The American Medical Association decides to come out against midwives delivering babies at home. Like dentists who won't let hygenists clean your teeth unless they get a piece of the action, obstetricians want to make sure no childbirth revenue slips through the cracks. This business of senseless supply restrictions isn't the health care problem in America, but it does make the other problems all much harder and more expensive to solve than they otherwise might be.
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Big Doctor Strikes Again
18 Jun 2008 04:21 pm
Comments (86)
I know this is silly, but might it not be a good idea to evaluate the medical arguments for and against before making the claim that obstetricians are hopelessly in the tank?
Now, I don't think there is much of an argument against midwives delivering in hospitals, but at home? Or even midwives delivering when there is readily available emergency care in some other capacity.
It seems to me that midwives are probably a)as good or better when dealing with typical pregnancies and b) much worse when something goes badly wrong. Further, when things go wrong, they can go wrong very quickly.
I am, of course, willing and eager to be proven wrong, but I find it very difficult to believe that medically complicated pregnancies are better handled at home rather than a hospital. Perhaps those cases are so rare there is no point regulating against them, I don't know.
So, I understand the supply argument in some cases, but I don't really get it here. Or at the very least, it seems like you have tossed off a prima facie plausible argument without reason.
Then again, there might be a libertarian argument that is more convincing, but I also find it hard to see how one's right to be give birth at whatever location they want outweighs the right of the born baby (and, presumably, now a full moral person) to be born safely.
One of my pet peeves is having to see an eye doctor to get a simple prescription for glasses. When I worked in Korea, getting glasses was like going for a haircut. A technician had you read the chart, flipped through and determined your correct lenses and you picked out your frames and walked out for $40.
If you don't have astigmatism or an eye condition, why shouldn't it be this simple?
Another area in which I think we'd be better off sharing responsibilities is regarding prescribing authority. In California at least, pharmacists can write prescriptions for patients, but it's one of the few that allows this. MDs may do alright with diagnosing a patient, but when it comes to selecting the meds they aren't always as knowledgable. Way too much time is spent by R.Phs trying to contact the MD to clarify messy, unclear, or inappropriate medication therapy. I think patients might be shocked to find how often the MDs screw up (or maybe not).
Count me as another person who wants to see the arguments pro and con.
As a side note, my wife was horrified at the idea of a nurse-midwife delivering our babies. She made the practice - which included several doctors and one midwife - promise that they would not stick her with the midwife when the time came. Well, she went into labor on the weekend and it so happened that that it was the midwife on call . . . Anyway, she made them send a doctor from another practice.
All due respect, Yglesias, but you have no fucking clue what you're talking about.
Gotta protect the turf.
All four of my kids popped out with the calming assistance of a mid-wife, but all were at a hospital, just in case. Can't fault the AMA for not blessing home birth midwifery.
I'll never understand why some people want to take us back to the Dark Ages when it comes to medicine. Just because some untrained dipshit utters the words "natural" or "holistic" doesn't mean they know anything.
DAS--You enforce it by convincing private insurers to refuse to cover midwifery except in hospitals... Let's say you're dedicated to using a midwife: Would you a) Pay a couple thousand dollars of your own money to use one at home, or b) Pay much less money to go to a hospital?
One of my pet peeves is having to see an eye doctor to get a simple prescription for glasses.
One of the middlin' level Con Law cases that led to the current devil-may-care attitude the Supreme Court takes toward economic legislation concerned a law that forbade optometrists from prescribing lenses. Things COULD have been different.
Seems like getting your teeth cleaned isn't the best comparison to make to obstetrics given the difference in the harm caused by potential negative results.
As someone said, first eliminate the potential medical concerns and statistics regarding outcomes of midwives deliveries at home before invoking the standard line about greedy doctors and their medical monopoly. Are midwives forced to carry large malpractice policies like doctors?
"but might it not be a good idea to evaluate the medical arguments for and against before making the claim that obstetricians are hopelessly in the tank?"
Uh, yea. There are a whole bunch of things that can go wrong during childbirth, and while if you really want to do one at home, I think you should be able to, someone who claims they're qualified to do so and who accepts money for the service ought to have the medical training to be able to cope with the emergencies that can result from a birth that doesn't go well. Otherwise, the cost savings that Matt alludes to will be used up at the other end.
NB - My wife is an OB. However, our second child was delivered my a midwife at a hospital, and the third is scheduled to be delivered by a midwife.
Gotta go with the crowd on this one, did you even consider any medical evidence before drawing your conclusion.
I don't want to defend the AMA, I am a physician but NOT an AMA member, but not every decision they make is motivated by greed.
And people can do whatever they want, but there is no way in hell my wife is delivering anywhere but a hospital.
Do the babies have to stay inside the mother in those rural/poor areas where there are not doctors much less obstetricians? Maybe hyperbole, but still....
Seriously I remember reading something a few years ago that may obstetricians were getting out of the business because insurance premiums were so high they couldn't keep up the payments. Apparantly this hit the underserved areas because of the few number of doctors as a whole.
This is very different from the dentist situation. There is a very real chance of an otherwise healthy delivery becoming life threatening to mother and/or child in a very short period of time. These situations sometimes require rapid (under 10 minutes) action.
Sure these are rare, but they are rare on the scale of 1-5%. When the hospital maternal death rate is virtually zero and the fetal death rate is also low, it's very understandable why the AMA and ACOG protest them.
In addition, some hospitals are setting up more and more centers that allowed for midwife managed births. The big difference is that a doctor can consult if something is beyond a midwifes training and an emergency room is only minutes away in case something unexpected happens. Why is this a bad thing?
Every state has passed laws which mandate that insurrance co. cover the sevices of midwives. Sounds like the repugs in the AMA are just crying like babies.
Both my brother and I were born at home using midwives (to my RN mother). We all survived.
For those of you calling for pros and cons (or defending the ban outright): wouldn't you say that the burden of proof is on those who want to make home birth illegal, not those who want to leave it as a legal option?
So Yglesias wants to make sure more pregnant women and babies DIE. Die for the midwifery industry.
