MOMS for the 21st Century

July 31, 2010 6:04 PM

Congresswoman Lucille Roybal-Allard introduced the Maximizing Optimal Maternity Services (MOMS) for the 21st Century Act on July 21st. This legislation proposed by Congresswoman Roybal-Allard of California is aimed at improving maternal and infant outcomes in the US.

The bill will create a Center for Excellence on Optimal Maternity Outcomes and calls for greater research on maternity practices in the US. A national campaign on evidence-based maternity care practices will be issued, and an interagency committee comprised of members of all government agencies involved with the delivery of health services will be established.

Amie Newman of RH Reality Check notes the bill's language includes support for birth attended by Certified Nurse Midwives and Certified Professional Midwives.

The American College of Nurse Midwives applauds the bill. Amnesty International USA supports the bill as a product of their report Deadly Delivery that found maternal mortality has increased from 6.6 deaths per 100,000 live births in 1987 to 13.3 per 100,000 in 2006.

The bill is numbered H.R.5807 and has been referred to committee.

posted by zizzle (59 comments total)

PG: Heh.

Sadly, while this should be the most uncontroversial of bills, I predict two foes: ACOG and Republicans.

Though I have hope that ACOG, at least, will be too ashamed to actually oppose it. But their hostility to midwives knows no bounds. PG already summed up the Republican platform.
posted by emjaybee at 6:27 PM on July 31, 2010 [1 favorite]

Laying by my side is my daughter, who was born at a midwife-attended homebirth 18 hours ago.

I have strong and complex attitudes about this bill, but, they're largely irrelevant. Midwives rock.
posted by The Giant Squid at 6:33 PM on July 31, 2010 [8 favorites]

Any money devoted to helping mothers and/or children in any way other than preventing abortions is communism.

Any money devoted to encouraging the use of CPMs is irresponsible.
posted by kafziel at 6:34 PM on July 31, 2010 [1 favorite]

"MOMS"? Does all legislation need to have cutesy acronyms these days?

Anyway why would you want to maximise optimal services?

Sorry for the minor de-rail - but please!
posted by schwa at 6:35 PM on July 31, 2010 [3 favorites]

Any money devoted to encouraging the use of CPMs is irresponsible.

A new study from The Netherlands disagrees.
posted by zizzle at 6:36 PM on July 31, 2010

A new study from The Netherlands disagrees.

Read your link closer. It's comparing home with midwife to hospital with midwife, not midwife to doctor.
posted by kafziel at 6:38 PM on July 31, 2010

preventing abortions for already-pregnant women

FTFY. The GOP has no interest in preventing the need for abortions.
posted by DU at 6:39 PM on July 31, 2010 [2 favorites]

Regardless, the findings of the study is that homebirths are safe.
posted by zizzle at 6:39 PM on July 31, 2010

No, the findings of the study are that if you start off trusting your birth to a midwife, the damage is already done, no whether they can start running for a doctor to handle the tricky stuff as soon as it comes up or whether you have to call an ambulance first. The study comparing having a midwife versus having a doctor says that your kid is between two and three times as likely to die in the process of birthing if you go with the midwife, and that's if it's a low-risk single birth already.
posted by kafziel at 6:43 PM on July 31, 2010

But a comparison of "low-risk" women who planned to give birth at home with those who planned to give birth in hospital with a midwife found no difference in death or serious illness among either baby or mother.

But even when she needed to be transferred to the care of a doctor in a hospital, the risk to her or her babywas no higher than if she had started out her labour under the care of a midwife in hospital.
posted by zizzle at 6:56 PM on July 31, 2010 [1 favorite]

The other day there was this shown on MSNBC comprised entirely of dashboard cam footage from police cruisers. In one segment the cop pulled over a van that was rushing to the hospital. In the end the cop actually delivered the baby right there on the side of the road, with a "birthing kit" he had in the back of his car. Crazy.

Aaanyway, I think it would be interesting to see what happened if you actually had doctors performing home births. It's not like it would be impossible. I think as a society, we need more doctors in total. One of the main reasons we have the number of doctors we do is because the AMA actually has some say over the number who get trained each year and restricts supply. That's one of the cost drivers that got talked about in the HCR debate.
posted by delmoi at 7:00 PM on July 31, 2010

I'm not sure why you aren't reading the things you are pasting.

the risk to her or her baby was no higher than if she had started out her labour under the care of a midwife in hospital.

Midwife in hospital is no safer than midwife at home. Midwife anywhere is significantly less safe than doctor.
posted by kafziel at 7:01 PM on July 31, 2010 [2 favorites]

The bill is numbered H.R.5807 and has been referred to committee.

That the bill has been referred to committee is insignificant--nearly every bill is referred to committee, and about 85% of them go no further.
posted by MrMoonPie at 7:27 PM on July 31, 2010

I am really annoyed by midwives who practice where doctors are available to expecting mothers, because I was dumber than a sack of shit when I was born, and I'm only alive because of the care I received.

