Thanks for responding to the discusssion yesterday. Here is a link to an article about safety in childbirth that you may enlightening or helpful.

Safety In Childbirth: How Safe is Safe Enough?
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The majority of complications (which midwives, especially CPMs are specially trained to recognize) do not require immediate intervention. In any case, women who seek home birth care go over and over these questions with their midwives - what if the baby doesn't breathe? What if I hemorrhage? What if? What if? Then the midwife and the mother set up an emergency transport plan based on the particular circumstances.

Midwives are trained to deal with complications and to seek prompt medical care as necessary. That said, not every death can be prevented either in home or in the hospital. But requiring all births regardless of risk to take place in a hospital setting is an overbroad requirement and risks subjecting far MORE women to the far MORE LIKELY risks of unnecessary intervention.

These are cost-benefit analyses that are best left to informed consumers. And themore midwives are allowed to practice and develop their skills, the better the complicated births will be handled in all settings. We need to remember that there are circumstances, such as in times of natural disaster (think Hurricane Katrina) when hospital care is just available. Traditional birth attendants - midwives - are able to handle these situations and provide a valuable service. It is in society's interest to be sure that low-tech practitioners such as midwives continue to be able to hone their skills because we cannot always depend on the high-tech solutions being immediately available, no matter what. Informed consumers of midwifery care - even if they choose a birthing experience that may not be to everyone else's liking, ensure that a full range of both low- and high-tech skills remain current in our society.

Another resource you may find useful is an article by an attorney, "What ARE Our Rights in Childbirth?"

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It urges the home birth movement to partner with good attorneys who are capable of defending rights such as the right of informed refusal to care (necessary if the right of informed consent is to mean anything in a free society) to expand birthing rights. The more women use midwives, and the more willing physicians are to provide back-up and to make quick emergency transfer seamless, the safer this option will be.

We need good attorneys in this fight. I wish you would inform yourself about it and join up.

I should add that the situations you are raising in your final paragraph are basic, typical questions that every mother asks the first time she meets with a midwife. They are by no means questions that mothers who are considering home birth have never occurred until mothers have read your posting here.

Umbilical cord issues come up all the time and are routinely handled by midwives at home.

Shoulder dystocia is also routinely handled, there being a technique with good success based on the research called the Gaskin Maneuver that was invented by a well-known home birth midwife, Ina May Gaskin. Unfortunately, this maneuver can often not be used in hospitals because women with an epidural cannot usually be moved into the correct position. Women at risk for shoulder dystocia under midwifery care (such as women with high blood sugar) receive much more prenatal counseling and support to avoid the problem and are freer to move in birth and give birth on hands and knees, or in an upright squatting position, which hospital births often do not allow.

Many childbirth emergencies in the hospital are iatrogenic. How many of the serious cases you've seen involved totally unmedicated natural childbirths in the hospital where there was NO routine electronic fetal monitoring, NO inducation of labor and NO epidural or narcotic pain relief?

My midwife who delivered my son had run into all the situations you mentioned in 30 years of practice and had never lost a mom or baby. She had thousands of births' experience on her side and I would have felt more safe in her care than an OBs any day.

I appreciate all the questions you brought up, which were the same ones I asked the midwives I interviewed before deciding to birth at home. I hope that you, too, have taken the time to interview midwives about their experiences with the emergency situations you describe. Your unfamiliarity with the Gaskin maneuver suggests that you have not done so.

"All occurred in the hospital setting and I can tell you that either the mother or infant (or both) run the risk of death unless prompt surgical intervention (often with the involvement of multiple medical specialists) is provided. This type of care cannot be provided in mother's home."

I find it interesting that the clients you represent suffered complications from hospital births, yet your blog posts yesterday concluded that midwives are a recipe for disaster and are a bad idea for Virginia. A + B does not equal C in this case. Please, before spreading misinformation, do your research. Mothers and babies in home birth with a qualified attendant suffer no greater mortality rates than those of low-risk mothers giving birth in hospitals. But they do enjoy much lower rates of interventions, thus reducing their overall risk.