Matt's man crush on Ezra Klein is responsible for that post...Just because somebody claims they know about health care and writes constantly about the topic just means they are an activist not someone who actually knows what they are talking about...Unfortunately the love light in Matt's eyes will I think lead to a lot more ridiculous anti-doctor posts in the near future...
Tom,
If we were engaging in a debate about the policy, then I would expect the AMA to adumbrate evidence for their position that homebirths are not safe for complicated pregnancies. I merely suggested that this was not a hard sell and prime facie plausible.
But I was discussing the claim that the AMA and ACOG were simply in the tank to protect their profits. That is a claim about the motivations about individuals. However, that claim only seems plausible if the evidence the AMA and ACOG produce is sufficiently bad that they are obviously in bad faith. No one on feministing or here has produced THAT evidence. Or even tried to...which is why I objected.
"For those of you calling for pros and cons (or defending the ban outright): wouldn't you say that the burden of proof is on those who want to make home birth illegal, not those who want to leave it as a legal option?"
Who said anything about making home birth illegal?
You people are full of shit:
...newborn mortality is 2.5 times higher in the United States than in Finland, Iceland or Norway, Save the Children researchers found.Only Latvia, with six deaths per 1,000 live births, has a higher death rate for newborns than the United States, which is tied near the bottom of industrialized nations with Hungary, Malta, Poland and Slovakia with five deaths per 1,000 births.
I had my first and my third child in the hospital. My third was a medical necessity. But I had my second child at home. It was a much much better experience. I won't go into the gross details here, but the midwife definitely did a better job with certain things than the doctor, and it was so much more relaxing being in my home environment; because I wasn't tense, the contractions didn't seem so bad.
Much preferable, but you need to get a thorough work up.
In Holland, home births are routine. Hospital births are rare. The infant mortality rate there is low.
I had my first and my third child in the hospital. My third was a medical necessity. But I had my second child at home. It was a much much better experience. I won't go into the gross details here, but the midwife definitely did a better job with certain things than the doctor, and it was so much more relaxing being in my home environment; because I wasn't tense, the contractions didn't seem so bad.
Much preferable, but you need to get a thorough work up.
In Holland, home births are routine. Hospital births are rare. The infant mortality rate there is low.
Note that the AMA is not calling for a ban. The following text is from link off of the feministing page
RESOLVED, That our American Medical Association support the recent American College of Obstetricians and Gynecologists (ACOG) statement that “the safest setting for labor, delivery, and the immediate post-partum period is in the hospital, or a birthing center within a hospital complex, that meets standards jointly outlined by the American Academy of Pediatrics (AAP) and ACOG, or in a freestanding birthing center that meets the standards of the Accreditation Association for Ambulatory Health Care, The Joint Commission, or the American Association of Birth Centers” 3 (New HOD Policy); and be it further
RESOLVED, That our AMA develop model legislation in support of the concept that the safest setting for labor, delivery, and the immediate post-partum period is in the hospital, or a birthing center within a hospital complex, that meets standards jointly outlined by the AAP and ACOG, or in a freestanding birthing center that meets the standards of the Accreditation Association for Ambulatory Health Care, The Joint Commission, or the American Association of Birth Centers.” (Directive to Take Action)
good idea to evaluate the medical arguments
..
wants to see the arguments pro and con
OK, here's a pretty good study: http://bmj.bmjjournals.com/cgi/content/full/330/7505/1416?ehom
There is a very real chance of an otherwise healthy delivery becoming life threatening to mother and/or child in a very short period of time.
There is also a very real chance of someone at the hospital erroneously concluding that they have to perform some dangerous intervention, and screwing things up royally.
Sure these are rare, but they are rare on the scale of 1-5%.
Yes, 3% of the mothers in the abovelinked study were transferred to hospital for reasons considered urgent (and another 9% for apparently non-urgent reasons such as failure to progress or exhaustion).
hospital maternal death rate is virtually zero and the fetal death rate is also low, it's very understandable why the AMA and ACOG protest them.
No,it isn't. Because the maternal death rate for homebirth is also very, very near zero (exactly zero out of 5000something in the above study), while the fetal death rate is similarly low (two out of a thousand in both situations).
If I had a criticism of the midwives, it would be that they're taking advantage of the hospital as a fallback - to my mind it doesn't reflect well on your capabilities if you have to hand off one in eight of your patients to someone else. But at the same time, it looks like the hospitals have some explaining to do: they did c-sections at five times the rate, vacuum extractions at nine times the rate, and episiotomies at fifteen times the rate as for the planned-homebirth cohort, without achieving any superiority in outcome.
Jerri,
While there may be coverage mandates, they do not extend to paying for home births. Other restrictions and limitations common to most policies (setting for delivery of care and fairly low dollar limitations for home health care) significantly restrict the insurance coverage available.
Not sure why you think there may be a political angle to this. The majority of home-birthers I know are the kooky leftist types, most of whom are perfectly fine people aside from politics, that I met through my wife's participation in la leche league and the other breastfeesding groups. These types adopt many of the extreme fringe freaky beliefs and practices like veganism ('cept for breast milk) home schooling, extreme environmentalism, etc.
There is significant ignorance about mid-wives, as many co=workers, neighbors, friends, thought we were kooky to go with a mid-wife and assumed that meant home birthing.
I'm gob-smacked. This post is way off-base. Check out the data: a home delivery with a midwife dramatically increases the risk of complications that can result in a debilitating condition for an otherwise healthy fetus, such as cerebral palsy; or even death. I personally know numerous cases of progressive couples whose natural births have gone horribly wrong, with severe cognitive defects in full-term, normally developing babies. Y'all hear that sound? That's the scornful laughter of all those pediatricians and Reproductive Medicine clinicians at New York-Presbyterian, the teaching hospital Cornell and Columbia with one of the highest well-baby take-home rates in the country. They're mocking Matt's ignorance on this topic.
Matt and Ezra have never gone through a pregnancy, let alone a high-risk one with, say, eclampsia or gestational diabetes or an erratic fetal heartbeat, so they haven't a clue when it comes to all the work and diligence that produces a healthy newborn. They just see for-profit conspiracies. Here's hoping by the time they become fathers they'll recognize the errors of their ill-informed thinking on this subject.
bbartlog,
But at the same time, it looks like the hospitals have some explaining to do: they did c-sections at five times the rate, vacuum extractions at nine times the rate, and episiotomies at fifteen times the rate as for the planned-homebirth cohort, without achieving any superiority in outcome.