I guess I was a relatively normal pregnancy when I was in the womb. My mother, a first-time mother, was not particularly qualified to judge, but as far as she could tell I was as normal as could be, aside from my congenital laziness, which demonstrated itself through my total reluctance to be born when my due date came around.

Said due date (25/12/1983) came and passed, and I completely failed to be born, costing my parents a significant tax writeoff. I guess I didn't really feel like it.

Fat and sassy, I lingered in my mother's womb until my actual eventual birthdate approached, and I was born exactly when I felt like it. I was born, and I came forth, and I swallowed my own shit -- who knew this was even a possibility? My mother did not -- and I was rushed off to the ICU, where they took care of me and made sure that I stayed alive though I swallowed my own shit -- which is called meconium when you do this. I was huge, and looked out of place among all of the premature babies in the ICU, except that we would all have been just as dead, without immediate treatment at that age.

I don't even know how to conclude this anecdote, except that giving birth is dangerous, and by preference I wouldn't do it without the absolute strongest medical aid I could summon.
posted by mayhap at 7:37 PM on July 31, 2010 [1 favorite]

preventing abortions for already-pregnant women

FTFY. The GOP has no interest in preventing the need for abortions.

But isn't that what "abstinence-only" sex education is all about?
posted by fuse theorem at 7:39 PM on July 31, 2010

What is your problem with midwives, kafziel? Or, more specifically, what is your problem with allowing women to make their own health care decisions? My own ob-gyn has midwives in practice with her, should I go running in the other direction and pick a more old-school asshole doctor like the one who left my mother in labor for three days and wouldn't let her get up and walk around? No thank you. Also, I had a minor inpatient surgery once and ended up with a raging staph infection that made it difficult to walk for months...tell me again why I should subject a newborn to that if I could help it? And finally, why is it that Canada and other civilized countries seem to do just fine with midwives...better than us, even?
posted by bitter-girl.com at 7:39 PM on July 31, 2010 [2 favorites]

why is it that Canada and other civilized countries seem to do just fine with midwives...better than us, even?

Canada and other civilized countries have better health outcomes than the U.S. for a variety of reasons that have nothing to do with midwives.
posted by moxiedoll at 7:44 PM on July 31, 2010 [1 favorite]

kafziel, you might want to check your sources. A study from the Journal of Epidemiology and Community Health in 1998 surveyed all single, vaginal births in the United States in 1991 done by doctors and nurse-midwives in hospitals. It said that "After controlling for a wide variety of social and medical risk factors, the risk of experiencing an infant death was 19 percent lower for births attended by certified nurse midwives than for births attended by physicians. The risk of neonatal mortality (an infant death occurring in the first 28 days of life) was 33 percent lower, and the risk of delivering a low birthweight infant was 31 percent lower. Mean birthweight was 37 grams heavier for the certified nurse midwife attended than for the physician attended births. Low birthweight is a major predictor of infant mortality, subsequent disease, or developmental disabilities."
I had my child at a hospital with a nurse-midwife, and would not ever want to attempt a birth with a doctor unless I was carrying multiples. Doctors today are trained to look for the worst-case scenario, and tend to want to treat illness instead of treating birth like the natural process that it is. The United States has a C-section rate of 32 percent, and the 2nd highest infant mortality rate in the developed world.
posted by mrstrotsky at 7:46 PM on July 31, 2010 [4 favorites]

And mayhap, plenty of babies inhale meconium. It's normal and doesn't normally necessitate a trip to the ICU. Midwifes, like mine, just suction it out and the baby is fine. Many babies go past their due dates as well, although doctors are happy to induce people for that "offense".
posted by mrstrotsky at 7:49 PM on July 31, 2010 [1 favorite]

Point is, moxiedoll, midwives are readily available there (normal, even, at least compared to the US) and no one thinks twice about it. There are other factors at play in terms of overall health outcomes, of course, but I'm concentrating on the more specific issue at hand, namely giving birth and the options available to women.
posted by bitter-girl.com at 8:05 PM on July 31, 2010

kafziel: Midwife anywhere is significantly less safe than doctor.

What's your rubric for 'safer'? Because it puts you at a significantly higher risk for c-sections and unneccesary inteventions that lead to c-sections as well. C-sections that carry higher risks for babies and mothers. Not to mention the absolute limitations on the study you linked (such as the US not having nearly the same sorts of licensing requirements for homebirth midwives) and the fact that you don't even seem to be using it to prop up your "you need a doctor" hypothesis.

As for birth being dangerous - yeah, it is. But inflation and misunderstanding what midwives do doesn't help anyone. People have pointed to the fact that baby anachronism's cord was wrapped too tightly around her for her to be born without intervention as a reason for ob. care. It isn't. Any competent midwife could have dealt with that. Misunderstanding birth in general, and babies in general, contributes to the idea that without a doctor hovering at every turn babies and women will die in droves.

