
neonatal intensive care, but not in hospitals that provide primary care."
The common interpretation of this study is that hospital personnel at
night aren't providing the same level of care as during the day.
As
many as 195,000 people a year could be dying in U.S. hospitals because
of easily prevented errors, a company said on Tuesday in an estimate
that doubles previous figures. [7/27/04]
Infants Too Easily
Misidentified in Neonatal Intensive Care Units
Throughout the 1-year study period, "there was not a single calendar
day without at least one pair of patients at risk for misidentification,"
the investigators report. On average, just over half the patients were
at risk on any given day.
Pediatrics 2006;117:e43-e47.
Vancomycin-resistant enterococcus
is just one of the many hospital-acquired
infections which create a life-threatening risk to otherwise healthy
people admitted to the hospital.
Hazards
of Modern Medicine - An Overview Based on a Selection of Findings from
the More than 10,000 Articles, Reports, and Scientific Research Studies
in the Medical LiteratureBy Barry M. Charles, MD
HOW THE MODERN
MEDICINE MONOPOLY HAS FAILED US by Dr. Carolyn Dean, MD, ND and Elissa
Meininger [8/18/05] containing How
Modern Medicine Killed My Brother by neurosurgeon and author, Russell
Blaylock, MD
A
38-year-old woman with fetal loss and hysterectomy.
This is a fabulous article from Mothering
Magazine:
Revealing
the Real Risks: Obstetrical Interventions and Maternal Mortality
Cleaning
solutions and bacterial colonization in promoting healing and early separation
of the umbilical cord in healthy newborns.
"The risk of umbilical infection has been reduced as a result of earlier
postpartum discharge from hospital." [From
CARE OF THE UMBILICAL CORD] Umbilical infection is just one of
the types of newborn infection that occur more frequently in the hospital.
I've never heard of a baby who got decapitated at a homebirth, but this
apparently isn't that unusual in the U.S.:
From: http:
"Some of you living in Orange County will remember a series of five
‘expose’ articles on the Medical Board that ran in the Orange County Register
in April of 2001. One was about a local obstetrician who had been sued
by two sets of parents about 3-4 years apart for making the very same egregious
“mistake” not once but twice -- two forceps deliveries in which the baby’s
skull was pulled off its spine by overzealous traction, resulting in immediate
death. While this doctor had a horrible reputation with the L&D nurses,
the hospital never revoked his admitting privileges, those two as well
as other malpractice awards against this doctor had never been reported
as required by law and the Medical Board had never investigated him.
After five of these articles in the newspaper, there were many “inquiring
minds” that wanted to know why not!. "
If you have information about other decapitations happening in the hospital,
please
contact me. Thanks. :-(
One of the risks of homebirth is that a major catastrophe could happen,
which could (possibly) be better handled in a hospital. This could be a
catastrophic cord problem, uterine rupture, abrupted placenta... however,
most of these things could also happen at home before labor begins, and
even when they happen during labor, there is almost always plenty of time
to get to the hospital, while taking appropriate measures en route.
Another factor to take into consideration is the dangers of the hospital.
There is a danger your doctor won't be there and an inexperienced student
or nurse might have to catch your baby, you or your baby could contract
a disease resistant to antibiotic therapy (these are not usually found
in your home), your baby could be snatched from the hospital (I know, a
wild idea, but the above mentioned catastrophes are rare too, and we worry
about those!) You could end up with a cesarean section (1 out of 4!) -
these are some pretty high risks that should be taken seriously.
[from sci.med.obgyn]
I believe that hospital delivery is safer by a few percent, and this
percent is the percent of parturients who have abruptions, cord prolapses,
convulsions, hemorrhages from cervical, uterine, or vaginal lacerations,
undetected rapid breeches, pulmonary embolisms, infections (undetected),
fetal stress, untreated obstructed labor, and on and on. Most gravidas
do not have disease, so are fine at home. But if yours is the case, you
become common parlance.
The Doctor has done a good job listing the risks of home birth relative
to hospital birth, and he notes that these risks are small.
In other messages, however, he has continued to assert that there areno
risks of hospital birth relative to home birth. This is a strong claim,
and it's patently false. We know that in the United States about one out
of twenty pregnant women who gives birth in a hospital has an unnecessary
cesarean. Cesareans are major surgery, and some (few) women die from them;
many thousand others get more minor complications like infections.
Some hospitals have practices that sabotage breastfeeding; these include
supplying routine bottles and separation of mother and baby right after
birth. Recovering from an unnecessary cesarean can also make it more difficult
for the mother to establish breastfeeding. We know that breastfeeding is
healthier for babies, so practices that discourage mothers from breastfeeding
endanger the newborns.
The Doctor may have meant to state that on balance, he believes the
risk of giving birth in the hospital is less than the risk of giving birth
at home (for a woman who would qualify for home birth). He hasn't provided
any evidence to make us believe this, however, or even to make us believe
that he has considered the hospital risks at all.
Blood Gases: Obvious geographical considerations aside, the safety of
homebirth has been questioned even in Holland, where back up is usually
excellent:
However, there's no evidence that this represents any kind of problems
for the babies. In particular, see:
This humorous analogy about "home sex"
helps to put the issues of "home birth" in perspective.
One of the easiest reasons to understand is the infection issue - Hospital-Acquired
Infections and Antibiotic Resistance
Homebirth Safety - What Really Keeps the Baby
Safe?
"The only additional risk of natural childbirth is possible emotional
trauma from mismatched expectations."
It's very important to be mindful that the historical improvements have
been because of access to timely medical care, rather than the routine
use of all obstetrical interventions. The medical community defines
timely access as 30-70 minutes from noting a serious problem.
Why Homebirth is Safer, an excerpt from the book, A Woman in Residence,
by Dr. Michelle Harrison, M.D. (who is a family practitioner and did residency
work in OB/GYN) will make us all do some reflective thinking.
"Imagine dancers on a stage. Once, doing a pirouette, a woman sustained
a cervical fracture as a result of a fall; she is now paralyzed. We try
to make the stage safer, to have the dancers better prepared. But can a
dancer wear a collar around her neck, just in case she falls? The presence
of the collar will inhibit her free motion. We cannot say to her, 'This
will be entirely natural except for the brace on your neck, just in case.'
It cannot be "as if" it is not there, because we know that creative movement
and creative expression cannot exist with those constraints. The dancer
cannot dance with the brace on. In the same way, the birthing woman cannot
"dance" with a brace on. The straps around her abdomen, the wires coming
from her vagina, change her birth.