While MDs are probably more apt to these interventions than midwives, the numbers aren't this much higher. People who are more at risk for these interventions are much less likely to even consider homebirths. In addition, people going to hospitals might also voluntarily get epidurals which increase the risk of some other interventions.
Lastly, the bmj paper focuses only on mortality. Certain things like a few minutes of no oxygen might not kill a child, but they certainly affect outcomes and can be prevented using some of the interventions listed.
Bryklyn:
I don't know what you're talking about. No midwife would go through with a home birth if the mother was showing signs of eclampsia or gestational diabetes or if there was erratic fetal heartbeat. Midwife attended home births are for the majority of women who don't exhibit any risk factors like the ones your describing. In those circumstances, homebirth is as safe as hospital birth; it is much more pleasant for all involved; it is much less expensive.
Doctors may not be chasing the money, but they are certainly suffering from selection bias. It is true that some births that start out at home end up in hospitals. While those are the minority, they are the only ones that doctors see. Most ObGyns have never seen a home birth, or even a birth that progresses naturally from start to finish. That's not how they think about birth, even though that's how birth can occur for the large majority of women.
Matt, I love ya, buddy . . . but this one is even dumber than your dumb-ass NBA opinions. And that's saying something.
TJ,
Check thine own internal body for fecal matter before declaring others to be full.
This topic is the relative safety of home birth vs, hospital birth in the US.
Overall infant mortality compared between countries is only as good as the counting. The US goes to super-human efforts to keep all premies alive. Many make it, some don't. Unless all of the counting is the same among all countries (which it is not) you cannot declare the US to be worse than anyone else. Plus, we have pathologies here (drug abuse) that drive up infant death rates.
Our overall infant mortality rates have nothing to do with whether a home birth in the US is safer than the same birth at a hospital.
Matt and Ezra have never gone through a pregnancy, let alone a high-risk one with, say, eclampsia or gestational diabetes or an erratic fetal heartbeat, so they haven't a clue when it comes to all the work and diligence that produces a healthy newborn. - BryklynLibrul
Indeed. It's interesting that some of the same rhetoric about the non-medical nature of childbirth here is so close to the "child-birth's a cinch" rhetoric you here from anti-abortion folks, with us pro-choicers making pretty much the same argument made by BryklynLibrul in response to the "we should allow home birth no matter what the studies say" crowd.
FWIW, I would imagine the crunchy-con types would be very much pro-home-birthers and the rhetoric fits (as it does with their anti-abortion stance)
That being said, banning home birth raises some serious questions as to enforcement. You can't make it to the hospital on time? Off to jail with you? Here is where there is synergy between pro-choice and pro-allowing-home-birth arguments: even big gummint liberals like me think that granting the government whatever powers are necessary to actually enforce laws against abortion or home birth really is granting some pretty horrendous (in terms of privacy rights) powers to the government. What's next? This country decides it's going Protestant and inspects homes for priest-holes like they did in England back in the day? (why even anti-b/c Catholics should support Griswold -- today it's condoms, tommorrow it could be the sacriments).
Anti-home birth? Well, then have your kid in the hospital!
As to the "countries with higher rates of home birth than ours have lower rates of complications" arguments: many of those countries have far better health care systems in general, so it could still be the case that, for a given health care system, switching to a home birth increases risks, but if you are healthy enough (because you've got good enough pre-natal care, etc.), the added risk of home birth is negligeable.
It is commonly assumed that midwife guided home births would be more dangerous than doctor guided hospital births - this is incorrect. Midwives are a substantial part of births in most of the industrialized world (including almost every nation that ranks above us in lowest infant mortality rates). Before making assumptions look into the facts. Infant mortality for home births vs. infant mortality for hospital births are nearly identical (see http://www.blackwell-synergy.com/doi/abs/10.1111/j.1523-536X.1997.tb00330.x).
Transport to the hospital can take place at the first sign of things going wrong, but when in a comfortable setting with freedom of movement, natural childbirth is much easier for many women. The easier and shorter duration of homebirths lends to better outcomes for both mother and child. Shorter labor, fewer C-sections, greater bonding with the child after birth - you know useless things like that.
This is a very hotly debated topic among people who care passionately about the subject and tossing out blithe assumptions about what is safer and prejoratives like "Dark Ages" in reference to a commonly accepted practice in most of the industrialized world demonstrates a profound lack of knowledge about the subject.
Matt, I love ya, buddy . . . but this one is even dumber than your dumb-ass NBA opinions. And that's saying something.
It is commonly assumed that midwife guided home births would be more dangerous than doctor guided hospital births - this is incorrect. Midwives are a substantial part of births in most of the industrialized world (including almost every nation that ranks above us in lowest infant mortality rates). Before making assumptions look into the facts. Infant mortality for home births vs. infant mortality for hospital births are nearly identical (see http://www.blackwell-synergy.com/doi/abs/10.1111/j.1523-536X.1997.tb00330.x).
Transport to the hospital can take place at the first sign of things going wrong, but when in a comfortable setting with freedom of movement, natural childbirth is much easier for many women. The easier and shorter duration of homebirths lends to better outcomes for both mother and child. Shorter labor, fewer C-sections, greater bonding with the child after birth - you know useless things like that.
This is a very hotly debated topic among people who care passionately about the subject and tossing out blithe assumptions about what is safer and prejoratives like "Dark Ages" in reference to a commonly accepted practice in most of the industrialized world demonstrates a profound lack of knowledge about the subject.
Yeah, I got to join the criticism here--regardless of whether they're in the tank or they aren't (and let's face it, I don't think Ob/gyns are going to go broke letting people have midwife home delivery because, well it's the 21st Century and the sane members of society like medicine and shit)--a trained doctor and proper tools can save lives. My wife's an ob/gyn and daily she tells me about 'normal' deliveries that turn tragic on a dime. And mostly she tells me that stuff at the dinner table, which may be why I'm losing weight at an unprecedented rate. Am I saying that women shouldn't have the right to do it? No, of course not, but any responsible ob/gyn shouldn't recommend that as a course of action.