I birthed with an ob. and would have needed to be transferred to his care even if I'd chosen homebirth. I totally support homebirth and midwife-care even if I don't choose it for myself.
posted by geek anachronism at 8:08 PM on July 31, 2010

I'm not pro-home birth for myself, just because I'm a weirdo who feels comfortable in hospitals and more selfishly, I expect to need a hard core bunch of pain killers. On the other hand, if my hospital has a midwife, she's welcome to supervise, as long as I have an anesthesiologist on hand too.

On the other hand, I don't see midwives as a retreat to folk medicine and unsafe birthing environments, rather having lots of specialists in a very common medical procedure, which often goes seamlessly. As long as you're simply adding midwives on top of the existing doctor staff. On the other hand as a Canadian I got free prenatal care, exit provided by a c-section, and nurse visits as follow up. Also free daycare, since I was in Montreal and well below the poverty line. I imagine any of these would be much more useful to many women and their children, than someone who specialized in pulling people out of vaginas above sealing holes in people, feeding people chemicals to make them feel better, removing unwanted objects and growths and straightening out bent and broken bits.
posted by Phalene at 8:11 PM on July 31, 2010

Yeah, the false dichotomy of "against midwives/pro-woman" is kind of dumb.
posted by Pope Guilty at 8:25 PM on July 31, 2010 [1 favorite]

I don't know why you're all arguing- having a midwife instead of an OB was the best thing I ever did for myself and my child, despite complications that landed us with an OB at literally the last minute.

For me, it's not about what happened in the final minutes- I believe I would have been safe at home, even though the drop in fetal heartrate would have had me transferred in a hurry. Midwives are trained to handle such emergencies, only in my province they are required to abide by a certain set of 'transfer of care' rules.

Really, it's about the care I received during my pregnancy, and the continuity thereof in the weeks following the birth of my child, that made the difference. It was absolutely a higher quality of care than what I've heard all of my friends/family complaining about with regards to their OBs. I had more of a personal relationship with my midwives, never felt rushed during an appointment, was provided with adequate information to make my own choices about tests/procedures and had several home visits on top of those provided by the public health unit. Oh yeah, and one of the two was by my side for the duration of my labour in hospital, instead of some shift-nurse who I'd never met coming in to stick her hand up me like a puppet.

Tell me again why midwives are not at least on par with an OB if not superior for low risk pregnancies? Is it because they can't just decide to slice me open after a failure to progress after an unnecessary induction? Because if that's the only reason, I'm laughing.
posted by sunshinesky at 8:50 PM on July 31, 2010 [2 favorites]

And for the record, I have heard of nary-a-one glowing experience with an OB and maybe a single solitary complaint about a midwife. Perhaps it's because OBs are the 'default' and midwives are a conscious choice, but seriously.. I think it's at least indicative of something if no one I know who was under the care of an OB had anything nice to say about them beyond "they're always on time!"
posted by sunshinesky at 8:54 PM on July 31, 2010

Well, if you want to get anecdotal, my mom glows about her OB because after many hours of labor I got stuck and they had to do an emergency c-section and they warned my parents that I might have been deprived of oxygen and might have cerebral palsy or be retarded. And I was neither - so, yay! Obviously, most of the time, no intervention is necessary and mother and baby come out just fine when left alone.... but not always. Obviously, you don't always need an OB - just like you don't always need an MD at all - I've had great experiences with nurse practitioners and physician's assistants - but please explain to me why people (men and women) with less training are supposedly better than men and women with more training. I'm sure that most c-sections are "unnecessary" - but the thing is that you can't know which ones were unnecessary, and which saved lives.
posted by moxiedoll at 9:29 PM on July 31, 2010

sunshinesky: And for the record, I have heard of nary-a-one glowing experience with an OB and maybe a single solitary complaint about a midwife. Perhaps it's because OBs are the 'default' and midwives are a conscious choice, but seriously.. I think it's at least indicative of something if no one I know who was under the care of an OB had anything nice to say about them beyond "they're always on time!"

You can be pro-midwife without being anti-ob. I love my ob to the point I'm seriously considering an interstate move should I get pregnant again. He was amazingly talented, amazingly considerate and knowledgeable and took brilliant care of me both during the pregnancy and during the labour. After I had the baby he came in just before going on holiday to tell me how great I was and what a good job I'd done under stress. While I was in hospital on rest because of blood pressure he came in on his day off to sit with me and see how I was. He intervened with some idiotic midwives on my behalf.

One of the more distressing horror birth stories I've heard came in bits and pieces from a friend about a homebirth. For years she didn't talk about it because other women would tell her that it couldn't have been so bad, she had a midwife! A homebirth midwife doesn't do things like that! She's just imagining things and making things up and over-analysing and reading too much. Not that her midwife was in fact unethical and abusive.

Anecdata doesn't prove anything.

moxiedoll: but please explain to me why people (men and women) with less training are supposedly better than men and women with more training. I'm sure that most c-sections are "unnecessary" - but the thing is that you can't know which ones were unnecessary, and which saved lives.

They have similar amounts of training in different areas. That's how. Obviously that's dependent on where you live though. And part of that training is that obstetricians have a tendency to intervene where no intervention is needed (assisted in the US by draconian healthcare insurance regulations) which increases the need for c-sections.