The birthing woman plays in an orchestra of her body, her soul, her
baby, her loved ones, her past and her future. And we do not know who leads
the orchestra.
Doctors cannot lead the orchestra, because they are not within the process.
Unable to hear the music, trained only in modalities of power and control,
they can only interfere with the music being played.
What should the be able to do? They should stand ready to help the player
in trouble to get back into rhthym. Instead, they take over. Instead of
supporting the mother, they say, 'Okay, you have failed. It's our piece
now.'
How do you (doctors) get a 30 percent Cesarean rate? You orchestrate
it. You write a piece in which the third movement is a Cesarean, then build
the first two with that in mind. You write in a different language; you
write in terms of centimeters of dilation, external fetal monitor, internal
fetal monitor, pH, scalp electrodes, Cesarean birth experience, arrest
of labor, protracted labor, fetal distress, episiotomy, prolapse, cephalopelvic
disproportion, ultrasound waves, amniocentesis, "premium baby', post-mature
(when the baby stays too long in the uterus), "maternal environment" (formerly
known as mother). Those are the words, the notes, while the piece is played
to the rhythm of fear.
In response to: "Is homebirth safe?"
Rather a large number of studies have been done on this. To date, the
studies show, without exception, a lower rate of mortality and morbidity
for mothers and infants in all risk categories with home birth.
This runs counter to what we believe as a society: that hospitals are
safer, and the right place to have a baby. All cultures have strong beliefs
about the "right" way to give birth. From the outside, the beliefs of others
may seem ridiculous. From the inside, anything else seems dangerous and
weird. The US has very poor outcomes for a developed nation. We make up
a lot of reasons why this must be so, but rarely face the fact that our
birth practices are not the best.
Who does have the best? The country with the best statistics, by far,
is Holland. They have about a 30% home birth rate. Pregnant women see a
midwife first. The midwife is the "gatekeeper", and refers high risk mothers
to OB/Gyns, who do hospital births. Healthy mothers birth at home. A significant
factor in the good outcomes for infants is the birth assistant, who does
light housework for a week after the birth, sparing the mother and allowing
her to spend her energy bonding with her infant. The birth assistant is
also a trained observer, who can detect unusual problems and alert a pediatrician,
teach breast feeding techniques, etc.
How can home birth be safer than hospital birth? Most "problems" in
hospital births come about due to "failure to progress". This leads to
interventions, and interventions have consequences and side effects. In
the hospital, this often leads to more interventions, etc. Why failure
to progress? Imagine for a moment that your cat is about to have kittens.
It will seek a warm comfortable place, where if feels safe. Imagine you
bring it out into a strange, brightly lit area full of strangers, who poke
it and examine it. Do you think it will give birth? Or will this profound
and difficult process be interrupted while it takes in its new surroundings?
You certainly are safer giving birth with a trained practitioner, who
has a deep understanding of the psychology and physiology of birth, who
knows when to transport to a hospital, how to intervene if needed, has
a certificate in infant resuscitation, knowledge of and license to use
pitocin and suture, etc. And you are safer giving birth within a short
transport of a hospital, should one be needed. Most licensed midwives in
the US have post-graduate training, and are experts in normal birth, and
will transfer you to the hospital from a home setting right away if your
birth is not progressing normally.
But healthy mothers are generally safer at home. It defies what most
of us believe, but the statistics bear it out.
Homebirth and Postpartum Hemorrhage
Safe
interval for emergency caesarean section is 75 minutes
When the decision to deliver by caesarean section is made, time to intervention
should be less than 75 minutes to avoid poor maternal and baby
Women laboring at home within 20 minutes of a hospital operating room
have the same access to emergency surgery as women laboring in that same
hospital. Most surgeons are not physically present in the hospital
while their clients are laboring; they are either at their office seeing
patients, home sleeping in their beds, or simply going about their business.
(Many doctors instruct the nurses not to call them until the baby's head
begins to crown.) Whether an emergency arises at home or in the hospital,
it still takes time for the surgeons to be paged, to drive to the hospital
and to arrive at the scrub sinks. It takes time to assemble the anesthesiologists,
nursing staff and neonatal teams necessary for a cesarean section.
Hospitals offering labor and delivery services must be able to start cesarean
surgery within 30 minutes of being notified of the need, which gives women
laboring at home plenty of time to get to the operating room ahead of the
surgeon.
How can this be safe? Childbirth "emergencies" usually develop
over the course of hours rather than minutes, especially when they're not
actively caused by interventions such as artificial rupture of membranes,
administration of pitocin, spinal/epidural anesthesia or pulling on the
umbilical cord to deliver the placenta.
What is a reasonable time from decision-to-delivery
by caesarean section? Evidence from 415 deliveries shows that
fewer than 40% intrapartum deliveries by caesarean section for fetal distress
were achieved within 30 minutes of the decision, despite that being the
unit standard.
Two papers and an editorial in this week's BMJ describe the difficulties
in meeting the target of 30 minutes between the decision that an urgent
caesarean section is necessary and delivering the baby. [May, 2001]
Interval between
decision and delivery by caesarean section -- are current standards achievable?
Observational case series
Editorial: Caesarean
section for fetal distress
A placenta abrupted in the hospital. They did a stat c-sec 30 minutes
later. How long does "stat" mean in your hospitals? 30 min. limit? 10 min.
max? Can you please send me, tell me your protocols/ experiences where
you are?
The ACOG standard is currently "30 minutes call to cut" for all non-scheduled
c-sections. In a small community hospital that may be an impossibly short
time, especially at 3 in the morning on a weekend, where you have to get
anesthesia and a whole ER crew in from home. And if the mom is a hard stick
for the IV, hasn't had any labwork drawn for the blood bank, or hasn't
given her consent! In a tertiary care setting where there is 24 hour coverage
of all specialties and the L&D nurses also have OR training, I have
seen a stat section done in 30 seconds call to cut (massive antepartum
hemorrhage, IV started and prepped for section during admission, seemingly
stable until the FHTs disappeared). I'm not sure that the mom was asleep
when they cut, but I know she didn't care...her words as we were hauling
her through the nurses station were "save my baby". You can't judge a hospital
in a small town (which should probably really be considered more like a
birth center in capabilities) by the standards of a tertiary care metropolitan
trauma center.
By us, large tertiary Israeli medical center, it means less than 10
minutes if the woman was already admitted, around 15 if we have no paper
work and blood. We have our own OR and staff on call 24 hours a day plus
anesthesiologist. If you are a small center and have to transfer to another
floor, wing or building and if you don't have your own OR staff waiting
on the hospital grounds, you aren't going to be able to do the 7 minutes
that we can.