Birth in any setting is not without risk. Women who are well-educated and well-informed of all the risks are better prepared to deal with birth and its consequent risks in whatever setting they are most comfortable. Those risks can be further reduced by allowing women to birth physiologically. Midwives do a fabulous job educating their clients about risk, and they attend physiologic birth every day. Unfortunately the same is not true of many OBs. At the same time, midwives are equipped to address complications that arise in home births, which rarely require the type of intervention you describe. I think if you did some reading you would find that midwives, are in fact, a very good idea for Virginia.

Seriously, it is sounding more and more like you are concerned about your wallet. Perhaps you are worried that midwives have such great outcomes that women will not need your litigation services. I find it very odd that, somehow, because every single problem you have reviewed and prosecuted has happened in the hospital setting you have concluded that homebirths with midwives are the bigger problem. Your logic is faulty.

Has it never occurred to you that the medical model of care is actually causing some of these problems? Has it never occurred to you that perhaps in a relaxed, drug-free, mom not on her back setting that many of the risks are actually removed? I'm guessing not since it's pretty obvious you are clueless when it comes to midwifery.

Again, you write another ill-informed article, based on what you have heard, not experienced. Concerning emergency cesareans "30 minutes from decision to incision" - reality is that it is two to three HOURS. Personal experience with my first son's birth at Fairfax Hospital demonstrated that. I arrived at 7 PM, my OB told them to have the OR ready when she got there. She arrived at 9 PM (at another birth), OR ready at 10:30. Please recognize that there is a HUGE difference between what hospitals advertise and what they actually practice.

Concerning the umbilical cord around the neck and shoulder dystocia, if you were actually informed about birth and midwifery, you would know that midwives know how to deal with both of those issues withOUT permanent injury to the baby. My third had both (double loop of the umbilical cord around his neck and shoulder dystocia). My midwife simply put her fingers between the cord and his neck, and when even turning would not free my son, she snapped his clavicles so he could come out. The broken bones healed within six weeks. Our family doctor was thrilled that the midwife knew how to handle that "problem" the as he phrased it "good old-fashioned way". He said that in the old days when he had the insurance to deliver babies, that was the normal way to deal with shoulder dystocia. Funny enough, it was done to me when I was born because I was breech and got stuck.

Seriously, you need to actually inform yourself before you continue to embarrass yourself writing drivel. Why don't you actually get out of your chair and research midwifery by talking to practicing midwives and their clients. Until you do that, your writing will continue to be a pointless hack job.

Good reply IMO.

It seems midwifery is a touchy subject.

Mr. Frith,

I am a midwifewho is the daughter of an attorney.
I am so glad this discussion is happening. Our professions have a lot to share and can work together to improve outcomes by exploring what truly are best evidenced based practices that should be the gold standard of care, and moving away from holding providers to a standard of "legal medicine" which is often times not evidenced based but fear based on the part of the provider to not get sued. "Legal medicine" is not care that is good for mothers and babies often times, it promotes practices that actually up iatrogenic morbidity, because hey, that's what the "community standard" is, and evidenced based care is out the window.

When all stakeholders with an interest in resolving this nightmare that our current maternity care system has become engage in dialogue and start working to unravel this twisted mess babies, mothers, docs, hospitals, and yes, even you guys are going to be a lot better off.


You wrote-

"My concern,...snip...What happens when the umbilical cord becomes wrapped around the fetuses' neck and her heart rate plummets?"

My reply: "Plummeting" FHR must be something that occurs in hospital with an immobile mother on a laundry list of interventions or involves existing compromises to the baby exaggerated by a poor model of care. My personal experience ( and one which the literature bears out) with births at home and when I have transported for decelerations without appropriate rebound during second stage is that we transport a mobile mother who is generally having such slight decels that the receiving docs are glad to see that we err on the side of caution. Our job as midwives is to transport early in order to leave patients with as many options for resolving the situation as possible rather than cornering them into last resort options- surgical birth. And yet, the literature shows how infrequent transport is utilized in a planned homebirth with a Certified Professional Midwife, and how low section rates are for those transport.

As well, yet another study was just published which involved showing differing docs with differing specialties, FMM, OB, etc., a tracing and the docs had different interpretations of how distressed the baby was, when in fact the baby was not born with no compromises, just fine and dandy. We know that monitoring FHR is mostly art rather than science, the literature bears this out over and over. Midwives are trained to calculate beat to beat variability in home monitoring and use this to standard of care.