And given the WHO does talk about unnecessary c-sections, it's not some mythical thing you can handwave away. C-sections for 'big' babies are mostly unnecessary. C-sections for gestational diabetes are the same. C-sections for twins are the same again. C-sections because of previous c-sections aren't necessary either.

So when you get a woman being pushed into a c-section (explicitly so or with more duplicitous methods) for non-necessary reasons that woman will tend towards having more c-sections because of hospital rules and regulations. When hospital can reduce the c-section rate simply by having standards that say "don't push a c-section just because patient is X" that implies there are a number of women receiving c-sections for unnecessary reasons and regulations.
posted by geek anachronism at 10:18 PM on July 31, 2010 [1 favorite]

Moxidoll, it's not a question of more or less training. It's a question of different training.

Take, for example, shoulder dystocia, where a baby becomes stuck after the head is born. This requires typically less than a minute to resolve before any damage is done and fewer than three before it is fatal. An OB is trained to perform an episiotomy to resolve it. Midwives are typically trained in the Gaskin maneuver, which is positioning the mother in a running start position --- like you see in track events. The Gaskin maneuver takes less time than an episiotomy, carries a lower risk of injury to the baby and a significantly lower risk of injury to the mother. Some OBs are familiar with it, but many, many are not whereas the vast majority of midwives are.

Oh, and like most procedures or maneuvers of this sort, it was named after the person who discovered and documented it. She happens to be a famed homebirth midwife that women travel from all over the country to see for prenatal and birth care.

There are risks associated with any type of birth environment, which this bill, if it passes, is hoping to address by creating a committee to conduct more research on birth outcomes in general. Informed consent means that women understand the risk of their choices as well as the procedures being performed. Some women wish and are willing to accept the risks of birthing at home. Some are willing to accept the risks of birthing in the hospital. Neither is without risk. Some women who have had a c-section would rather accept the 1% risk of uterine rupture (and of that 1% only 1% is fatal to either mother or baby). Some women who have had a c-section are not and opt for repeat c-section, even though the risks to mother and baby are significantly higher because it is a second major surgery for the mother and because c-sections carry greater risk to babies.

And with some emergencies, such as a placental abruption, there's no guarantee whatsoever the baby can be saved. It takes 8 minutes to perform an emergent c-section to get the baby out. That's a long time to have fetal-maternal blood transfusion and oxygen deprivation. But placental abruptions are so rare and incredibly unpredictable that it's not even talked about as a risk or a possibility during prenatal care.

Point is, there are risks associated with everything in life, and women have the right to choose which set of risks they are willing to accept when giving birth. It's not a matter of risk in choosing a midwife or an OB or birthing at home or in the hospital. Each of those choices has a risk, but which of those risks a woman wants to take on is highly individual. Regardless, she should have the choice to choose which ones.
posted by zizzle at 10:21 PM on July 31, 2010 [4 favorites]

I developed a wicked, deep infection while in the US. Something evil wrought by Disneyland, probably. I saw a "nurse practioner" in a drugstore. She prescribed the obvious heavy-duty antibiotics appropriate the infection and my allergies. When I returned home I checked-in why my physician. He would have made the same prescription.

The NP visit was cheaper than the Dr visit and had the same results. Foolishly, we do not have NPs in Canada. They are an appropriate frontline against the most common maladies. A good many issues are resolved using a perfectly sensible "flowchart".

IMO the birthing process is so routine and documented that there is no reason why it shouldn't proceed under the guidance of a specialist nurse practioner/midwife. In a hospital if there's an unreasonable risk factor.

tl;dr: trained to a good standard? it's all right with me, then.
posted by five fresh fish at 10:55 PM on July 31, 2010

sunshinesky: "And for the record, I have heard of nary-a-one glowing experience with an OB and maybe a single solitary complaint about a midwife."

The obstetrician that delivered my daughter a few months ago was the single best medical practitioner I have ever had the pleasure dealing with. My wife (whose opinion is obviously more important) says much the same. She doesn't say the same about several of the midwives she dealt with during the labour and in the couple of days in hospital afterwards.
posted by markr at 12:19 AM on August 1, 2010

kafziel, the study you cite is politically motivated horseshit.

The researchers whose data it misuses have made comments such as the following:

Dr. Michael Klein, an emeritus professor of family practice and pediatrics at the University of British Columbia, said the U.S. conclusions are "crap" that don't consider the facts.

"It's a politically motivated study that was motivated by the American College of Obstetrics and Gynecology who is unalterably opposed to home birth, and they probably were quite happy to publish this article because it fits with their political position," Klein said.

UBC epidemiologist Patricia Janssen, who collaborated with Klein, said the American study mixes their work with research dating back to the 1970s, and surveys with as few as five recorded births.

"The data and the methods taints the quality of the study," Janssen said, noting the review includes studies where the qualifications of the caregiver were not known.

Source: CBC news, which covered this shoddy hatchet job study extensively.