P.s. just talked to a friend who works in Jerusalem...she says it takes
5 minutes there. We're talking about centers with over 500 births a month.
Depends. At the private hospital I currently work in, MDs are required
to live within 30 min of hospital. But if it is 0200, and they are sound
asleep, it will be longer than 30 min before they get to the hospital.
And the OR crew needs to be called. An assistant, and an anesthesiologist.
If you are at a hospital that has 24hr in house coverage by OB, CNM
and OB anesthesiologist, with C/S being scrubbed and circulated by the
L/D staff, or have in house OR crew, then you can get from "decision to
incision" within just a few minutes. The shortest I have been involved
in was 3 minutes.
A
Native American community with a 7% cesarean delivery rate: does case mix,
ethnicity, or labor management explain the low rate? [full
text]
This study is an object example of the principle of low-risk women safely
laboring without immediate access to cesarean surgery. Most of the
birth attendants were not obstetricians, and in fact, cesarean delivery
required transport to another hospital!
First-Time Moms Ideal Candidates for Homebirth
Faith Gibson's Homebirth
VBAC Consent Form
HBAC FAQ - Q&A about Homebirth After Cesarean
Is Homebirth Appropriate for a VBAC?
[from ob-gyn-l]
It is my opinion that home VBAC regardless of the number of prior cesareans
is tempting fate. Perhaps one might get away with it 990+ times out of
a thousand.
Yes, and perhaps one can "get away with" not having a severe shoulder
dystocia or abruption or cord prolapse 990+ times out of a thousand, too.
There are established risks to giving birth. Meconium does happen.
By your logic giving birth is tempting fate. You say you don't oppose homebirth,
but I would ask you to evaluate more closely the thinking underlying your
statements.
This is not meant to dismiss the gravity of obstetrical complications,
be they a uterine rupture or a terrible shoulder dystocia. Any time a mother
or baby is harmed we all grieve. However, there are two important points.
1) We cannot eliminate all risks. Giving birth is as safe as life gets
(here we should remember the people who die every day in "freak" accidents,
like air conditioners falling on them, as well as all the predictable causes
of death). Our medical and legal standards now assume that anytime a baby
dies someone must be at fault. We all know that is not true.
2) We must be aware of the danger of adding new risks by trying to prevent
others. A case in point is VBAC management. Bruce Flamm recommends continuous
fetal monitoring for all VBACs because the commonest sign of rupture is
fetal distress. While this may be an intelligent way to most of the time
notice a rupture while you still have a chance to save the baby, we all
know very well the risks of continuous fetal monitoring (increased use
of pain meds, dysfunctional labor, more cesareans, etc.) In individual
cases it doesn't make sense to argue that putting the mother at risk for
an(other) unnecessary cesarean is worth saving one baby from death, however
in the big picture treating every woman with a scar on her uterus as though
she is a ticking time bomb is very destructive and sounds like all the
arguments for hospital birth for any old laboring woman "Well anything
might happen at any moment, so it is better to be on the safe side" etc.
etc. etc., which has led us directly to current obstetrical "management"
complete with routine inductions at 40 weeks, epidural on demand, continuous
fetal monitoring, etc. (don't call me crazy, I worked as a nurse for three
years in such a place).
The real reason for treating VBACs differently from other laboring women
is POLITICS, despite the fact that depending on how you look at it, either
all labors are potential disasters (shall we call it the "OB" approach
without offending too many of our good docs?) or most labors will go smoothly
and most complications are either can be anticipated or ameliorated without
major intervention but occasionally "the big one will hit" and there is
little we can do to avoid it (the "midwife" approach), .
The fact is that if there is a uterine rupture in a hospital and the
baby dies, everyone will say "well, we did everything we could" and sweep
it under the rug. If there is a uterine rupture outside of the hospital,
even if the caregivers notice the rupture right away, give supportive care
and transport immediately to a waiting surgical staff (where I work we
could transport in less than ten minutes to a prepared labor suite) and
the baby still dies, then the wrath of the entire medical community would
rain down on that poor birth center or OOH midwife for "violating standards
of care".
So, as long as you cover your butt, even if you are not actually making
labor and birth any safer, you are doing the right thing???? And if in
the process you are exposing the women and her baby to additional risks,
such as overzealous medical staff, easy access to pain meds, the dangers
of electronic fetal monitoring, the psychological stress of being in a
"medical" environment to complete a natural biological process, etc., etc.,
you are still doing the right thing?? If you make the woman give birth
in the hospital and thereby decrease her chances of giving birth vaginally
because of her fears and you expose her and her baby to the attendant risks
of surgery (infection, bleeding, etc.), then have you done the right thing??
I am sorry, but your argument sounds like the one the anesthesiologists
at my former place of employment used to try to convince all laboring women
that they needed an epidural -- IF there was an emergency then the anesthesia
for the emergency cesarean would already be in place. That is kind of like
saying, considering the high numbers of automobile accidents, we should
all go around NPO all the time in case we crack up the car and need emergency
surgery at least we won't have to worry about aspiration when the fresh-out-of-medical-school-resident
attempts her first intubation.
If an intelligent woman carefully weighs the risks and feels safer and
more comfortable attempting a VBAC outside of the hospital, then why shouldn't
we support that and help her to do it as safely as possible?
Abstracts about Pit and Home VBAC
[from ob-gyn-l about hospital VBAC]
I would think that Previous cesarean would be a High Risk indication
and hence should not be managed by a midwife unless there was a MD there
also. However, I agree that management by a Midwife who is present is much
better than management by a MD who is not present.
OK, how many women here had the constant attendance of their OB once
they were in active labor?
I'm assuming the answer is none.
So the set of {MDs who are not present} is the same as the set of {MDs},
and this OB is saying that Midwives offer better management of VBACs than
MDs.
This is one of the reasons I think homebirth is safer for VBAC - the
caregiver providing constant attention is much more likely to notice the
earlier, less threatening signs of a rupture.
Is Weight a Contraindication for Homebirth?
Choosing
a Size-Friendly Health Practitioner [THIS FAQ TEMPORARILY DOWN.
NEW UPDATE COMING SOON]
I agree that smoking is a habit I would discourage in a pregnant woman
- it introduces toxins into her system and potentially reduces the oxygen
flow to her baby. Then again, I once knew a chain smoker who carried
twins to term and gave birth to babies who weighed 7.5 and 8 pounds and
were extremely healthy.
I don't think the question is whether smoking is beneficial or not.