We area also aware of as a profession,the 30 minutes from decision to incision standard and that is in consideration when drawing up each individual transport plan for patients during care.


"What happens when the fetus' shoulder cannot pass the pelvis resulting in a brachial plexus injury?"

This is where your profession and mine would make excellent bedfellows : ) You all should be asking midwives why we DO NOT see this in the catastrophic fashion that it occurs in the hospital and ask "Why?"

My reply-We are working with unmedicated mobile mothers who are not physically confined in a narrow hospital bed, but in an upright or hands and knees position which resolves this situation by allowing the pelvis to give and additional 23% more room to the average pelvis. Do we have tight shoulders, and compound presentations at births? Yes. But midwives are trained skilled professionals working with mobile, unmedicated mothers which makes this simply another variation of birth, and not a medical disaster with damaged mothers or babies. We should be the gold standard on managing dystocias.


"What happens when the mother experiences DIC (disseminated intravascular coagulopathy) and risks bleeding to death?"


Holy smokes!!! We're not waving chicken bones here and talking with the elves! We do use diagnotic testing like urinalysis and labs! DIC is the most extreme coagulopathy you could have picked, and that would be risked out so quickly between the extraordinarily through hands on prenatal care and diagnostics. Statistically we also do not see the high levels of toxemia, blood sugar management issues, premature births, and low birth weight babies. EVERY prenatal is a screening/risk visit for these issues, and they are best served by a liberal application of "socially mediated preventative medicine". In other words an very long prenatal which involved clinical assessment along with nutritional counseling.





"I have seen and litigated cases with these very facts. All occurred in the hospital setting and I can tell you that either the mother or infant (or both) run the risk of death unless prompt surgical intervention (often with the involvement of multiple medical specialists) is provided. This type of care cannot be provided in mother's home."


My reply- yes, take a look at your very statement and I think that you will start to see the issue. You have seen and litigated cases with these very facts which occurred in the hospital setting. Yes, I bet you have, over and over again.

Maybe, just possibly, location and management model are what is failing women.

You are blessed with having some very sharp minds on this subject in your state. My hope is that you all are able to engage in a fruitful dialogue which benefits mothers and babies.


Regards,


Tracey Johnstone

Childbirth is a very complicated process. Always has been and always will be. I can certainly understand why he would be more willing to advocate the more popular choice of childbirth in a hospital as opposed to at home. The hospital seems like it should be able to handle anything.

I responded to the first article and am glad to see that you have clarified your position in several ways and become less aggressively anti-midwife.

I am neither a midwife nor am I someone who has (yet) experienced a homebirth with a midwife, although it is something I would like to do for my next birth. I, am, however, a former editor and one of the things I received in my training was education about logic. I also had a hospital birth that ended up with "cascading interventions" culminating in an "emergency" c-section which did NOT occur in under 30 minutes.

The biggest problem with your position is that all of your information comes from one side: that of they physicians. You have not spoken to midwives, read any of the literature about midwifery, or looked at studies and statistics that affirm the superiority of midwife-assisted birth in all but the highest-risk cases. In that regard, your position is completely uneducated.

The second problem with your position is related to the first: all of your information comes from physicians, who themselves are subject to their own overly-medicalized training, biases, fears of litigation, interpretation of data, and overly-surgical approach to resolving problems that occur during labor. Has it not occurred to you that these doctors may not be making the best judgments? OBs themselves differ over interpretation of events; what makes you think that these doctors you were with at the time actually made the best decision, or that the decisions they reached were actually "inevitable"?

Furthermore, your "expertise" in childbirth comes from review of a doctors' records. You may not be aware of this, but doctors' records are often inaccurate and reflect the way that the doctor would LIKE his/her actions to be interpreted, especially by an attorney! After all, NONE of these physicians want to be sued for medical malpractice. After my c-section, I joined the International Cesarean Awareness Network, and heard unbelievable stories about women who had requested the medical records of their c-sections from the hospital only to find that the doctor had recorded a conclusion (reason for the c-section) completely different from what the woman had been told in labor and afterward and that in some cases even differed from the obvious phsyical evidence (type of incision, for example, as verified by other OBs).

Before you step on your soapbox, you really ought to do a better job of questioning your own sources and investigating the truth of the statements you are making.

Several midwives have posted links for you to look at and have given you valuable information to get you started. I hope that you are professional enough to take them seriously and act on them.