Midwifery and home birth are funded and regulated in multiple provinces in Canada, very popular, and unambiguously supported by the data.

Klein, incidentally, was the College of Family Physicians of Canada “Family Physician Researcher of the Year” in 2004, among many other career honours, and is renowned for work demonstrating that routine episiotomy causes the problems it's been claimed to prevent.

How have the study's authors responded to their motivations and, in fact, integrity being questioned by the researchers whose data they misuse?

[T]he study's authors themselves declined repeated requests for interviews from CBC News.

What a surprise.
posted by namasaya at 12:36 AM on August 1, 2010 [1 favorite]

My OB was fantastic. Maybe you haven't heard those stories because they're not trendy and popular. I don't know.

Regardless, my feeling is that if you want to risk your health and your baby's health by having a home birth significantly away from a hospital, fine. It's your choice. I also have the choice to think you're irresponsible.

Of course most births go fine. Some do not and require significant assistance. You don't usually know which is which ahead of time.
posted by miss tea at 3:54 AM on August 1, 2010

Our second child was to have been a home delivery. The midwife checked things out, saw a show of meconium and sent my wife to the hospital. There was a late term birth (much as described by mayhap) that was not without incident. The doctor fucked up. I saw her do it. I had been reading up on birthing so I knew that you never, never pull on the cord to hasten the afterbirth. She did. A nurse saw that the doctor was insecure and used this as an opportunity to one-up the physician. When the doctor ordered a certain dosage of oxytocin, the nurse cut it down. The doctor bowed. And left. That night my wife hemorrhaged from a piece of afterbirth left in place. I have complex feelings about this subject. I know some mid-wives and doulas and trust some (like the one who attended this birth) and I know some doctors and nurses and trust some -- but I don't trust anybody much. You have to look out for your own body and any bodies you might be carrying as well. Home births are a good idea, but keep your alternatives open.
posted by CCBC at 3:57 AM on August 1, 2010

Mean birthweight was 37 grams heavier for the certified nurse midwife attended than for the physician attended births.

Why would the method of delivery affect the weight? I would figure the weight would be determined and set before labor and birth.
posted by Mavri at 7:23 AM on August 1, 2010

The first thing I'm going to say is that when you are dealing with the debate about bringing midwives and midwifery practices into maternal health, is that you are not going to find a neutral commenter. They don't seem to exist.

The second thing is that if you will actually look at the studies that the pro-midwifery advocates cite, versus those that ACOG cites (in the US, they pretty much *are* the anti-midwifery representatives in this debate), midwifery's advocates, in my opinion, come out ahea.

I am not just talking about having midwives attend birth; I am talking about research that shows better outcomes when a midwifery model of care (regardless of who is actually attending) is followed. Which means that there is no reason OBs, if they are willing, cannot utilize the approach of lower interventions, better psychological support, more mobility for a woman during labor (which aids in pain relief and in allowing the baby to move down), and allowing women to eat and drink during labor if they need to to keep up their strength/avoid dehydration.

The midwifery model is also much more respectful of women's rights to determine their own care as patients. Distressing reports of "pit to distress" coerced c/sections, and other violations of women's autonomy have energized those demanding that women be given back their voice and their respect during the birth process.

I would suggest spending some time, if you really want to learn about the science end, reading the excellent Science & Sensibility blog, which provide full links to studies as well as analysis and strives to approach this issue honestly although from a pro-midwifery-model position.
posted by emjaybee at 8:40 AM on August 1, 2010 [4 favorites]

It would seem that the answer would be "more feminism in medicine", not "more paraprofessionals in medicine".
posted by Pope Guilty at 8:53 AM on August 1, 2010 [1 favorite]

Mavri: I believe that the statement is slightly misworded. CNM's have bigger babies because we spend more time doing pt education about diet, emphasizing a diet high in protein and complex carbs and fruits and vegetables. We're also less likely to induce before 40 weeks gestation.

Yes. I said we, because, lo and behold, there is a CNM on Metafilter.

Kafziel, I am going to try my best to be patient with you and not angry, because I believe you are misinformed. CNM births attended at a hospital are very safe. We have a much lower c-section rate, not because we are cavelier and take risks, but because we sit and labor with patients, observe what is happening, work with patients on ways to naturally progress and intervene medically only as needed. OB's do not labor sit. Most of them rely on nurses to tell them how the labor is progressing (and if you have ever been a labor and delivery nurse sitting on a bad fetal heart rate tracing, you know that can be very nerve-wracking).

Nurse midwives use less Pitocin (NOT a benign medication), do less inductions of labor and spend considerably more time with patients in the prenatal, labor and postnatal period than OBs. CNMs know their patients very well and know their needs. We also work closely with OBs and perinatologists , whenever more high risk situations arise. The bottom line is patients have safe births with far less intervention than typical OB care. This also dramatically reduces health care costs.

We deliver evidence-based care. We follow ACOG guidelines. Over the last several years, CNMs have developed a large body research on the parameters of "normal labor" (which are much broader than the obstetrical parameters that lead to unnecessary interventions).