And by the way, the comparison to this dental tooth cleaning crap is really dumb. Your teeth get cleaned badly you have a hard time picking up at a bar, a delievery goes badly and you end up with a brain damaged child. One society can deal with, the other not as much.
Yeah, I got to join the criticism here--regardless of whether they're in the tank or they aren't (and let's face it, I don't think Ob/gyns are going to go broke letting people have midwife home delivery because, well it's the 21st Century and the sane members of society like medicine and shit)--a trained doctor and proper tools can save lives. My wife's an ob/gyn and daily she tells me about 'normal' deliveries that turn tragic on a dime. And mostly she tells me that stuff at the dinner table, which may be why I'm losing weight at an unprecedented rate. Am I saying that women shouldn't have the right to do it? No, of course not, but any responsible ob/gyn shouldn't recommend that as a course of action.
And by the way, the comparison to this dental tooth cleaning crap is really dumb. Your teeth get cleaned badly you have a hard time picking up at a bar, a delievery goes badly and you end up with a brain damaged child. One society can deal with, the other not as much.
Yeah, I got to join the criticism here--regardless of whether they're in the tank or they aren't (and let's face it, I don't think Ob/gyns are going to go broke letting people have midwife home delivery because, well it's the 21st Century and the sane members of society like medicine and shit)--a trained doctor and proper tools can save lives. My wife's an ob/gyn and daily she tells me about 'normal' deliveries that turn tragic on a dime. And mostly she tells me that stuff at the dinner table, which may be why I'm losing weight at an unprecedented rate. Am I saying that women shouldn't have the right to do it? No, of course not, but any responsible ob/gyn shouldn't recommend that as a course of action.
And by the way, the comparison to this dental tooth cleaning crap is really dumb. Your teeth get cleaned badly you have a hard time picking up at a bar, a delievery goes badly and you end up with a brain damaged child. One society can deal with, the other not as much.
bbartlog,
But at the same time, it looks like the hospitals have some explaining to do: they did c-sections at five times the rate, vacuum extractions at nine times the rate, and episiotomies at fifteen times the rate as for the planned-homebirth cohort, without achieving any superiority in outcome.
While MDs are probably more apt to these interventions than midwives, the numbers aren't this much higher. People who are more at risk for these interventions are much less likely to even consider homebirths. In addition, people going to hospitals might also voluntarily get epidurals which increase the risk of some other interventions.
Lastly, the bmj paper focuses only on mortality. Certain things like a few minutes of no oxygen might not kill a child, but they certainly affect outcomes and can be prevented using some of the interventions listed.
This is also true for the other posts linking to the Birth paper comparing home birth to hospital birth. If the paper doesn't explicitly adjust the hospital birth rates to match the relative health population of the home births, it is a flawed paper. They do seem to control for populations a bit, but I can't image how this could be done well in a meta-study.
Andrew:
Something like a major fluctuation in a laboring woman's blood pressure or a rapid drop in a fetal heartbeat can't be adequately addressed by a midwife. This happened with my first child: the fetal monitor picked up dangerous problem with his pulse, even though he was full-term and the pregnancy had been normal. At the last possible minute he'd shifted position and each mild contraction pushed his face into the still-closed cervix, necessitating an emergency C-section. Thank God for the intervention: if we'd been at home with a midwife he would surely have been cognitively impaired.
At it happens, he does suffer from a genetic disease called Spinal Muscular Atrophy, or SMA; his muscle weakness likely caused the switch in position after the birth process had begun. Again, no midwife would have caught this had my wife insisted on staying at home and "owning" the experience of birth.
The baby's welfare is paramount. So many of the home-birth advocates fail to appreciate this, as I've found in many conversations related to my freelance work in medical journalism. This is why Matt's post is so offensive: it propagates myths that can lead directly to life-time disability or even death.
Say what you will of Ricky Lake, this documentary is incredibly compelling. http://www.thebusinessofbeingborn.com/
My wife and I saw it, switched from a traditional OB to a midwife at 30 weeks and couldn't be more satisfied with the result.
Big doctor indeed. Healthy women need not treat childbirth as a medical emergency. It's not.
Christ, there are alot of people spouting off crap about childbirth in this thread who don't know much about it.
Over 40% of the babies born in the Netherlands are born at home. But hey, they're Euro weenies living in the dark ages over there.
Christ, there are alot of people spouting off crap about childbirth in this thread who don't know much about it.
Over 40% of the babies born in the Netherlands are born at home. But hey, they're Euro weenies living in the dark ages over there.
BryklynLibrul, could you amend your last paragraph to say "the mother and the baby's welfare is paramount"? The mom's health is as important as the baby's health.
Matt and his colleague Ezra have misidentified the real problem with ob/gyn because they dont know how medicine is practiced in this country. Go to a hospital and talk to real midwives next time before you reveal your ignorance.
Home births are currently legal in all states, and yet they are hardly ever used. Why? There's absolutely no law preventing any midwife from opening shop and doing as many homebirths as they want.
The AMA/ACOG stance is just posturing, they have no real power over home births or midwives. The AMA trying to ban home births is similar to them hoping that Medicare increases reimbursements by 100%--you can shit in one hand and hope in the other and see which fills up first.
The reasons why home births are so few state-side is because the liability is absolutely enormous. Out of every 100 midwives, less than 10 choose to do homebirths. The vast majority opt to work in hospitals or "birthing centers" in coordination with OBs. Why is this, you ask? Because malpractice insurance for working in a hospital-based environment with OBs results in malpractice premiums that are ten times cheaper than doing home births, where there is no OB backup and operating facilities are far away.
THATS why home births are so rare--its because midwives are opting out, not because the big bad AMA is stifling them. Any midwife is free to do home deliveries any time they want, they just have to pony up the malpractice insurance which is many times more expensive for home births.
Midwives arent stupid--they follow the money just like doctors do and thats why they overwhelmingly choose to work in hospitals and birthing centers as opposed to solo home births.
Matt and his colleague Ezra have misidentified the real problem with ob/gyn because they dont know how medicine is practiced in this country. Go to a hospital and talk to real midwives next time before you reveal your ignorance.