Best wishes.

After sitting/standing through the delivery of three children (all in the hospital) I can't imagine a parent having to tell their brain damaged or otherwise disabled child, sorry I thought it would be fun to deliver at home. Had we delivered at the hospital you wouldn't be disabled. It seems to me the choice of delivering at home is a selfish one having nothing to do with the child.

Dear Sir,

I do not think your "response" addresses the blatant ignorance of your first posting. If anything, you are just repeating yourself.

Let me ask you...of the many cases you have litigated, how many were with midwives???? I would hazard a guess that very few were. The reason for this is simple..HOLISTIC CARE!

Let me illustrate this by responding to a few of your "concerns"....

"What happens when the umbilical cord becomes wrapped around the fetuses' neck and her heart rate plummets?"

Many babies are born with the umbilicus around their neck. I am a paramedic and have delivered several babies in the field, and ALL of them had an umbilicus around their neck. What happens if the umbilicus is around the neck? Simple...You remove it over the babies head, or clamp it and cut it if too tight and then proceed with the rest of the delivery. There are MANY such situations that occur during a normal delivery...so the real question is, do you want a doctor (who probably has had very few natural deliveries in his career and is not in tune with the ways of women and childbirth) handling that situation, or do you want a seasoned and experienced midwife?

"What happens when the fetus' shoulder cannot pass the pelvis resulting in a brachial plexus injury?"

Big babies can occur but I believe that with a midwife's care from conception to birth, are less likely to occur. Often they are a result of poor diet on part of the mother, or things like gestational diabetes. There are also exercises and other preparations a mother can do to prepare her body for birth that a doctor may never even consider suggesting. Also, hospital births expect the woman to push a baby out in a position that goes against anatomy and simple laws of gravity. The rigidity of the medical protocols for how a woman delivers, and not the "size of the baby" are the real reason women are seeing these issues.

"What happens when the mother experiences DIC (disseminated intravascular coagulopathy) and risks bleeding to death?"

I think these sorts of questions are ones you should ask a midwife who has delivered 1000s of babies. But I suspect that many of the problems women experience in l/d are side effects of the medicines and procedures they must undergo in a hospital setting. What about the risks associated with epidurals? pitocin? These are the REAL dangers to mother and child that often are the fast track to a c-section, which includes even MORE risks.

Your statement is telling...ALL your cases occurred IN THE HOSPITAL SETTING. Maybe you should consider that it is the hospital, and not the act of birthing a child that is the real risk factor.

As to your 30 minute guideline. Midwives ensure that they have a means of getting mom and baby to hospital QUICKLY if an emergency does occur, and with their experience, they can usually see the warning signs of an emergency long before it is an emergent situation. Further, who says that because you have a midwife you have to deliver at home? The only reason for this in Virginia is because this state is so backwards and there aren't enough midwives or laws that recognize their ability to care for the patient in a hospital setting... WHY? Simple... they do the job better than doctors and for a lot less money and the doctors (not to mention the pharmaceutical companies cramming pitocin down our throats) fear being put out of a job.

It's undereducated posts like yours that scare women into thinking that the hospital is the right choice, rather than showing them that they actually have options.

I personally go to a Birth Center (one of only FOUR in the entire state of VA). It is just FIVE minutes from a hospital and allows for home births or hospital births or births in their birthing center rooms. I see a midwife not only for pregnancy and birth but for well woman exams. They KNOW me and know my personality and personal issues and health history. They are not just there to catch a baby, they make sure I'm feeling ok, eating right, not feeling stressed, and educated about my own body. They also look beyond the scope of my womb to my whole body and how other things such as my job, activity, thoughts and feelings, and even my food choices are going to ultimately come together and affect my birth process. But most importantly, they CARE. They instill trust and confidence rather than fear and uncertainty, and they make sure I consistently see the same person so that they know me as a person and a friend.

This is how you prevent injury my friend.

I think it is sad but your narrow view of birth experiences has really affected your ability to truly see the answer staring you right in the face.

You should really consider talking to some midwives, attending a few births, looking into the actual numbers of births and find out just how many cases go "wrong" for midwives and compare that to your litigation history with hospitals and I think you'll see where the future of childbirth SHOULD be.

Maybe if there was a lawyer advocating for a change, people might start listening.