I see the questions as: "For someone who is addicted to smoking,
where is the safest place for them to give birth?"
Since the primary consideration is maximizing the oxygen flow to the
placenta and minimizing the stress on the baby, I see home as the most
appropriate place. Hospitals have a strong tendency to introduce
anxiety, pitocin, and epidurals. Anxiety and a stressful environment
reduce a woman's blood flow and the amount of oxygen available to the placenta.
Epidurals lower a woman's blood pressure, which also reduces oxygen flow
to the placenta. Pitocin increases the stress on the baby, thereby
increasing the oxygen need.
When people are talking about risk factors for homebirth, they often
compare the ideal homebirth candidate with the high percentage of non-ideal
candidates.
This makes no sense, since you can't turn a non-ideal candidate into
an ideal candidate. All you can do in the real world is to look at
your non-ideal candidates and figure out which is the safest place for
them to give birth.
Research is crystal clear on this point. Homebirth is safer for
all risk categories except the highest, and I've never figured out how
sick you'd have to be to be in that highest category - probably actively
seizing from pre-eclampsia or actively bleeding from a placental abruption
or uterine rupture.
From Ken Johnson and Betty-Anne Daviss, co-authors of the 2005 Homebirth
Safety Study.
Contacting your local media
We invite you, if you have not already done so, to contact your
local radio stations and newspapers this week about the study, and if you
cannot get to it this week, to contact any media people you know in local,
national, or international community newspapers or magazines over the next
week or two. Try the health reporters. Strategize with your consumer
groups to figure out the best talk shows that might pick this up in your
home town. The study has already appeared in numerous national media (see
below), and your actions to bring the study to the attention of your local
news media can generate more news coverage for the public as well as draw
attention to your CPM credential and /or to local advocacy efforts. If
you participated in the study, that might be a special interest story for
the local press.
For ideas and materials you can give to a reporter, the following are
available: the BMJ press release (at www.bmj.com); the Citizens for Midwifery
press release and relevant grassroots network message (at http:
the NACPM press release (at http:
(at www.ican-online.org). Also see “What to emphasize” below.
When contacting the media take the time to educate them on the CPM credential
and make sure they know that NARM, MEAC, CfM, MANA, and NACPM have information
on these maternity care providers.
We also want to formally thank all of you who have taken the time to
contract your local newspaper or disseminate news of the article by postings
on websites and listserves. We understand that Katie Prown and Steve
Cochran helped organize an effective grassroots effort through the BirthPolicy
network. Please be sure to write to us about your interactions with
the press.
4) What to emphasize with the media:
You can still phone your local media today. Here are some pointers
about things to emphasize:
* Why This Study Is Special: The study is groundbreaking because
former studies have been criticized for not being big enough, for not being
able to distinguish between planned or unplanned births, and/or for being
retrospective, that is only looking at old records as opposed to engaging
health professionals in the requirement of registering births they are
going to do and then accounting for all outcomes. This is the only study
ever published that has met all three of these criteria: the study is big
enough, the study distinguished between planned and unplanned home births,
and the data are prospective.
* Emphasize the low intervention rate: For the year 2000, your
chances with a CPM in a planned home birth of having some kind of medical
intervention -- a cesarean section, forceps or vacuum delivery, induction,
episiotomy, epidural -- were 1/10 to ½ (depending on the intervention)
of what they were if you planned a hospital birth, using statistical outcomes
from the US population from the same year and comparing to largely low
risk group in hospital by using US birth certificate data for all
vertex, term, singleton births.
* Low Rate of Transfers: We purposely reported transfers as: “over 87%
of mothers and neonates did not require transfer to hospital,” and
most of the transfers were for lack of progress, because the mother was
tired or wanted pain relief. This kind of detail is especially important
when communicating with the media. For example “over 87% of the mothers…”
conveys a sense of confidence, while “thirteen per cent of women still
had to be transferred,” which one television broadcast did (even though
it was overall a positive study) focuses on the negative end of the curve.
And to be clear: only 3.4% of women who began labour at home had a transfer
which the midwife thought was urgent, and even these “urgent” transfers
did not necessarily mean there was some avoidable trauma involved, just
that it was felt that things needed to be checked out right away, e.g.,
anomalies in a baby, observation of babies having breathing difficulties
but who had oxygen and bag and mask at home as they would in hospital,
mothers losing more blood than was felt safe. The outcomes speak
for themselves, but the rapid response from Rivet, and others which may
follow, has said that the doctors don’t have the luxury of taking only
low risk women. This clouds the point of the article; it is like
saying, obstetricians don’t have the luxury like the midwives and family
docs, of not doing cesareans. That is precisely a good use for their
skills, so why complain? It is not that the CPMs do not get high
risk women; we showed in our study precisely how the CPMs handle them –
generally screen them out for hospital birth, but did the low risk women
at home with good results , except in cases where obviously the mother
chose not to go, which is an informed decision.
* Only “low risk” births were appropriate for this study. The
study shows that, if you are not a high risk Mom -- that is, carrying twins
or multiples, having a premature baby or having a baby coming bottom first
or transverse, all of which can be judged before the baby is born --your
chance of having a healthy normal safe delivery are the same whether you
plan a home or hospital birth. One journalist actually tried to fault
the study for this. It is precisely the methodology necessary – to
compare as closely as possible to a similar low risk population in the
U.S.
* A Validation Study Verified the Data. Over 500 mothers were phoned,
including at least one client from every midwife, to verify that what the
midwives said happened at the births actually did occur.
* Policy Implications: The study suggests that legislators and policy
makers should pay attention to the fact that this study supports the American
Public Health Association’s resolution to increase out of hospital births
attended by direct entry midwives. The American College of Obstetricians
and Gynecologists still opposes home birth, but has no valid evidence to
support this position. The Society of Obstetricians and Gynecologists of
Canada and several provinces have written statements either acknowledging
that women have the right to choose their place of birth or supporting
it.
For continuing information on creative and effective ways to highlight
this study in the policy arena, consider joining the BirthPolicy listserve
(birthpolicy@yahoogroups.com). It is a great resource for midwifery
policy discussion. Plus list moderators Katie Prown and Steve Cochran
have their own personal tips on how to become more media savvy.
6) Regarding Our Long term effort:
We understand that there are critics who do not understand the length
of time it takes for scientific articles to be written and actually published.
Let us assure you, our diligence has paid off, as we had anticipated:
we made sure our methodologies met the highest standards; we followed up
all CPMs who wanted to remain CPMs to make sure they got their data to
us; and we had draft articles scrutinized by other professional epidemiologists.
