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Friday, March 28, 2008

In a perfect world, healthy childbearing women would have reliable access to science-based birth care. They would never be forced to choose between an obstetrician and a midwife or between a hospital and a planned home birth in order to get the appropriate, physiologically-managed maternity care they are seeking. In the mean time, the controversy is almost exclusively focused on PHB and midwives, while little or nothing is being done to rehabilitate our national maternity care policies. An example of the asymmetrical nature of childbirth politics is the Homebirth Debate blog.

For the last 18 months, Dr. Amy Tuteur, a retired Ob-Gyn physician and mother of 4 has been hosting the Homebirth Debate blog. According to Dr. Tuteur’s bio, she practiced obstetrics in Massachusetts and was an assistant professor of obstetrics at Harvard. She also provided backup for planned home birth (PHB) midwifery at one time during her obstetrical career.

Many readers are already familiar with the regular topics discussed on the Homebirth Debate blog. In general, it insists that hospital birth is orders of magnitude safer than PHB. It may be a legal choice from the parents’ standpoint, but regular HBD bloggers believe that compared to hospital-based care, PHB is an irresponsible and unsafe choice that risks preventable death to both mother and baby. According to Dr. Tuteur, not a single study published in the last half century has ever been able to establish that:

(a) PHB for healthy women with normal pregnancies who have had appropriate prenatal care, are (b) attended by an experienced birth attendant (c) with appropriate access to medical services for complications or if requested by the mother (d) is a safe or responsible choice

In that vein, Dr. Tuteur also claims that no credible research has *ever* identified any unnecessary risk (iatrogenic or nosocomial complications) to be associated with the universal medicalization of normal birth -- hospital-based obstetrics that includes the routine or ‘pre-emptive’ use of medical and surgical intervention as the standard of care for healthy women.

Dr. Tuteur assures her readers that any ‘natural birth’ advocate who says otherwise is either personally deluded or, if they are birth educators or provide any birth-related services, such as labor attendants or midwives, they are misleading a gullible lay public.

The HBD blog expresses unbridled contempt for:

(1) Unattended Childbirth and the often ill-informed advise dispensed by its UC Internet user groups;
(2) untrained, unregulated lay midwives;
(3) the formal direct-entry education, clinical training and certifying exam for CPMs
(4) all forms of PHB and to a great extent, OOH birth in free-standing birth centers

One assumes that HBD bloggers want to influence on our national maternity care policies and practices in a positive direction. However, conflating these four quite different topics makes it unnecessarily confusing and argues against coming up with concrete plans for improvement. The waste land of Internet user groups will always defy the best effort of society and government to control, whether the topic is unattended childbirth, unconventional religion, dieting or white supremacy. No blog can eliminate the faulty thinking that may be promoted on various Internet sites.

My own direct experience as both a L&D nurse in the obstetrical ‘system’ and now licensed midwife who attends both PHB and planned hospital births, constantly reveals disturbing and potentially dangerous practices institutionalized in our obstetrical model of care over the last century. Sadly, being in a hospital L&D unit is no a guarantee of a perfect outcome. Babies and even mothers die in hospitals, sometimes from complications that could not be neither be predicted or successfully treated, no matter where the mother was or who provided care and sometimes from routine hospital practices that are inherently risky and introduce unnecessary dangers.

Complications caused by human error are known as ‘iatrogenic’ - actions or omissions by the physician or medical staff – and ‘nosocomial’, complications associated with institutional care, such as being given the wrong drug or contracting a drug-resistant infections like MRSA. Opportunities for iatrogenic harm include the obstetrical practice of routinely inducing labor at 40 or 41 weeks in healthy women with no medical reason. Cesarean section rate for first time mothers who are induced before their cervix is ‘ripe’ is 35%.

Unless or until our maternity care system is rehabilitated, the elimination of PHB would certainly put healthy women in an impossible situation. Any thoughtful person who has access to the scientific literature acknowledges that PHB is associated with a specific set of risks. While relatively rare in a healthy population with good prenatal care, risks for women who labor or give birth at home are real and when they occur, they can be life threatening.

For example, maternal seizure caused by a fulminating pre-eclampsia (high blood pressure), an umbilical cord accident or prolapse or a uterine rupture in a VBAC mother are much less likely to result in serious morbidity or fatality when the laboring woman is in the L&D unit of a tertiary hospital. Homes, independent birth centers, small and medium-sized community hospitals -- any place that cannot provide 24-7-365 blood banking services and operating rooms staffed around the clock by obstetricians (or obstetrical residents) and anesthesiologists -- cannot provide instant access to surgical delivery. It would be foolish to argue that emergency obstetrical services did not makes childbirth safer for those women with certain types of complications.

However, it must be noted that the ever-escalating rate of Cesarean surgery is not a safe way to use hospital services. Reducing medically-unjustified Cesarean sections can only be done by first questioning and then making changes in business-as-usual hospital obstetrics. The obstetrical profession’s bitterly argues the safety of ‘permitting’ VBAC labor in or out of the hospital but the very best way to prevent uterine rupture is to prevent the original, often unnecessary Cesarean that forever leaves the mother with scarred uterus and unnecessarily vulnerable to this catastrophic complication.