Or you can just follow the herd and keep preaching fear. The choice is yours.

Steve - your position that a baby is more likely to be born disabled at a home birth is NOT evidenced-based. There is good evidence in the research that a low-risk mother who delivers at home with a Certified Professional Midwife will be just as safe as one who delivers in a hospital.

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At the same time, the mother will be opting for a birth that is likely to result in many fewer routine interventions that can themselves cause birth injuries.

You are writing from the point of view of your own cultural prejudice against home delivery, not from the point of view of the objective evidence.
That's okay - just understand that that is what you are doing.

You can see good evidence about which interventions in childbirth are likely to help and which are more likely to cause harm at the Childbirth Connections website ("A Guide to Effective Care in Childbirth"), which has an evidence-based (referenced) list.

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You might be surprised to see how many interventions in the hospital not only have no evidence to support their routine use (such as routine electronic fetal monitoring - a favorite of attorneys and doctors afraid of malpractice, but admitted even by ACOG to have no value in reducing perinatal death rates!), but are actually likely to do more harm than good.

For a good introduction to physiological childbirth and the risks and benefits of intervention, you can read The Official Lamaze Guide to Childbirth. (Based on the evidence, Lamaze International holds that birth can safely take place in the hospital, in birth centers and in homes.)

Unfortunately, I suspect that the few naysayers represented in these commboxes have already closed their minds to the possibility that professional and highly-skilled midwives, in partnership with their educated and well-informed women clients could never be as smart about figuring out where to have their babies as the uninformed commenters themselves.

As comedian Stephen Colbert likes to quip - "Don't give me facts! Facts can change, but MY OPINIONS never change!"

Thanks for bringing out this important point.

Please ignore the mass e-mail alert responses from these greedy midwives protecting their turf. Everytime there's an article pointing out how much worse their outcomes are they notify everyone and ask them to post.

Midwives are the ones that greedy and controlling. They hoodwink women into believing that births with them and especially at home are no different from the hospital in an emergency -- everything can wait for them to recognize it and transfer them. They flash intubation equipment at prospective moms, when they have never mastered intubation. Most have never done one single baby! They are not good at IVs either, especially in a crisis when the vessels constrict. There's a case in England where the mom died because the midwife waited for the ambulance crew to do it. And doesn't even address the fact that saline and pitocin won't help much if there is massive bleeding, a torn vessel, or DIC.

University hospitals can react in 10 minutes, not 30.

In short, midwives lie and lie and lie so they can make a lot of money and be Queen Bee for standing around and catching. If anything goes wrong, all they do is make up stories about how the baby wouldn't have survived anyway and how it was somehow the mother's fault.

The standard lie when midwives don't transfer soon enough -- the mom was advised but she refused. They often get more milage out of it by falsely claiming the mother refused because she feared negative reactions from staff for using a midwife!

Touche Ladies. You get your blood money (they are paid up front regardless of how it all ends), cover your butt (at someone else's expense BTW), cover-up that you don't really know that much about what you are doing, and blame the doctors and nurses and mom for causing it all!!!

Moms don't feel empowered by being deceived. Moms don't feel empowered by being used and ripped off. Moms don't feel empowered by being scapegoated.

Moms don't feel empowered when their babies are hurt or die.

Midwives' victims don't have a listserve.

OK, how many of you were alerted to this post by a midwife (doula) or midwifery (doula) organization?

Creating the false impression of concensus of opinion message boards is yet another of midwifery's prime skill -- deception of moms.

It is motivated by midwives greed and their desire for control and power.

Do we really need to license deception? Isn't that called fraud?

Dear Tracey Johnstone,

I will be forwarding a copy of your post on DIC to the state licensing board of Ohio.

I think they will be quite surprised to learn that DIC in pregnancy can be detected with your oh-so-fabulous pre-natal care so that midwives would never have it appear on their watch.

The rest of the world thought that it can occur rather suddenly and without much warning. That it can evolve into a life-threatening condition in a short time. The rest of us thought the main obstetrical causes of DIC are abruption and amniotic fluid embolism. So how exactly do you predict those in the first place, then predict who will get DIC as a result of those or other causes?

I'm sure you won't be in any trouble. Just tell us all how do you do that. It's amazing.

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(more midwife lies)