Home births are currently legal in all states, and yet they are hardly ever used. Why? There's absolutely no law preventing any midwife from opening shop and doing as many homebirths as they want.
The AMA/ACOG stance is just posturing, they have no real power over home births or midwives. The AMA trying to ban home births is similar to them hoping that Medicare increases reimbursements by 100%--you can shit in one hand and hope in the other and see which fills up first.
The reasons why home births are so few state-side is because the liability is absolutely enormous. Out of every 100 midwives, less than 10 choose to do homebirths. The vast majority opt to work in hospitals or "birthing centers" in coordination with OBs. Why is this, you ask? Because malpractice insurance for working in a hospital-based environment with OBs results in malpractice premiums that are ten times cheaper than doing home births, where there is no OB backup and operating facilities are far away.
THATS why home births are so rare--its because midwives are opting out, not because the big bad AMA is stifling them. Any midwife is free to do home deliveries any time they want, they just have to pony up the malpractice insurance which is many times more expensive for home births.
Midwives arent stupid--they follow the money just like doctors do and thats why they overwhelmingly choose to work in hospitals and birthing centers as opposed to solo home births.
BryklynLibrul, could you amend your last paragraph to say "the mother and the baby's welfare is paramount"? The mom's health is as important as the baby's health.
KCN:
"The welfare of both mother and baby is paramount." Amendment done.
I would imagine that most of the time that the midwife is perfectly fine and results are great. But when things go to hell in a hurry there is no time to wait to get trained medical doctors there to perform whatever procedure is necessary, for both the mother and the child. Fetal brain injury can result in less than ten minutes of fetal distress. There is no time to take an ambulance to the hospital. While the odds are low of this happening I cannot think that this could ever be worth the risk to your child.
No amount of statistics-citing makes a difference to me. I don't care if all the babies born in the Netherlands are born at home and born healthy. The question for me is: what if something went wrong? Could I live with myself if my baby was impaired because of my decision to have a home birth? The answer is no, so off to the hospital I went, three times.
I believe some people choose home birth because they think it's best for the baby (less "traumatic"?), but in many cases I'd guess it's also related to the parents' desire to have a certain kind of birth experience. I just couldn't take the risk of something going wrong at home when there's a level 4 NICU available to me and my baby in town....even if that risk is very small.
pls,
Over 40% of the babies born in the Netherlands are born at home. But hey, they're Euro weenies living in the dark ages over there.
If you're going to list a number, please give a source.
With a quick search, http://en.wikipedia.org/wiki/Home_birth says the Netherlands has only 30% and they are in home OR midwifery run units.
http://www.ncbi.nlm.nih.gov/pubmed/9767222
says the rate was around 1/3 of births in 1998 and dropped from 2/3 in 1965
http://bmj.bmjjournals.com/cgi/content/full/317/7155/384?ck=nck
says that 30% of births in the Netherlands are PLANNED at home, which means fewer end up occurring at home. (That paper referenced and article from 1987 so the number is probably lower now).
So yes, the Netherlands have more homebirths than the US, but please make sure attempt to use accurate numbers.
Matthew is right. Luckily, as a gift to you free market Yanks, the National Institute for Clinical Excellence, flower of the NHS, has done the work on this and concluded that:
for normal pregnancies without complications of a sort that can be identified 6 months in, there is no statistically measurable difference in outcomes between hospital births vs home births carried out by midwives in districts within ambulance range of a hospital. In other words, the (very rare) cases in which a complication develops at home too quickly for a hospital transfer, are offset by the (also very rare) cases in which nosocomial (treatment-caused) complications arise in hospital.
NICE assessments are generally regarded as being on a par with Cochrane Reviews - that is, this is settled science, all the possible quibbles you may have, have almost certainly been taken into account. In related news, there is no additional risk from epidurals.
But now having looked at the NICE guidelines whose URL I gave, I can't find the conclusion Dsquared says are there.
According to Wikipedia, these are the conclusions of that NICE assessment:
"The quality of evidence available is not as good as it should be for such an important healthcare issue and most studies do not report complete or consistent outcome data. Planning birth outside an obstetric unit seems to be associated with an increase in spontaneous vaginal births, an increase in women with an intact perineum and improved maternal satisfaction."
“Of particular concern is the lack of reliable data, relating to relatively rare but serious outcomes such as IPPM [intrapartum-related perinatal mortality] in all places of birth. Uncontrolled confounding and selection bias are particular methodological limitations of most studies. The GDG was unable to reassure itself that planning birth in a non-obstetric setting is as safe in this respect as birth in an obstetric unit."“Women should be offered the choice of planning birth at home, in a midwifery unit or in an obstetric unit. Women should be reassured that intrapartum-related perinatal mortality is low in all settings. Before making their choice, women should be informed of the variable quality of the information comparing the potential risks and benefits of each birth setting.”
http://en.wikipedia.org/wiki/Home_birth#Safety
Doesn't sound that settled to me.
dsquared. I'm not sure where you got your inforation from, but that document seems to not match your words. In fact they seem to agree more with the idea that there could be a not fully quantified amount of additional risk.
http://www.nice.org.uk/nicemedia/pdf/IPCNICEGuidance.pdf
Section 1.1.1 says:
That the available information on planning place of birth is not of good quality, but suggests that among women who plan to give
birth at home or in a midwife-led unit there is a higher likelihood
of a normal birth, with less intervention. We do not have enough
information about the possible risks to either the woman or her
baby relating to planned place of birth.
Page 8 on planning says:
That if something does go unexpectedly seriously wrong during labour at home or in a midwife-led unit, the outcome for the woman and baby could be worse than if they were in the obstetric unit with access to specialised care.
Gee, dsquared is making sh*t up? I'm shocked.
Not.
This AMA resolution is very disturbing to me. I am also extremely concerned by the majority of the responses this post has recieved.
If you want to give birth at the hospital then by all means do so. I can understand why so many believe it's the right choice for them. But a mother's right to a safe homebirth overseen by a midwife should NEVER be taken away, It would mean putting her at the mercy of the medical protocols that often tend to increase complications and costs.
