Married to Medicine

Married to Medicine

Tuesday, June 10, 2014

The Home Birth, "Natural" Child Birth, and U.S. Hospital Birth Debate Part II: What I Would Want to Know About Out-Of-Hospital (OOH) Birth.

Two months ago I wrote Part I of this blog series, which discussed some of the myths surrounding U.S. hospital safety, c-section rates, and "paternalism."  Now that I finally have a chunk of time on my hands, I present to you Part II:  What I Would Want to Know About Out-Of-Hospital (OOH) Birth.

On "Home Birth 'Midwives.'"

  • There are two basic paths to midwifery in the U.S.  CNMs are certified nurse midwives; they have lots of education and training, including hospital-based training in which they actually see all types of births and can see for themselves "low-risk" births that turn out to be dangerous - and how fast that can happen.  
  • In the U.S., the vast majority of home births are performed by non-nurse midwives:  CPMs, LMs, and LDMs.  But other nations prohibit those with lesser training than CNMs from practicing midwifery at all.  Canada, for example, has specifically abolished the CPM designation.   
  • See this article from "Safer Midwifery for Michigan" for a brief description of the requirements to become a CPM and why they are so terrifyingly inadequate.  And check this out - and be sure to note the fine print ("Note:  Currently the majority of CPMs have completed the apprenticeship-only (PEP) pathway to the CPM credential.").  Finally, read this blog entry showing statements by CPMs themselves that reveal CPMs to basically be "passionate about birth" but not interested in actually studying it in any sort of rigorous, organized manner (a little odd if you ask me).
  • By the way, if they do screw up, they can't be sued - they don't carry malpractice insurance.  Attorneys almost never take on medical malpractice lawsuits with no hope of a payout; it's cost-prohibitive in terms of time and resources.  That's also, by the way, the reason it's illegal to drive a car without auto insurance - to ensure that car accident victims will be able to recover money for their medical bills and injuries caused by other drivers.  Whenever we try to pass a law requiring that midwives carry malpractice insurance, they fight it.  As a lawyer, that's all I would need to know about home birth midwifery to know I would never, ever even consider it.  
But what if I get a non-nurse midwife who happens to be competent? 
  • Can you become a competent lawyer by only completing one year of law school, or by becoming a paralegal instead?  Not in my book; in my book, competence comes from training and education.  But, okay...
  • Also, I'm not sure how you would be able to discover even any "known" incompetency in advance, since the only "professional" board regulating non-nurse midwives (NARM - the North American Registry of Midwives, a board founded by MANA - the Midwives Alliance of Northern America) will only even potentially revoke a CPM license if it is the second time a practitioner has screwed up; the first time, the only possible consequence is "additional educational recommendations."  NARM also has a policy of ceasing to review any complaint as soon as a civil law suit is filed (again, for the rare cases in which the victim is lucky enough to find a lawyer willing to work for free... what a mess).  But, okay...
  • Even if your home birth midwife was as competent as a CNM or even an OB, you should know that there are unforeseeable situations in which even a small amount of transfer time matters a great deal to the outcome of your baby, both in terms of life and in *especially* in terms of mild to moderate hypoxic brain injury (brain damage).  For example, a diaphragmatic hernia not visible or caught on an ultrasound - which is actually not that uncommon - will mean that your baby will need a ventilator immediately upon being born, until emergency surgery can be performed. Your baby will die if born at home, but would, after surgery, have a 65-90% chance of survival if born in a hospital (the success rate depends on the hospital).  That is just one example of what can happen and why it is that hospitals bother with all their fancy equipment and specialists.  
  • While we have plenty of mortality statistics that show home birth in the U.S. to be about 3-5x as dangerous as hospital birth - every single study I've ever seen confirms this, even those funded by MANA itself (see the next section for details and links) - there have been no studies on brain damage.  Mild-to-moderate brain damage is, IMO, probably a much more common problem with out-of-hospital births than is actual death.  Just because you live through something doesn't mean it didn't harm you - especially when you're a newborn.  My blog followers know that my father is a pediatrician and professor in the UW-Madison system.  He has personally and fairly recently seen a case of hypoxic brain injury out of a freestanding birthing center; a case in which the time lost in transfer will probably ultimately show up in cognitive delays.  In some cases, the parents don't even really know to suspect that there's been damage until their child is much older and starts showing delays.  They think their birth was scary, but that their midwife "saved the day."  
  • I'm trying to avoid all the limitless anecdotal evidence of births going terribly wrong at home in ways that could never have happened in hospitals.  But you can read such stories on the Hurt By Home Birth blog; these are all babies who would have been saved if born in hospitals; the inverse, the notion that there are babies dying in hospitals who could be saved by birthing at home, is not true.  
  • The bottom line is that there is no magic wand that can make up for a lack of equipment or specialists, or that can make a 15-minute transfer time (the bare door-to-door minimum, in reality) disappear.  Did you know that obstetric groups in good hospitals train and practice to be able to deliver babies safely via c-section in two minutes or less if a labor suddenly tanks?  I don't have a citation for that, but it's what the nurse midwives running my prenatal class told us was the case at Massachusetts General Hospital, which is one of the top hospitals in the world.  
  • There are no crystal balls either.  "Low-risk" doesn't mean "No-risk."  It just doesn't.
  • If that's not enough for you, check out the outrageous tragedy that happened recently to little Gavin Michael and his mother Danielle.  Danielle was over 42 weeks pregnant (already a dangerous situation) and showing no amniotic fluid when her CPM hemmed and hawed and asked around for advice while little Gavin died.  Who did she ask?  None other than Jan Tritten, editor of Midwifery Today.  Did Jan advise her to transfer care immediately to a hospital?  No.  Jan crowd-sourced other midwives on Facebook for advice.  And their suggestions were outrageous: 
  • Here's another personal account, this one from a friend of mine who birthed in a freestanding birthing center.  Remember, just because a baby lives through an out-of-hospital birth doesn't mean he survived undamaged. 