As some of you know, we originally sent the study to JAMA (the Journal
of the American Medical Association), a publication that told us that they
did not think their readers would be interested. Then, in December, 2004,
we sent it to the BMJ. In contrast to the BMJ, the ACNM Journal takes
one year from submission to publication, largely because they are an organization
that very positively helps and encourages new researchers. On the
other hand, the BMJ publishes only about 9% of papers they receive, and,
although this study was accepted unanimously by all editors, it still took
six months to process between submission and publication. We went
the extra mile because we knew that at this time in North American history,
home birth needs a credible boost, and this study will be critical for
parents and professionals for many years to come.
Study:
High-tech interventions deliver huge childbirth bill - Childbirth is
the leading reason for hospitalization in the USA and one of the top reasons
for outpatient visits, yet much maternity care consists of high-tech procedures
that lack scientific evidence of benefit for most women, a report says
today. [10/8/08]
REPORT REVEALS SERIOUS PROBLEMS IN MATERNITY CARE QUALITY AND VALUE
[Press
release] [Full
report]
Over 31% of U.S. births are now by cesarean section although a 5% to
10% rate is best for mothers and babies. The extra cost is well over $2.5
billion per year. The excess cesareans buy no reduction in maternal and
newborn deaths. But they cause unneeded exposure to the dozens of adverse
effects more common with csections. This is just the most striking example
of how health care provided to mothers giving birth exposes them to avoidable
harm and expense. These conclusions are found in Evidence-Based Maternity
Care: What It Is and What It Can Achieve, a report released today by Childbirth
Connection, The Reforming States Group, and the Milbank Memorial Foundation.
The report cites an extensive body of evidence to make the case that,
despite paying top dollar, American women do not receive the best maternity
care. It is the most comprehensive review to date of how maternity care
is delivered, financed, and experienced by mothers, families, and health
care payers. It concludes that maternity care can be significantly improved
using evidence-based care.
Look
at numbers on midwife birth bill by Carol Leonard, Hopkinton - a cost
analysis of home vs. hospital birth in New Hampshire.
HealthCost provides information
on the price of medical care in New Hampshire
Summary of Critical
Points from "Safety of Alternative Approaches to Childbirth" by Peter F.
Schlenzka - A doctoral thesis comparing safety and costs of natural,
out-of-hospital birth with in-hospital obstetric births. He finds
out-of-hospital births to be slightly safer and significantly superior
in terms of economic costs ($13 billion annually) and social costs (reduced
incidence of birth trauma and bonding disorders).
HOME BIRTHS CHEAPER, SAFER. Low-risk home births are cheaper and safer
than deliveries in hospitals and birthing centers, according to a recent
study by Centre College professor David Anderson. He and certified nurse
midwife Rondi Anderson reviewed data from more than 33,000 deliveries in
the U.S. and found that home births could reduce delivery costs by more
than two-thirds with no increase in the risk of infant mortality. "Childbirth
makes up one-fifth of all health care expenditures in the U.S., and there
is increasing interest in birthing alternatives that could free up resources
for other healthcare needs." David Anderson: Email David@centre.edu; Phone
606-238-5282. News Contact: Patsi Trollinger Email trllngrp@centre.edu;
Phone 606-238-5719
The
cost-effectiveness of home birth.
As health care costs increase and a growing number of women are without
insurance, the one health service that every family needs deserves further
attention. Even for the 40% of births covered by Medicaid, safe birthing
alternatives that permit a reduction in the $150 billion Medicaid burden
would allow the United States to devote more resources to other urgent
priorities. Informed birthing decisions cannot be made without information
on costs, success rates, and any necessary tradeoffs between the two. This
article provides the relevant information for hospital, home, and birth
center births. The average uncomplicated vaginal birth costs 68% less in
a home than in a hospital, and births initiated in the home offer a lower
combined rate of intrapartum and neonatal mortality and a lower incidence
of cesarean delivery.
This article quantifies and compares birthing charges and safety figures
among modalities. The combined analysis permits rational decisions
based on cost-effectiveness tradeoffs.
Please send correspondence to:
David A. Anderson
After years of midwives' joking that with a homebirth, you don't have
to worry about having your baby switched with another baby, I'm finally
adding this section.
It's a
Girl... No Wait, Hospital Sends Mom Home With Boy Instead - (11/7/08)
- Staff said the mix-up was down to the babies having similar family names
and being in adjoining bassinets.
OK, here's a bit of levity . . . one of the benefits of homebirth is
that you can choose your own, deluxe mattress: Here's the
famous Spanish homebirth mattress ad.
Home
Birth and Breastfeeding May Set the Stage for Healthy Immune Systems in
Infants
Factors
influencing the composition of the intestinal microbiota in early infancy.
CONCLUSIONS: . . . Term infants who were born vaginally at home
and were breastfed exclusively seemed to have the most "beneficial" gut
microbiota (highest numbers of bifidobacteria and lowest numbers of C difficile
and E coli).
New
moms and newborns need privacy, study shows by Barbara Morrison, a
nursing professor at Case Western Reserve University, published in
Rise
In Hospital Noise Poses Problems For Patients And Staff
Announcements blare from overhead speakers. Electronic devices beep.
Heating and cooling systems rumble. Employees and visitors speak loudly.
This sound snapshot, researchers say, comes not from a factory or a
sports stadium but from a typical hospital. In a new study, Johns Hopkins
University acoustical engineers found that hospital noise levels internationally
have grown steadily over the past five decades, disturbing patients and
staff members, raising the risk of medical errors and hindering efforts
to modernize hospitals with speech recognition systems. Some studies even
indicate that excessive noise can slow the pace of healing and contribute
to stress and burnout among hospital workers.
[Ilene
J. Busch-Vishniac's web pages]
I would love to see a study that compares the one-year outcomes of care
with a homebirth midwife contrasted with care with a hospital-based obstetrician.
You read newspaper stories about tragedies that happen to vulnerable new
moms and babies who are getting standard care, and you just know these
things would never happen with a homebirth midwife. I'm thinking
of the tragic case where a new mom killed herself and her baby, and the
dad is suing the OB for not noticing or treating signs of depression.