Since being in practice, I have had several labor and delivery nurses and postpartum nurses choose me to be their provider over all the other providers at the hospital. If nurse midwives are so dangerous, you would think they would avoid me like the plague.

The perinatologist at our hospital has trusted me to deliver very complicated pt's, because I consult responsibly and appropriately, as do most CNMs.

Lastly, zizzle, you are slightly mistaken about how OBs manage shoulder dystocia. We are all taught, both med students and nurse midwifery students, that shoulder dystocia is not a soft tissue problem. Therefore, episiotomy is never recommended, unless the provider cannot get his/her hand in the vagina to try a Wood's Screw manuever. The first thing docs are taught to do in this situation is McRoberts position with suprapubic pressure.
posted by janakf at 9:29 AM on August 1, 2010 [6 favorites]

janakf:

My wife and I endured the classic 'hospital-birth-from-hell' the first go-round, with our son, who is now two. We were told by our OBGYN that we'd be allowed a natural childbirth in hospital (let's call it Hospital A), only to be basically bullied into the pit/epidural/forceps/episiotomy chain-of-events. It was only upon onset of labor that the nurses informed us that our doctor does not allow natural childbirth (in other words, we were straight-up lied to about it for 9 solid months). And, of course, having a steady stream of nurses, one after another, telling us that we were going to kill our baby if we didn't do the pit/epidural/forceps/episiotomy path. Near the end, our OB told us that she was late for dinner, and if the kid didn't come out in time, it'd be a c-section. Thank God our child's birth didn't interfere with her dinner plans.

Only after delivery, did we find that the hospital we went to performs between 9k and 10k births a year. 40-45% (depending on the year) end up as C-Sections, and there is almost a 'mandatory episiotomy policy' as 90+% of all vaginal deliveries involve episiotomy.

Six months ago, another facility (Hospital B) opened up in town, with OBGYNs on staff, only for emergencies, with the majority of delivery attended by CNMs. In the past half-year, they've released stats that show a C-section rate of 8% (and an episiotomy rate in the single digits).

Needless to say, they've managed to absorb 10% of the business of Hospital A, and were our provider of choice up until we found a CPM (whom all of the CNMs knew personally, and whose work they respected).

The respect, attention, quality of pre-natal and post-partum attention and care we've received in the past 6 months from both the Hospital B's CNMs and our CPM have been just outstanding.

And, yes, on yesterday morning we had a CPM-attended homebirth. No pitocin. No epidural. No forceps. No episiotomy. And the CPMs cooked breakfast for us after they cleaned up and left.
posted by The Giant Squid at 10:25 AM on August 1, 2010 [2 favorites]

As a quick follow up. Last week, Hospital A's board of directors actually voted to start using CNMs. They had to forcibly remove all OBGYNs from the room to allow a vote on it.
posted by The Giant Squid at 10:27 AM on August 1, 2010

Congratulations to you and your family, The Giant Squid!
posted by janakf at 10:29 AM on August 1, 2010

Maybe they can save some money by removing all the primary care physicians from the room before voting to have acupuncturists in the hospital.
posted by Pope Guilty at 10:41 AM on August 1, 2010

“You’re getting drugs whether you want them or not. You should have though about that before you had sex.” -OB to a mother who stated she did not want narcotics.

More where that came from...
posted by bitter-girl.com at 11:23 AM on August 1, 2010 [2 favorites]

Maybe they can save some money by removing all the primary care physicians from the room before voting to have acupuncturists in the hospital.

Pope Guilty, this is ignorance and bigotry. Read some research instead of spouting bias. CNMs are trained professionals with good birth outcomes. OBGYNs often fight to protect their turf, without justification.
posted by namasaya at 1:35 PM on August 1, 2010 [1 favorite]

Doctors today are trained to look for the worst-case scenario, and tend to want to treat illness instead of treating birth like the natural process that it is.

Agreed. My mother was a labor & delivery nurse for decades. I don't need to read studies, I have personally heard every single horror story you can imagine - including babies that died simply because of inept doctors.

My OB's office has three CNMs on staff and I will be working with one of them through my pregnancy. I know the risks involved, but when it comes down to it, when it's time to deliver my baby I want to be assisted by someone trained in birth as a *natural* process and not by someone who sees constant need for medical intervention. Obviously if something goes wrong, I will be able to have OB assistance right away, but I don't want to start off down the road of IVs and constant monitoring if I don't have to. Birth is risky, but women have been doing it since time began. There's absolutely nothing in my experience that tells me that I need to be treated as a *medical* patient while giving birth.

Though I will conceed that I'm risk-averse enough to be choosing a birthing center (hospital affiliated, but not *in* the hospital) birth and not a homebirth. I do want to be able to get medical assistance ASAP if it's actually *needed.*

(I also inhaled meconium and was 2 weeks past my due date. The OB suctioned it out of my nose and I was fine.)

Regardless, my feeling is that if you want to risk your health and your baby's health by having a home birth significantly away from a hospital, fine. It's your choice.