More on the statistics:  Even the (two) studies funded by home birth proponents still show a 3-5x perinatal death rate, when compared to hospital birth.  They also show that MANA is an organization 100% willing to lie about statistics even as babies die and suffer permanent damage - this is absolutely unconscionable.

  • In 2005, MANA funded the "Johnson-Daviss" Study; Johnson being the former head of research for MANA and Daviss being his wife, a home birth midwife.  This study showed home birth with a mortality rate of 1.7-2.0 per thousand.  In the "conclusions" section of their study, they "concluded" that this means that home birth is as safe as hospital birth.  How did they do that?  They compared their 2005 home birth data to hospital mortality studies taken largely from the 1970s… and not appearing to control for only low-risk birth, which is significant since women with high-risk pregnancies are less likely to attempt home births.  Whoops!  I mean, do you really want people who are that dishonest to have anything to do with your healthcare?
  • Over the past 5+ years, we've known that MANA has been keeping data on their rates of mortality, "interventions," and hospital transfers.  They proudly released their intervention stats as soon as they had them, but only recently and under great pressure released the price paid for that lack of intervention - their mortality stats (again, long-term brain damage data has never been kept).  Sure enough, when total mortality is considered (intrapartum deaths - deaths during labor - as well as neonatal deaths), we're once again at a 1.62 per thousand perinatal death rate, even when we limit the statistics to low-risk women (why high-risk women are birthing at home in the first place is beyond me).  As hospital safety has improved for low-risk women since the 1970's (currently: about .35 - .55 per thousand for low-risk women; I'm linking to a blog that both cites the best available primary sources and gives a thorough analysis and explanation), home birth has stayed about the same.  Hardly surprising since hospitals innovate and improve as science progresses and home birth just … is what it is.
  • So how did MANA cope with having to release its atrocious mortality rates for the second time?  Well, it did the same thing it did back in 2005.  It called the release a "study" and simply announced that its "new study" showed home birth was safe - there was even a HuffPo article that had to undergo a title change because the author assumed the legitimacy of MANA's report until people complained and she read it more thoroughly herself!!  So if you're one of those people who refuse to read anything Dr. Amy Tuteur (the "Skeptical OB") writes on this, well, too bad, you'll have to come up with a new excuse.  Plenty of other people are also analyzing this "study" and concluding the same thing (see also this, this, and this).  
  • And here's the kicker:  The new "MANA study" was limited to voluntary self-reporting.  Hardly a "study"; really just a survey.  And the compliance rate was low - somewhere around 40%.  I'm sure I don't have to tell you that that means that the 3-5x higher mortality rate involves only the top 40% of midwives (the most organized and professional), and probably only those who actually think that the deaths they reported would have happened anyway.  
  • Can you imagine if we only assessed hospital safety by looking at voluntary reporting from physicians in which only 40% of physicians ever bothered to give feedback?
  • Final kicker:  Again:  No studies on brain damage.