In addition to our skyrocketing Cesarean section rate and the astronomical expense, there are a host of other problems associated with using ‘industrialized’ obstetrics on healthy women. The obstetrical profession’s rejection of physiologically-based management of normal labor and birth and its replacement with the routine use of the pre-emptive strike is a cost-inefficient, illogical policy that needs to be reevaluated and rehabilitated.

These complex questions are inter-related with the history of American obstetrics and the long tradition of midwifery. The current form of PHB is a consequence of the irreconcilable conflict between these two very different models of maternity care. In a perfect world, healthy women would never be forced to choose between an obstetrician and a midwife or between a hospital and a planned home birth in order to get physiologically-managed maternity care.

So why the extreme difference of opinion on what the scientific literature has to say about interventionist obstetrics and PHB? Why the level of vitriol over these diverging opinions? Is there a ‘best answer’ and if so, what is it? What would it take to implement ‘optimal’ birth practices? How can healthy childbearing have reliable access to science-based birth care? What would it take for the US to develop a single standard of care for all healthy women based on the physiological management of normal childbirth? What kind of educational changes would be needed so this universal standard would used by all birth attendants (OBs, family practice physicians and professional midwives) and in all birth settings (hospital, home and independent birth centers)?

This Normal-Birth blog will devote a series of posts to the topics discussed on the Homebirth Debate blog. According to the HBD blog, PHB disasters occur with disturbing frequency, attributed in part to the OOH (out-of-hospital) location and partly because Dr. Tuteur believes the direct-entry (i.e., non-nurse) education for CPM midwives is substandard. If these claims can be substantiated, it would lead responsible people to seriously question the care of CPM midwives and PHB as a reasonable or responsible choice. For the next few weeks, we will try to take the different aspects of this controversy and see what we find.

The first topic will be the presence of formally untrained and unregulated midwives in the United States.


Jawndoejah said...

How odd, out of hospital births are dangerous? I have birthed 6 babies and they have all been born in the hospital. However, four of the six were labored at home until less than 2 hours. I have had no real complications, and three of the babies were birthed fast enough that an OB was not in the room. One baby was born with the nurse not there to catch (she was across the room) and my pushing stages were all under 15 minutes except this last one. I could have birthed these babies at home, very likely. My last three did have meconium in such that the nurses used deelees. I do not know that a midwife at home would have needed to do this with my babies, and would not have transfered due to mec anyway as my bag of waters stayed intact. I feel the worst time in the hospital was my last time, and that my nurse put me at risk. I did not have any issues until she "checked me" while flat on my back. Monitor read a decel. After this the next four hours were in confinement and I was told to push on my back (nurse said baby would move over my spine better??? and that I'd love the stirrups...this is baby 6 for me and I've maybe used them during the stitch up stage), I was made to push before I was fully dilated. Nurse stretched my cervix manually during several contractions having me push while her fingers were inside. I pushed for 1 1/2 hours before the OB declared I needed to move and then baby was born in 10 minutes. Had I been left alone as I would be at home, allowed to move, and no cervical checks or none on a flat back, I think I would have had baby sooner and with only a few pushes. The OP position might not have even been a problem as my natural tendency was to be upright or to lean forward while standing. The scared nurse wanted me flat on my back and wanted to break the bag of waters. Glad at least the OB didn't do that to me. Baby was born with an intact bag of waters while I was on my side after I was pushing in several positions such as hands and knees, leaning over the back of the bed on my knees, on my back, on each side. Nurse was struggling to "get her credit for her contractions" with that monitor all the while. Another nurse told her that the doctor didn't want to break the water as he said the head would get stuck, but she called him to do it anyway. I am glad my baby came out before she tried to convince him to do this. Even though I've had so many hospital births, I've had some hands off births for the most part, and could have easily done it at home. Everything would have been the same. Only in my last two did the placenta stage get management...with pit (I never consented). Only in my last birth was there excessive bleeding, which OB said was due to a blood clot he went in and removed. I believe all the excessive pushing may have played a role. At any rate, a home birth midwife would know how to remove a clot also. He also had pulled the placenta out, would this cause a clot and excess bleeding? I don't know.


Jill said...

In investigating any crime (and if a c-sec rate of over 32% isn't a crime, I don't know what is) the question to ask is: "Who benefits?" Which usually leads to "follow the money." The health care system in the U.S. is FOR-PROFIT. While individual doctors, OBs, and midwives might be motivated by pure altruism, these people are not usually free agents--they work under considerable legal contraint. Who designs this legal contraint, and why? And, why, despite spending twice as much money on childbirth as any other country in the world, do our maternal and infant survival rates trail the entire industrialized world? If our system is designed primarily to make money--and, obviously, in a for-profit system, more profit will be derived from failure (i.e., unhealth) than from success (health)-- then conducting a reasoned debate on what constitutes effective care has to sift out the arguments of those who are in it for the money. You might succeed better by limiting the discussion to analysis of birth policies in countries which have already eliminated profit as a motive in birth management.