I would give ANYTHING to be able to have had my children at home, but I could not due to risking-out factors. (Yes, midwives do risk out cases that they deem require advanced medical care.) Hospitals are like prisons for new mothers and newborns with their rules and regulations and protocols. At least, that is how I felt. The round the clock interruptions, the separation of babies from mothers, the doctors who treat births as emergencies, etc.
The ignorance about the safety of homebirthing with trained midwives among these replies is positively mind-boggling. Numerous friends of mine have given birth at home and had amazing, peaceful, and safe births - the way birthing was meant to be.
Again, that's fine if YOU do not feel comfortable birthing at home, but that right should NEVER be taken away from mothers who want to do it that way.
Disturbed,
Please read the resolution (posted by me above and linked off of the feministe post). Despite what the title of this post says, they are not advocating a ban. They are trying to encourage legislation to state than home birth is not the safest option. Yes that's a strong statement that you can disagree with, but it is definitively not a ban.
Also, you would give ANYTHING for a home birth. Does that include your life or the life or health of your child? No one is questioning that there are thousands of healthy home births every year. AMA is saying they believe that some home births with problems or deaths probably would have been avoided in a hospital or birthing center.
Yep, add me to the irresponsible post crowd. OBs don't need anymore patients, and the attitude of doctors trying to protect their turf and wallet is tiring and unsubstantiated.
First post, long time reader. Agree with Y most of the time, but he can't be more wrong on this one.
My partner and I had both our children at home. We did a LOT of research before we made our decision, and it seemed to us that - assuming a normal pregnancy - the safety argument was more or less a wash. Yes, in a tiny fraction of normal pregnancies, things can happen during labor where the availability of medical intervention can make a real difference between a good and a bad outcome. But on the other hand, at a hospital, birthing mothers tend to be pressured into accepting interventions such as syntocin (synthetic hormone to speed up labor), pain-killers and invasive monitoring that can trigger the classic "cascade of interventions" that results in an "emergency" C section, all of which carry their own risks to both baby and mother.
That's why the overall outcomes for home birth and hospitals turn out to be virtually the same.
For example, my partner's first labor went almost 24 hours. If she had been at a hospital, she would almost certainly have been given syntocin. Hospitals just will not wait that long. Now, syntocin substantially increases the pain of contractions, so she may well have needed an epidural. Once a woman has had an epidural, she's no longer able to move her body into any of the ideal postures to give birth, so the chances of needing an "emergency" c-section rise enormously.
In short, she was (events proved) perfectly capable of birthing normally, but had she been in the hospital system, she was a likely candidate for an "emergency" ceasar.
So if you don't get scared away by the bogus safety argument, you then look at the other pluses and minuses. Home birth gave us control, a comfortable environment, people around who we knew and trusted, and our best possible chance of having a natural birth - including the oxytocin-induced bonding that follows a natural birth.
Assuming another normal pregnancy, we would not do it any other way.
Please read the resolution (posted by me above and linked off of the feministe post). Despite what the title of this post says, they are not advocating a ban. They are trying to encourage legislation to state than home birth is not the safest option. Yes that's a strong statement that you can disagree with, but it is definitively not a ban.
What the hell does "legislation to state than home birth is not the safest option" mean? So all they are doing is trying to pass a meaningless resolution? Does the proposed legislation actually produce any policy results, or is it nothing more than an endorsement?
I can see why people assume that they want to ban home-births. "Legislation" usually means "regulation or banning."
It seems to me that even if there's little extra risk for home births with qualified midwives and reliable emergency transportation, this really isn't a very good procedure to de-medicalize. If the current hospital environment is hostile and the doctors unpleasant, that should change, not removing doctors and hospitals from the equation. Because, quite simply, childbirth is for the average mother and the average child still the single most dangerous event in their lives.
If we were looking at relative differences in risk with something that wasn't sentimentalized, like automobile safety, people would be vilifying those who call for less safety and more risk.
I'm quite certain that there's a great number of things that MDs do that could be handled more efficiently and cheaply by other medical professionals (especially advanced nurses, pharmacists, and such) but childbirth is so far up the relative risk scale that it should be among the last things we de-medicalize, not the first.
And I say all this as someone who, by nature and class and background, finds the idea of home births with only midwives appealing. I just happen to recognize that it's irrational. I certainly believe that midwives in a hospital setting with doctors available and monitoring equipment and so forth to be a good idea. A doctor can be at hand to interpret subtle clues and intervene without spending large amounts of time actually delivering babies, most of which is terribly routine.
But childbirth is inherently very dangerous. If only one in a thousand births go awry with midwives at home, the stakes are often death and we, as a society, don't usually accept a 0.1% increase in mortality for things that every person experiences at least, and almost half of us twice.
The malpractice statistics mentioned above prove this. I don't doubt that the larger portion of the increase in malpractice claims is due to simply home midwives being more vulnerable targets than midwives and doctors in hospitals, but that also proves my point. People are not really willing to accept this sort of a risk. Putting aside the fact that than an increase in risk must exist, though it might be very small, people will believe there's greater risk in every case where something goes wrong and a mother of baby dies.
Because mothers and babies die. Childbirth is dangerous. It's very far from tooth cleaning, it's not even in the same ballpark. Let's start with low-risk stuff to liberate from doctors, not the high-risk stuff.
My mother has been a nurse midwife for more than twenty years and she adamantly refuses to do home births.
Perhaps someone should ask midwives what they think?
Sorry, but I had a friend who died having home delivery by midwives. They weren't well enough versed to recognize that her rising blood pressure posed a real problem. The baby died, too. Both my kids were born in the hospital -- and I thank heaven for it, because both of them had minor problems that might have been major if they had been born at home, or if we'd had to leave home in the middle of a delivery to get to the hospital.
Home births are currently legal in all states, and yet they are hardly ever used. Why?
In part, I'd suggest that it's one of the few opportunities that those with limited or no access to private insurance have to get thee to a hospital.
In that regard, this is a debate worth having when the US has a healthcare system befitting its status as a developed nation.
I think that midwives may do an excellent job of delivering children, but in the hospital, a mother also can draw on high-technology medical equipment to monitor the health of the child. If the equipment shows that something is going wrong with the baby in the womb, a doctor can then intervene immediately.