How does the NCB ("Natural" Child Birth) Movement play into all this?

There's nothing wrong with aiming for an unmedicated child birth.  But too often, the classes and practitioners trying to sell women on the "benefits" of an unmedicated birth are not only far overstating those potential benefits, but they are far overstating the "dangers" of hospital birth, pain relief, and "interventions" as well - needlessly scaring women.  I've discussed this at length in Part I of this blog series and in "Five Mommy Myths I Believed," but perhaps the most compelling read on all of this is my friend Dani's story.  When she was unable to have the home birth she dreamed of - it would have been $4,500 out of pocket for this "natural" and "perfectly safe" at-home event - she was shocked to find that her unmedicated hospital birth was actually pretty nice.  Ironically, she also ended up very thankful not have been able to afford a home birth; it turned out she had postpartum hemorrhaging.  Still, she continued looking into becoming a CPM herself until a dangerous situation she witnessed exposed home birth for what it is, and it all started unraveling.  She's now a practicing doula and on her way to being a hospital-based CNM.

I think one thing we can all agree on is that any time information is falsified or misrepresented, a woman deciding whether to birth in a hospital or have an epidural is robbed of true choice.  As a feminist, I don't think that home birth should be outlawed; I would love to see the U.S. follow in the footsteps of other nations like Canada, whose thoroughly-trained midwives are highly integrated into the hospital systems and have high rates (40%) of transferring home births to hospitals.  But also as a feminist I believe that women deserve to know the truth about home birth, hospital birth, and pain relief.  Home birth in the U.S. is essentially unregulated and it's dangerous.  It's a national tragedy that parents are misled into thinking it's safe, only to then experience the needless loss of or permanent injury to their precious child.  That's why I participated in the Not Buried Twice video campaign - you can share our video and help ensure that the babies already lost in home birth tragedies have not died in vain.

Watch the video here.







4 comments:

  1. Have you seen the study that shows HB has a 18x risk of HIE? Skep OB covered it, and has the links to the actual studies here: http://www.skepticalob.com/2014/01/risk-of-anoxic-brain-injury-is-more-than-18-times-higher-at-homebirth.html
    Here: http://www.skepticalob.com/2014/04/how-babies-brains-get-injured-during-childbirth.html

    You are right- brain damage is a real issue that is generally ignored.

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    1. Yes! I did see that. Thanks for posting it here. I didn't refer to it only because it's more of a collection of data than the sort of long-term, focused study that I have in mind. My understanding from physicians I know is that mild hypoxic brain injury in particular would merit a nebulous, long-term study... so I guess we'll have to rely on common sense for now: Oxygen lost in transfer time isn't good, it's bad.

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  2. Awesome post. I wish I had read this and known this information about OOH birth before our birth turned tragic. Thank you for putting this information together for other families. I will share this.

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  3. One thing I point out on my ex home birthers blog a lot is that midwives don't even believe in the risk of out of hospital birth, so by definition its impossible for them to adequately get informed consent from patients. I also really think its worth noting how the midwifery community reacts to deaths and arrests for negligence (fundraising for midwives, trying to keep the law unchanged, etc). I really wish that states would put together a proper informed consent for out of hospital birth so that it wouldn't be left up to midwives who relish the opportunity to attend breech, vbac, and twin births.

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