Right off the bat, midwives help prevent postpartum depression through
attention to good nutrition and simply by attention to the woman herself;
their concern and the large amount of time they spend with their clients
helps women to feel better about themselves, their superior birth experiences
prevent the depression that comes from disappointment in the way they were
treated at birth, and ideal midwifery care continues into the weeks after
the birth. In my practice, I visit the moms and babies in their home
at 24 hours, 48 hours, 4-6 days (depending on breastfeeding needs and scheduling
of Newborn Screen heelstick), and 10 days. These home visits reinforce
the idea that the mom is supposed to be RESTING and recovering, rather
than getting right back into the swing of things and taking the baby back
to the pediatrician for jaundice and weight checks at 5 and 14 days, which
are tiring for the mom and serve to shift her focus to the baby's well-being
at the expense of her own. And midwives are always asking about how
moms are feeling, and paying special attention to any warning signs about
moods or feelings that aren't quite normal. And even in the break
between the 2-week home visit and the final 6-week office visit, a midwife
would probably be checking in with a mom who hadn't been convincingly healthy
from an emotional point of view at 2 weeks. And dads would feel more
comfortable about calling the midwife on their own initiative to talk about
any worrying signs. And there's always a thorough evaluation at 6
weeks; if I'm concerned, I'll use the Edinburgh test or refer for professional
evaluation.
And that's just the issue of postpartum depression.
When I think of the studies that show that the infant mortality rate
in the first year is reduced by 20% just by breastfeeding, I think of the
fact that almost all the babies in my practice are happily breastfeeding
through to at least one year - often longer. Right there, my practice
has a 20% reduced infant mortality rate compared with those babies in OB
practices where the birth experience or lack of breastfeeding support result
in the baby's being fed with artificial breastmilk shortly after birth.
And the reduced c-section rates result in reduced allergies and asthma.
And the list goes on and on . . . Why haven't researchers taken the
long view of how our birthing practices affect the one-year health of mothers
and babies?
Indie Birth - an online homebirth
magazine. Here's the purpose of Indie Birth:
To fire up the minds of modern-day mamas, so that they are inspired,
educated and aware of all the choices surrounding them concerning their
pregnancies and births.
To cater to those that are already independent, free-thinking and maybe
a little bit radical... and to transform those mamas not yet in touch with
their instinctive abilities to birth and nurture naturally.
A Field Guide to Birthing: A Conversation
With Michael Witte, M.D., and Heidi Bednar, R.N. - A great discussion
of homebirth options from Medical Self Care, edited by Tom Ferguson,
M.D., 1978.
Reclaiming the Rights of Birthing
Women: A Primer plus Fact Sheet, Tips and Appendix from birthpolicy.org
The "Trust Birth Initiative"
is a La Leche League style organization for birth. Pretty promising,
actually.
Ward
environment hinders labor -14 June 2005 -A survey of new mothers in
the UK explores whether the environment in which they gave birth influenced
their delivery.
Angela Horn's Home Birth Reference
Page - from the UK
HOME
BIRTH BRIEFING by Angela Horn, NCT Home Birth Support Coordinator.
Reading Britain's
Homebirth Policy is refreshing!
Home Sweet Home - Is
Homebirth right for you? by Karina L. Fabian
Summary
of Critical Points from "Safety of Alternative Approaches to Childbirth"
by Peter F. Schlenzka - A doctoral thesis comparing safety and costs
of natural, out-of-hospital birth with in-hospital obstetric births.
He finds out-of-hospital births to be slightly safer and significantly
superior in terms of economic costs ($13 billion annually) and social costs
(reduced incidence of birth trauma and bonding disorders).
There’s
no Place Like Home - The advantages – and joys – of giving birth where
you live By Pam England, author of Birthing
From Within
Yvonne L. Crynn's site The
Midwife and Home Birth, including Midwifery/Homebirth
Articles and information about the video, Home
Sweet Homebirth- This site is intended to help you educate yourself
and others about the choice of midwifery and homebirth. Families need to
be aware of birthing options. Midwifery is a model of care which
includes good nutrition, skillful midwifery, natural childbirth, homebirth
and breastfeeding. Also available in Spanish - LA
PARTERA Y PARTO DOMICILIARIO
Midwifery
care and out-of-hospital birth settings: how do they reduce unnecessary
cesarean section births?
National Certified
Professional Midwives Guild
Response to a Homebirth Complication or Tragedy
A Mother's Letter to Illinois Gov Edgar
Group Health in Washington not only offers midwife attended home births,
they have written a very positive pamphlet about this service and hand
it out to all their clients -- both licensed midwives and CNMs are covered.
Group Health Cooperative of Puget Sound (GHC), one of the country's
oldest health maintenance organizations, was one of the first managed care
plans in Washington to respond to a 1993 "every category of provider law."
Although certified nurse-midwives were well-established at GHC hospitals,
the law required that enrollees also have access to licensed midwives (i.e.,
direct-entry midwives attending births in out-of-hospital settings).
In addition, GHC members had for years been requesting access to home birth
services, so a panel of physicians, managers, and midwives was created
to examine the evidence concerning safety of home birth, the qualifications
of licensed midwives, and the demand for home births among GHC members.
GHC concluded that it should contract with licensed midwives as the
preferred providers for home birth services, created a credentialing mechanism,
and circulated a memo to inform enrollees about this option (excerpts follow):
[To contact Group Health Cooperative of
Puget Sound, write to 521 Wall Street, Seattle, WA 98121 - Customer
service: 206-901-4636, 888-901-4636. Public relations: 206-448-6135/]
Homebirth Policy at a British Hospital
Home Birth - An Old
Tradition, A Safe Choice by Jennifer Houston, CNM
Given the state of the evidence, we should now challenge the hospitalists
to prove that hospital deliveries can match the results of home deliveries.
The statistics are interesting when applied in the reverse direction. Also,
showing that midwives at home do as well as physicians in the hospital
is an entirely different matter than challenging physicians with all their
expense and operative intervention to prove that their methods offer some
advantages. When studies are done showing that indeed the hospital-medical-model
offers no advantages, payors, be they third-party or be they private, will
refuse to keep going along with the joke.
Modern obstetrics needs to be laughed out of existence and replaced
with a cooperative science that complements the midwifery model. Farces
don't usually respond to debate but to humour.
Proverbs 26:4 Do not answer a fool according to his folly, Lest you
also be like him. 5 Answer a fool as his folly deserves, Lest he be wise
in his own eyes.
A Comment on Natural Childbirth, including
mention of the "Steiger curve" of penile performance.
Spoof about Absurdity of Hospitals for Normal
Births
A Thanksgiving Dinner to Remember
- some more humor about a medicalized family event
Faith Gibson's pages
on Informed Consent for Special Circumstances
New York - Class Action Suit for Homebirth Rights
5/31/97 Update on New York Class Action Suit
5/31/97 Update on New York Class Action Suit
- Morning Session
Home
births: 'Buy some black bin liners' - [8/14/09] More women in Britain
are giving birth at home, which a recent study suggests is as safe as going
to hospital.