For example, for our first child, it turned out that his umbilical cord was wrapped around his neck. The medical staff was tipped off that something was wrong, I think, by the drop in our baby's heart rate in the womb. They did a caesarean, and discovered the position of the cord. Our baby was born fine. Had our child been born with a midwife and without this high-tech equipment, there's a real possibility that our child would have suffered brain damage, as the cord would have cut off oxygen supply to his head.
I'm going to join the criticism too. To hell with the statistics, my son wouldn't be alive if he were born at home. He was delivered at a hospital very competantly by a midwife. My wife had been tested for Group B strep, like all pregnant women are, but in her case the test came back falsely negative. So there was no concern during the birth, everything was proceeding normally, and no antibiotics administered during birth. As a home birth, no red flags would have been raised.
Meanwhile, my son had not only picked up the infection, it had advanced quite a bit by the time he came out. The doctors had no idea what he had (because of the false negative test) but immediately administered antibiotics. Without that, he would have died.
As it was, he was still in a struggle to survive. He needed immediate life support that our community hospital couldn't provide, so a helicopter was sent from the nearest regional hospital. Good luck parking that helicopter in your driveway.
Even then it was a close call - at the NICU the nurses told me they had never seen a baby take so much blood pressure medication. My son is now 7, perfectly healthy, and I couldn't imagine life without him.
Afterwards, I felt compelled to share this story with my friends, to show them how essential it is to have medical resources at reach during birth. And given the topic of this thread, I decided I have to share it here too.
If you are considering home birth, please don't do it. If you are advocating home birth to others, please don't do it.
Anonymous: For example, for our first child, it turned out that his umbilical cord was wrapped around his neck.
Our second child too had the umbilical cord wrapped around his neck. Our midwife proceeded to stick her forefinger between it and his neck and pulled it up and over his head between pushes. As she had dozens, if not hundreds, of times over her 25-year career as a midwife. It was routine.
Amazing how pervasive the fear of childbirth is in this culture. But what do you expect when general practitioners can finish their residencies without ever seeing a natural birth. (One of our backup midwives--an RN training to become a midwife--had just finished a course with residents, none of whom had ever seen a natural birth in all their years of training. Not one of them knew what a woman looked like or how she behaved when giving birth).
Thanks for sharing that story, Ben V-L. It's very, very similar to our own.
Please, PLEASE don't encourage people to do home births.
My wife went with a certified nurse/midwife, but in a hospital's birthing center with plenty of backup in case of problems. That turned out to be a good thing. Won't go into details, but things can go wrong in childbirth and our daughter nearly died. (My wife lost enough blood that she needed a transfusion, too.) Anyway, our daughter is now the sweetest, most wonderful six-year-old on the face of the earth. Having her has been the greatest experience of my life. I can't fathom how awful it would have been to have lost her at the moment of her birth.
Childbirth is not comparable to having your teeth cleaned or your eyes tested. I'm no shill for the medical-industrial complex, but I'd strongly encourage everyone to go to a hospital for delivery. If you're inclined towards alternative childbirth ideas, by all means do what we did -- work with a certified nurse-midwife during pregnancy, have a doula present, and demand that your hospital provide a comfortable environment for the birth. But DO go to a hospital!
THATS why home births are so rare--its because midwives are opting out, not because the big bad AMA is stifling them. Any midwife is free to do home deliveries any time they want, they just have to pony up the malpractice insurance which is many times more expensive for home births.
This is also why you no longer see family practice docs doing deliveries-- the insurance is just too much.
Free-standing or more-or-less independent birthing centers seem like the best choice-- access to high-tech care if needed without the paranoid intervention-heavy mindset most hospital-based OB wards have. (And yes, there are too many interventions. I had a premature birth at a hospital and literally had to fight with the attending OB-GYN to stop her from doing an elective procedure I did not want that had absolutely nothing to do with the health of my child.)
I think homebirths are a bad idea but I can see why people want them, especially if there aren't a lot of childbirth options available. Not everyone wants an epistiotomy or an epidural.
Full disclosure: I'm sure my own stance is colored by a couple I know who lost a child during a home birth, and by the incredibly positive experience I had with the midwife at my local birthing center, which does treat women with respect and dignity.
In my rural area a woman in the town next to mine gave birth in the local hospital. A few hours later she died of massive internal bleeding. Proof positive that having a baby at a hospital is too risky. I encourage everyone to not consider hospital birthing as a safe option.
Statistics be damned.
Snark over.
pls. This is getting repetitive, but for this woman you knew who died of massive internal bleeding, could it have been avoided by a midwife at a homebirth? I highly doubt it.
I think "statistics be damned" is exactly your problem. You accept facts that agree with you and ignore evidence that contradicts your beliefs.
It's amazing to me how much of this discussion is anecdotal. My experience was this ... I knew a family once ... I met people who had home births and they don't eat dairy ... Good Lord!
These are teeny data points, and certainly not sufficient arguments to support the fevered pleas that no person ever should have a home birth. Are there risks to a home birth? Sure, although home-birth midwives screen out pregnancies that foreseeably present issues. There are risks to hospital births, too, like staph infections, for example, even aside from all of the bad stuff with high c-section rates and the cascade of interventions.
(My anecdotal experience is that my wife and I originally planned on a birthing center birth, but switched to a home birth. I didn't know much about it, and thought it was crazy at first, but after researching it, concluded that it was the best thing for us. During labor, our home-birth midwife found that our son had turned into the breech position and we transferred to a hospital for a c-section, and had a very sucky hospital experience after that. Everyone's fine and healthy now, eleven months later).
One last point about the anti-home-birth hysterics: even if you plan on a hospital birth, you don't know what's going to happen. If you show up at the hospital too early in labor, they're going to send you home. You could give birth before doubling back to the hospital (which happened to someone I know). If you try to time it so that you won't get sent back, you could give birth en route (another friend of mine gave birth in a NYC taxi en route to St. Vincent's). Home births eliminate the timing problem, because the midwife comes to you and doesn't have an assembly line of c-section candidates to slot you into. I realize that I'm slipping back into the anecdotal argument I criticized earlier. Sorry. But the point is that it's an individual decision.