Midwife birth =/ home birth. Many, many women who choose to birth with a midwife do so in hospitals or birthing centers. Home birth is just *one* of the options if you choose to work with a midwife.
posted by grapefruitmoon at 1:36 PM on August 1, 2010

Grapefruitmoon, I was specifically responding to those advocating home birth.

I agree midwives very frequently provide excellent care. However I also think home births are irresponsible. Those two beliefs are not incompatible.
posted by miss tea at 2:55 PM on August 1, 2010

I also think home births are irresponsible.

miss tea, here's what a vast body of research says. (Research in this case means dozens of peer-reviewed studies, in leading medical journals, worldwide, over a period of decades.)

Planned, attended home births are as safe or safer than hospital births. They have equivalent levels of mortality, and considerably lower levels of morbidity.

"Planned, attended" means a skilled caregiver, a normal pregnancy, and a safe transport distance from emergency care.

Midwifery protocols preclude home births when they aren't safe, and require consultation and then transfer of care to an expert in non-normal birth for a wide range of complications.

Planned, attended home births are entirely responsible. The science is unambiguously on the side of this option. There may be all kinds of reasons not to choose it, and a personal sense that you don't feel as comfortable doing it is one of the best.

But you need to realize that in suggesting home birth is irresponsible here, you're on the side of touchy-feely intuition, in defiance of data, while the science supports the supposed home birth radicals.
posted by namasaya at 3:54 PM on August 1, 2010 [5 favorites]

Following on to namasaya:

With our CPM, we had 6 months of regular hour-to-two-hour consultations, and around 4 separate pre-natal home visits. (Compare this to Hospital A, in which our consultations with the doc usually averaged 6-7 minutes, excluding the three-hour-wait in the room).

Our CPM wouldn't even touch us if:
* the baby was breech
* it was twins (or more)
* if there were any signs of maternal sickness (diabetes, for example)

She also had all of the equipment and medicine to do just about anything a hospital can/could do, save a cesarian section. (doppler, episiotomy tools, oxygen, resuscitation equipment, vacuum extractor, forceps, etc).

Also, she will be performing 6 post-partum homevisits. Our former OBGYN only does one, at six weeks.
posted by The Giant Squid at 4:45 PM on August 1, 2010

Take, for example, shoulder dystocia, where a baby becomes stuck after the head is born. This requires typically less than a minute to resolve before any damage is done and fewer than three before it is fatal. An OB is trained to perform an episiotomy to resolve it. Midwives are typically trained in the Gaskin maneuver, which is positioning the mother in a running start position --- like you see in track events. The Gaskin maneuver takes less time than an episiotomy, carries a lower risk of injury to the baby and a significantly lower risk of injury to the mother. Some OBs are familiar with it, but many, many are not whereas the vast majority of midwives are.

Oof. On the contrary: OBs are taught to attempt several mechanical maneuvers, in a certain sequence, and including the all-fours maneuver, to resolve shoulder dystocia before resorting to what are considered extraordinary measures (such as forcing the baby back into the birth canal and delivering via C-section). The thing is, the maneuvers don't always work, and if they don't, it sure is nice to have someone for whom the surgical route is open.

Episiotomy wouldn't help, since the baby is stuck behind bone, not vaginal tissues.
posted by palliser at 8:59 PM on August 1, 2010

palliser: Episiotomy wouldn't help, since the baby is stuck behind bone, not vaginal tissues.

They may not help but I still shudder remembering an ob. talking about deliberating on a fourth degree episiotomy for dystocia AFTER cutting a third degree. The ob. was talking retrospectively as she'd only just learnt about the mechanical manoeuvres and was explaining how inappropriate the training she got on that topic was. It's not like she was trained in the 50s either.

(The patient, burdened with fetal monitoring, ended up shifting herself enough to shift the baby and allow birth without the fourth degree cut)

I went to an ob. who looked at me funny when I asked his epi rate - he thinks he's done four or five the ten years he's been practising. A friend had to repeatedly tell her ob to back the fuck up with the scalpel during labour because he insisted (against explicitly and repeatedly stated wishes) on episiotomies to 'prevent tearing'. Even though evidence shows tears heal quicker and easier. Even though he'd agreed prior to the labour to not do one. Labour is not the time to have to defend yourself.

Like anything there is a vast difference between practitioners and hospital culture plays a huge part.
posted by geek anachronism at 4:12 AM on August 2, 2010

They may not help but I still shudder remembering an ob. talking about deliberating on a fourth degree episiotomy for dystocia AFTER cutting a third degree.

This is why I mentioned the episiotomy in my comment above because I've heard this from more than one source and many times.
posted by zizzle at 6:49 AM on August 2, 2010

going to second geek anachronism here:

Like anything there is a vast difference between practitioners and hospital culture plays a huge part.

See, as far as I'm concerned, it's not specifically midwives that make things better, it's the "Midwifery Model of Care", which is to say: Labor takes time, and there are plenty of non-invasive, non-medicinal, and non-surgical ways to get this done, and we'll try those first.