UK
recommends return to homebirth as the standard of care
More women should have babies at home, not in hospital, says Health
Secretary
The move comes as new figures reveal that more than . . . a third of
all who give birth every year, suffer some psychological distress after
delivery.
"It has taken decades for this issue to be taken seriously, . . . that
having birth at home is as safe or safer than in hospital"
#include "trailer.incl"
by Lauredhel on January 16, 2010
< http:
>
January 20, 2010 – 7:58 pm, by Croakey
< ACOG and AMA's Explicit Attack on Homebirth - 2008
This "study" isn't overtly connected with the ACOG attack on homebirth,
but the study author has a clear bias towards MDs: "As for why in-hospital
deliveries by certified nurse midwives had a lower risk of mortality in
his study than in-hospital physician deliveries, Malloy said he assumes
it's because physicians are delivering babies at higher risk." Malloy
is apparently able to understand that the different categories have different
kinds of risks, but he is unable to extend this thinking to the homebirthing
demographics. He completely ignores a well-known fact: Neonatal mortality
in the United States is falling overall because most babies with anomalies
incompatible with life are terminated during the pregnancy and so never
get to be born or counted as a neonatal fatality . . . AND . . . this does
not apply to religious groups who oppose abortion and often, as it happens,
also choose homebirth.
Escobedo MB, Malloy MH, Jesurun CA, Denson SE, Koops BL, Jarriel WS,
Hansen TN.
Tex Med. 1994 Jun;90(6):64-9.
Homebirth Safety Equivalent to Many Mainstream
Choices
Homebirth Safety
References - North American Prospective Study, 2005
Kenneth C Johnson, senior epidemiologist, Betty-Anne Daviss, project
manager
BMJ. 2005 Jun 18;330(7505):1416.
”Home births safe for low-risk pregnancies: North American study”
and if you look to the right of this article, the video clip is available,
a story of Barbara Scrivers, Alberta midwife, in her practice and Betty-Anne
as co-author of the study explaining its importance. You can go to
http:
and if you go to the story to the right of the written story, click on
the video by Terry Reith.
In the Boston Globe: “Home Births as safe as hospital deliveries
for low-risk mothers”
In the Washington Post: “Home Births”
Births, Study Finds”
I-Newswire.com: “Home>Friends of Wisconsin Midwives: Study Shows
Benefits of Licensed Home Birth Midwives”
On Kaisernetwork: Planned, Low-Risk Home Births With Nurse-Midwives
as Safe as Hospital Births, Involve Fewer Interventions, Study Says <http:
Home
superior to hospital birth
Source: British Medical Journal 2005; 330: 1416-22
Homebirth Safety References - Pang Study, Washington
State, 2002
Pang JW, Heffelfinger JD, Huang GJ, Benedetti TJ, Weiss NS.
Obstet Gynecol 2002 Aug;100(2):253-9
"Despite this flawed study, the existing research demonstrates as well
as we can ever expect that homebirth is a safe and valid choice for mothers
and babies. What needs to happen now, in both the world of research
and in practice, is to accept what is known about the safety of homebirth
and move on to determine what changes could make homebirth and hospital
birth even safer. Currently, the controversy over the safety of homebirth
actually makes it more dangerous. In states where physician groups
have managed to make homebirth midwifery illegal, or where obstetricians
refuse to provide reliable backup care to midwives, homebirth is not as
safe as it could be. A lack of midwives in some areas makes it more
difficult for mothers to find well-trained, experienced homebirth attendants.
Increasing the number of practicing midwives and ensuring a coordinated
system of transfer for hospital care when necessary will add to the proven
safety of homebirth.
Homebirth Safety References - Australian Outback
Study, 1998
Hilda Bastian, Marc JNC Keirse and Paul Lancaster
BMJ 1998; 317:384-388
While home birth for low risk women can compare favourably
with hospital birth, high risk home birth is inadvisable and experimental.
This is the only study that Aetna could come up with to justify its unreasonable
anti-choice policy regarding homebirth.
Another more recent publication on homebirth in Australia[34]
has methodological flaws so serious as to make their conclusions unjustified.
The appendix to this paper includes my scientific critique of this Australian
study in which I conclude: "It is well known in Australia that the reason
for the several shifts in data collection methods in this study (which
effectively eliminated any possibility of scientific validity) is because
so many midwives felt betrayed by the researchers that they refused further
participation in the research. It is intellectually dishonest not
to report this fact in this paper."
The subject of intellectual dishonesty in medicine and the decline
of evidence-based medicine was addressed recently by the New England Journal
of Medicine [June, 2002], which announced that it has given up finding
truly independent doctors to write and review articles and editorials for
it. It seems that Aetna is having a similar problem in finding medical
advisors who are more interested in healthcare than in the dollar.
Homebirth Safety References - British Suite of Studies,
1996
BMJ No 7068 Volume 313, Editorial Saturday 23 November 1996
Davies J, Hey E, Reid W, Young G.
BMJ 1996;313:1302-5.
BMJ 1996;313:1306-9.
Wiegers TA, Keirse MJNC, van der Zee J, Berghs GAH.,
BMJ 1996;313:1309-13.
Ackermann-Liebrich U, Voegeli T, Gunter-Witt K, Kunz I, Zullig M,
Schindler C, Maurer M, Zurich Study Team
BMJ No 7068 Volume 313
Homebirth Safety References - Other Studies
Symon A, Winter C, Inkster M, Donnan PT.
BMJ. 2009 Jun 11;338:b2060. doi: 10.1136/bmj.b2060.
Murphy PA, Fullerton J
Obstet Gynecol 1998 Sep;92(3):461-470
CONCLUSION: Home birth can be accomplished with good outcomes
under the care of qualified practitioners and within a system that facilitates
transfer to hospital care when necessary. Intrapartal mortality during
intended home birth is concentrated in postdates pregnancies with evidence
of meconium passage.
Luke Zander, Geoffrey Chamberlain.
BMJ 1999;318:721-723 ( 13 March )
Birth 1997 Mar;24(1):4-13; discussion 14-6
Olsen O
CONCLUSION: Home birth is an acceptable alternative to hospital
confinement for selected pregnant women, and leads to reduced medical interventions.
P.A. Janssen, S.K. Lee, E.M. Ryan, D.J. Etches, D.F. Farquharson, D.