I'm not going to scan through this whole comments thread again, but I can't think of a single commenter here that say no one should ever have a home birth.
People are saying that the data shows a small, but real greater danger of home vs. hospital or birthing center births. If someone wants to give birth at home, that's fine with me, but they really should do the research in advance and understand the added risks.
Amazing how pervasive the fear of childbirth is in this culture.
There's a good reason for that. For the vast majority of human history, childbirth was the #1 killer of young women.
I can't think of a single commenter here that say no one should ever have a home birth.
Check out Happy at 9:07 am and Ben V-L at 2:47 am. And then there are those like Brooklyn Liberal who say that if you have a home birth, your baby will die. I think that comes close enought to warrant my response.
All three of them are strongly advocating against home birth, but
none are suggesting a ban on homebirth. Of the three only Ben V-L comes close to your statement of someone saying that no one should have a home birth.
Happy:
"I'd strongly encourage everyone to go to a hospital for delivery."
Ben V-L
If you are considering home birth, please don't do it. If you are advocating home birth to others, please don't do it.
BryklynLibrul
"The baby's welfare is paramount. So many of the home-birth advocates fail to appreciate this, as I've found in many conversations related to my freelance work in medical journalism. This is why Matt's post is so offensive: it propagates myths that can lead directly to life-time disability or even death."
Why is this an either/or issue? Are many hospitals and doctors impersonal and push heavy medical intervention? Yes. Can horrible things happen at a home delivery? Yes.Can we try to have a better medical system? I hope so. I can only speak from personal experience. My wife's experience at the hospital was less than ideal for what appeared to be a "normal" pregnancy. After our son was born, he was not breathing properly and had to be rushed (one floor down) to the neonatal unit where he stayed one week. Thank God we were at the hospital. A co-worker and his wife had a similar experience at a home delivery, by the time the infant had medical help massive and irreversible brain damage was the result. The horror and guilt they feel is inconceivable, but at least the birth process was "natural" and in a comfortable environment.
The baby's welfare is paramount. So many of the home-birth advocates fail to appreciate this
On the contrary, home-birth advocates (of which I'm one) believe that homebirth is safer (or at least as safe). Nice try at setting up a strawman though - if you could convince people that homebirth advocates don't give a damn about babies I guess it would make winning the argument easier.
My hope is that eventually we will have enough data that we can actually compare long-term outcomes for babies born at home with those born in the hospital. As someone else pointed out above, just looking at mortality doesn't tell the whole story - but unlike them I don't start with the presumption that lesser problems will be more prevalent in a homebirth setting.
but for this woman you knew who died of massive internal bleeding, could it have been avoided by a midwife at a homebirth? I highly doubt it.
Depends. If the folks at the hospital pulled on the umbilical cord to encourage the placenta to come out (yes, they do this sometimes even though it's a very bad idea), they could have caused the bleeding. Also, the stress of being in a hospital rather than at home could have been a factor in causing the bleed (higher blood pressure), and so could the use of various labor-inducing drugs (Pitocin et. al.). Without knowing specifics, we can't say, but it's not prima facie impossible that she would have survived at home.
Honest Partisan: I just put my teeny 62 lb. data point to bed (we're in Germany for the summer, so it's 9:30pm here). He has a school concert tomorrow and needs his rest.
Granted - babies can make it out of the womb on their own just fine. Yet, in the era when we used to let them do just that - many women died.
Would you really want to take a chance on your wife's life? Where is the manly instinct of protecting his family? Alternatively, one could advocate such as a path to changing wives without divorce. But seriously, have we suddenly forgotten how dangerous child birth is for a woman.
This idea to 'save money'could have only come from a man.
Alice A.N: You gotta be kidding. Is this snark?
The homebirth movement was pioneered and developed by women in the 1960s. One of our midwives was one of those pioneers. Her journey began when she had her first child in a hospital in Boston in the early 60s. She decided she might not want to do it that way again after she was strapped down to a gurney against her will for hours during labor (and this wasn't unusual at the time). Got an episiotomy against her will too.
To once again cite an actual study (http://www.indyweek.com/gyrobase/Content?oid=oid%3A258691):
Fawcett points out that this opposition comes in the face of a study published in the British Medical Journal showing planned homebirths to have at least as good outcomes for both mothers and babies as planned hospital births, with drastically lower rates of cesarean sections (4 percent versus 19 percent) and episiotomy (2 percent versus 84 percent). The statistics were compiled from all planned homebirths in the United States in 2000 and included 5,418 women.
Becky Bagley, the director of the nurse-midwifery education program at East Carolina University, explains that the disconnect stems from the assumption by obstetricians that a homebirth is just like a hospital birth without all of the equipment.
"They don't know because they have never been to or seen one," Bagley says.
Nothing could be further from the truth, Bagley explains. Women who birth at home don't have epidurals, maintain much more autonomy over their own movement, and play a far more active role in the management of their own labor. "Physicians are not taught that; they are taught to intervene," Bagley says, adding that the interventions themselves are associated with higher risks of complications.
Yglesias. What are you talking about? I assure you that midwives who advocate for home birth are quite interested in their bottom line. In fact, since you are willing to malign physicians without any evidence, I would say it is equally likely that the home birth advocates would cut hospitals out of their turf if they could. Too bad about that whole - whoah, this delivery isn't going as planned and I could sure use the services of a hospital and a well-trained OB.
Comments closed July 02, 2008.
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Heads in the Sand
Like dentists who won't let hygenists clean your teeth unless they get a piece of the action
This one I actually buy, somwhat ... I used to go to an excellent dentist who obsessively supervised every aspect of his practice. Whenever I got my teeth cleaned, everything was better.
Ever since he retired, even when I got my teeth cleaned by the same hygenist under different supervising dentist, my gums seem somehow damaged and shrink a bit following each cleaning. And my teeth somehow didn't seem as clean
It seems to me that the only way to get a proper cleaning is to have the right kind of OCD person supervise the hygenist.
As to the law in question -- as I asked on feministing: how would they enforce it?
Posted by DAS | June 18, 2008 4:39 PM