There are a couple of OBs in town who are basically midwives with MDs, and they're comfortable with that description (both are male, surprisingly). But, the majority of OBs (here) are of the "cut-it-out-of-you-because-I-have-dinner-plans" mindset. Yes, and I find the "I schedule all of my inductions on a Friday so I can have plenty of time for golf" (actually heard this) culture to be pretty appalling, and I fear that it's not maternal and child health which guides their decisions, but a culture of convenience and turnover.

So, if more OBs acted like midwives, I'd be pretty happy with the overall result.
posted by The Giant Squid at 7:03 AM on August 2, 2010 [1 favorite]

giving birth is dangerous

Not compared to driving an automobile.
posted by mrgrimm at 10:33 AM on August 2, 2010

I've been swamped but I wanted to come back to this. The most recent metaanalysis states that home births are significantly less safe for the babies being born (3x mortality).

I do agree that some aspects of the home birth/midwifery model are wonderful and should absolutely be brought into the hospital or birthing center setting. (For example, the hospital where I had my daughter has tubs in each private room, one-on-one nursing care, and a policy that babies not be separated from the mother (among others).

However in the case of emergencies, which do occur, the presence of an operating room and doctors provides added safety for mother and child.

Of course, if you live in close proximity to a hospital, that's one thing. But if you're more than five minutes away the window for effective surgical interventions begins to close rapidly.
posted by miss tea at 1:58 PM on August 4, 2010

miss tea: I've been swamped but I wanted to come back to this. The most recent metaanalysis states that home births are significantly less safe for the babies being born (3x mortality).

As a metaanalysis it compares a lot of things that shouldn't be compared. A THIRD of US homebirths are attended by a certified midwife whereas in most other Western countries the norm is a certified midwife so the commentary about poor midwife training is very specific to only one area. Add in homebirth vs hospital for financial reasons in the US and there's a whole lot of socio-economic data that isn't being controlled for and absolutely affects neonatal outcomes. Homebirths in a situation where you're choosing it because it's cheaper, because you've had previous bad outcomes with hospital birth and none of it happening in conjunction with hospitals or birth centres is vastly different to the NZ/Swedish model.

Similar analysis in Australia hasn't shown the same results.
posted by geek anachronism at 2:32 PM on August 4, 2010 [1 favorite]

miss tea, as I cited above, the study you refer to is horseshit. It's been met with extraordinarily blunt condemnation by the researchers whose data it (mis)uses.

It mixes decades-old data with current data. It mixes births where there is no information about caregivers with planned, attended births. It blends studies with 5 births in them with studies of thousands of births.

It's a political document, not a medical one. One of Canada's leading academic researchers in this field (as noted above), a distinguished emeritus professor of family practice and pediatrics at the University of British Columbia, whose own work was misused, was provoked enough to call the conclusions "crap" that don't consider the facts.

Quoting him again: "It's a politically motivated study that was motivated by the American College of Obstetrics and Gynecology who is unalterably opposed to home birth."

This is the fading tail end of a change process that's been going on for decades. When I first researched planned, attended home birth 22 years ago, there turned out to be about 65 peer-reviewed international studies validating its safety and none showing the opposite. And, doctors in my jurisdiction were threatened with drastic professional censure if they had anything to do with it.

My (Canadian) province did its research, found the science unambiguous, and funded and regulated home birth. It's been very successful here, and is ever more popular.

Here's just one recent peer-reviewed study from the journal Birth showing the results. It includes 6,692 home births between 2003 and 2006.

Data like this explains why home birth is now funded and entirely routine in a number of other provinces.

Why does ACOG continue to fight the science, in favour of uninformed preconceptions, as other jurisdictions around the world modernize their approach? Good question.
posted by namasaya at 4:21 PM on August 4, 2010 [4 favorites]

It's also important to note that the hospital that metanalysis is out of his notorious for opposing VBACs, despite their statements that they do, and has a c-section rate higher than the national average. In fact, it was above 40% in 2007!!!!

Maine Medical Center is not using best practices of medical care if the c-section rate is 10% of the national average, and the national average is considered to be too high by the WHO, the ACNM, AI USA, and many other organizations.

Any research coming out of MMC on birth should be suspect in light of their own practices and outcomes.
posted by zizzle at 7:40 AM on August 5, 2010 [1 favorite]

I should hope the nay-sayers have found themselves schooled now, and have radically altered their views on mid-wifery.
posted by five fresh fish at 8:00 AM on August 5, 2010

The Netherlands not only have the highest home birth rate in Europe, but also the highest rate of death during birthing.
posted by Pope Guilty at 4:30 PM on August 16, 2010

Pope Guilty: The Netherlands not only have the highest home birth rate in Europe, but also the highest rate of death during birthing.

Post-22 week death does not mean death during birth. And as far as the abstract goes, it recommends more research.

I know that screams "it must be homebirth" but I'm inclined to think more research. And that depending on what definition you're using, the USA is worse off.
posted by geek anachronism at 1:56 AM on August 17, 2010