Peacock, M.C. Klein
CMAJ 2002:166(3)
Régis Blais
CMAJ 2002;166(3):335-6
Tew M.
Br J Obstet Gynaecol. 1986 Jul;93(7):659-74.
Online version of a pamphlet created by the now-defunct Friends
of Homebirth in Texas.
The Farm Midwives (1994)
What you will discover, by reviewing the research, is that
every valid study every published - currently or in the past and in any
country - shows home to be safer than the hospitals for many, if not most.
. . .
More excerpts from
the chapter "Midwifery: Safe, Cost-Effective Maternity Care for All
(from Faith Gibson's site)
Send check payable to NAPSAC, Route 1, Box 646, Marble Hill, MO 63764
Marjorie Tew, S M I Damstra-Wijmenga
Midwifery (1991) 7, 55-63
for low risk: hospital=17.9 home=5.2
for moderate risk: hospital=32.2 home=3.8
for high risk: hospital=53.2 home=15.5
for very high risk: hospital=162.6 home=133.3
Mehl-Madrona L, Madrona MM.
J Nurse Midwifery. 1997 Mar-Apr;42(2):91-8.
Homebirth Safety References - General
Faulty Homebirth Research Results Leaked Rather Than Published
Homebirth Safety - Equipment Only Part of the Picture
ACOG's Position on Out-Of-Hospital Birth
Homebirth Safety - Dangers of Hospitals
Gould JB, Qin C, Chavez G.
Obstet Gynecol. 2005 Aug;106(2):352-8.
A
baby's death prompts reforms in care [8/17/05] - Rare article
recounts errors and response at a Beth Israel hospital. Unfortunately,
many hospitals still operate under the kind of system that allowed this
labor crisis to deteriorate, resulting in the baby's death. This
is one of the biggest problems with assembly-line medicine - it's so easy
for problems to be ignored.
Sachs BP.
JAMA. 2005 Aug 17;294(7):833-40.
Issue 118, May/June 2003
By Marsden Wagner
Medves JM, O'Brien BA.
Can J Public Health. 1997 Nov-Dec;88(6):380-2.
[This web page is about political stuff; this extract is from about
2/3 of the way down; search for "forceps".]
Umbilical
cord gases in home deliveries vs. hospital based deliveries.
Eskes TK, Jongsma HW, Houx PC
J Reprod Med 1981;26:405-8.
The
effect of labor on the normal values of umbilical blood acid-base status.
Yoon BH, Kim SW
Acta Obstet Gynecol Scand 1994 Aug;73(7):555-561
CONCLUSION. There is a significant fall in umbilical artery
pH and bicarbonate with the presence of labor and increased duration of
second stage of labor in healthy term neonates. This should be taken into
consideration in evaluating neonatal well-being by cord blood pH and acid-base
measurements.
And here's an article that concludes that the prognostic value of acidosis
is low:
Acid-base
equilibrium in umbilical cord blood. Apgar score and acid-base equilibrium
in umbilical cord blood as control parameters during labor.
Oksefjell H, Ipsen HE, Okland O
Tidsskr Nor Laegeforen 1990 Jan 20;110(2):209-212 [Article in Norwegian]
Why Is Homebirth Safer?
Emergency Cesarean As Accessible for Homebirth
As In Hospital
BMJ 2004;328 (20 March), doi:10.1136/bmj.328.7441.0
outcomes. Thomas and colleagues (p 665) analysed 17 780 singleton births
by caesarean section in Wales and England in 2000. They found that,
compared with deliveries completed within 15 minutes of the decision
for an emergency caesarean section, mothers' and babies' outcomes did not
differ from deliveries within 75 minutes. Babies delivered after 75 minutes
were more likely to have an Apgar score of less than 7, and their mothers
were more likely to require special care. Never the less, the target of
30 minutes should remain as the benchmark for service provision, the authors
say.
"Conclusions: The current recommendations for the interval between
decision and delivery are not being achieved in routine practice. Failure
to
meet the recommendations does not seem to increase neonatal morbidity.
"
Leeman L, Leeman R.
Ann Fam Med. 2003 May-Jun;1(1):36-43.
Homebirth Special Circumstances - First-Time
Moms, VBACs, Large/Heavy Women, Smokers
Smokers
I must agree with smoking being a reason to risk someone out of a homebirth;
as homebirthers we need to make sure we don't set ourselves up for problems,
and smoking is definitely asking for trouble.
Talking to the Press
Cost Effectiveness of Homebirth
Overuse of Cesarean Section and Other Interventions Puts Women and
Babies at Risk, Increases Costs
Anderson RE, Anderson DA.
J Nurse Midwifery. 1999 Jan-Feb;44(1):30-5.
Centre College
600 West Walnut Street
Danville, Kentucky 40422
E-mail: david@centre.edu
Babies Switched At Birth
Other Benefits of Homebirth
Penders J, Thijs C, Vink C, Stelma FF, Snijders B, Kummeling I, van
den Brandt PA, Stobberingh EE.
Pediatrics. 2006 Aug;118(2):511-21.
Journal of Obstetric,
Gynecologic, & Neonatal Nursing - The official journal of AWHONN
[From
the Johns Hopkins web page]
Homebirth Advocacy
Sakala C
Soc Sci Med 1993 Nov;37(10):1233-50
U.S. women beginning labor with midwives and/or in out-of-hospital
settings have attained cesarean section rates that are considerably lower
than similar women using prevailing forms of care--physicians in hospitals.
One of the most important factors in the credentialing and integration
of Licensed Midwives into managed care plans in Washington state has been
the existence of well-developed quality assurance mechanism, first crafted
by the Midwives Association of Washington State, and now administered by
Quality Midwifery Associates, a private, midwife-owned company that contracts
risk management services with Washington Casualty, the administrator of
the Joint Underwriting Association. This mechanism includes the preparation
of a self-evaluation report by the midwife, a site visit for practice review,
guidelines for consultation and referral, and reporting and evaluation
of certain sentinel events.
"Women traditionally have attended other women in childbirth. For
thousands of years women have delivered their babies, at home, in their
own beds, supported by their friends and family, calling on the strength
of the collective wisdom and experience of those who know birth.
. . ."
An MD Comments On Homebirth Safety
In all these studies there is a bias in evidence that reflects a no-longer-needed
defensive posture on the part of midwives. That is, they all refer to the
fact that birthing at home is as safe as birthing in the hospital.
Here are 3 "Special Circumstances" informed consent documents for home-based
care and/or refusal of customary obstetrical protocols for VBAC, Twins,
Macrosomia
Homebirth Outside the U.S.