Madwife goes for a swim
People wonder why I frequently use the term madwife.
A lack of insurance means hundreds of independent midwives up and down the country could be forced to stop work in the face of government guidelines by the end of next year. Partner at the Ashford-based Kent Midwifery Practice, Kay Hardie, said:
“No one will insure us.""We are a high risk group and the pot is small for any coverage because we work outside the NHS. We offer invaluable one-to-one care for pregnant women and many more are choosing alternative methods to give birth. We hope that the Primary Care Trusts will buy our services in the same way they do for GP services."
So now the madwives are running a campaign to ask the government (aka the taxpayer) to pick up the tab. Let us hope that the government does not fall for this one.
Kay, no one will insure you because you are dangerous. Insurance companies are not interested in the pros and cons of home births. They are interested in risk assessment. And you are not a good risk. But you don't understand that, do you?
Kay, no one will insure you because you are dangerous. Insurance companies are not interested in the pros and cons of home births. They are interested in risk assessment. And you are not a good risk. But you don't understand that, do you?
Following numerous comments and emails, I sent details of Kent Midwifery Practice to Helen O'Dell who is the Midwifery Officer for South East Coast Local Supervising Authority. She has replied as follows:
Dear Dr Crippen
You are able to refer directly to the NMC and enclose the details that you have sent me. There is an information leaflet on the NMC website regarding how to make a complaint. I will ask for an investigation to take place. If there is any further information that you think is relevant please forward it to me.
Regards
Helen
I have therefore also sent copies of the email to the NMC.
Helen O'Dell can be contacted at : helen.odell AT nhs.net or Helen.O'Dell AT southeastcoast.nhs.uk and the email address of the NMC is : fitness.to.practise AT nmc-uk.org
Labels: madwives, risk assessment
53 Comments:
A midwife is a specialist in her own right who is trained to care for women and babies during pregnancy, childbirth and after the baby is born for up to 28 days. She is the only professional who is legally allowed to attend a birth other than a doctor who must have had training in obstetrics.
Taken from the madwife's website.
This is utter wibble, of course. There is no "legal" component to it at all.
Chris
Madness or dishonesty, who knows.
All doctors have had training in obstetrics. Any doctor can attend a birth, though few would want to if they did not have regular experience and specialised knowledge. Oh, and any doctor attending a birth in an emergency is FULLY INSURED with UNLIMITED LIABILITY. Apparently, the actuaries, having done the risk assessment, think it is economic to offer doctors insurance.
John
"She is the only professional who is legally allowed to attend a birth other than a doctor who must have had training in obstetrics."
Other than the poor HCAs/work experience kids they have covering them as they try to balance 3 women in labour at once...
But isn't it a case of lack of numbers rather than a particularly high risk compared to hospital or NHS home berths? If the cost of a single claim for cerebral palsy can be as high as £2 to £5 million (http://www.foot-ansteys.co.uk/index.cfm/solicitors/News.Details/sectionzone_id/3/news_id/101) and there are only a few hundred independent midwives, you can see why it wouldn't be economical to insure them. A single claim would wipe out years of profits even if they charge thousands for the insurance.
Sorry, me again. Claims against the NHS are handled by the NHS Litigation Authority. It runs the Clinical Negligence Scheme for Trusts which acts as a national risk pooling scheme. So effectively the NHS provides it's own insurance. Given that maternity claims account for 60% of the total sums paid for NHS clinical negligence claims, and given the high cost of individual claims, do you think a profit making insurance company would cover NHS maternity employees?
For 60% of the total NHS negligence compensation budget, I'd say yes they would.
Perhaps to make it more clear, the number of midwives is completely irrelevent to how economic it is - what is relevent is the (independant) probability of a claim per midwife, if there is a 1 in 1000 chance of a £5million claim per year the insurance will be somewhere over £5000 a year, and it just forms one more part of any private companies diverse portfolio or risk.
If the NHS provides its maternity staff with unlimited liability that just means that the cost of those staff is much greater than it appears - writing the number down in a different part of the accounts doesn't make it go away.
Having one collective NHS risk pool doesn't change any of the associated risks, it just means the NHS has enough risk for economies of scale to make in-house actuarial services more cost effective than outsourcing (allegedly).
Dr John Crippen...many women don't want a doctor trained in obstetrics male or female at their birth, nor do they want births in hospitals. I had one hospital birth and secondly a home birth with midwife (in the USA) and the second was about 100 times better for me and the child. Although I see your point about the insurance costs.
emma, why do you think this? The NHS Litigation Authority doesn't have to make a profit for shareholders from their 'insurance' unlike insurance companies.
Looking at the NHS Litigation Authority figures for claims since the scheme began in April 1995 until the end of March 2007, 21.2% of the claims were for Obstetrics and Gynaecology but they accounted for 48.9% of the total value of claims (http://www.nhsla.com/NR/rdonlyres/C1B3F310-E13D-4C71-B248-C5384438E603/0/NHSLAFactsheet320062007.doc). Seems quite a high risk. An insurance company would obviously want to charge Obstetric staff more for their insurance.
Back to independent midwives. It looks as though there are between 120 and 150 in the UK. If they each paid £2000 p.a. (slightly more than German midwives pay, http://64.233.183.104/search?q=cache:Ecs7W1XsoY4J:www.scottish.parliament.uk/s3/committees/petitions/petitionsubmissions/sub-07/PE1052D.pdf+independent+midwife+insurance+germany&hl=en&ct=clnk&cd=2&gl=uk&client=firefox-a), the total income for the insurance company per year would be £300,000. If a single claim can run to £2 million or more, it would take more than 7 years for an insurance company to break even without taking into account wages, rates, electricity, etc. Obstetrics is high risk. I don't think independent midwives would need to have a higher than average risk (compared to other Obstetric staff) for insurance companies not to want to take the risk. Economies of scale are against them.
I suppose this would be a good way for govt to introduce individual insurance of the parents cover the costs - a la US of 'a' Health Insurance.
If a parent chooses to have a child at home and is making an informed decision - it is THEY who are taking the risk, not the clinicians.
Clinicians should not assist in the determination process of hospital/home delivery and parents have a right to choose.
Midwives do not have a right to legal cover just so they can have a dabble at cost to taxpayer.
Personally I think home birth is acceptable if parents so choose. But with it, they choose to accept the risks just as they do for immunisation, which school they go to, what religion they follow or even which take away foods they allow. Parenting starts at the pre-conception stage and is not the responsibility of the state to control or contain. Just like it's my life (thanks Mum) tho I am interested in the idea of suing her because it's her fault I am me.
Why would they pay 2000 quid a year for insurance crying out loud!
Consultant obstetricians with all their training and experience pay 70-80K yearly for insurance for practicing obstetrics in a private hospital with immediate access to an operating theatre and resus facilities if needed.
So, the economic amount for these jokers is probably going to be about 2-3 times that, given the risks of death or brain damage are 2 or 3 times higher, even in low-risk cases (if not more).
You can therefore see why they don't want to pay their way in an honest fashion.
Dr John Crippen...many women don't want a doctor trained in obstetrics male or female at their birth, nor do they want births in hospitals. I had one hospital birth and secondly a home birth with midwife (in the USA) and the second was about 100 times better for me and the child. Although I see your point about the insurance costs.
++++
Sure. And, wise or not, that is their right. But why don't they use a midwife working within the NHS who is properly trained, has the proper kit, and is insured?
John
There is a lot of stupidity surrounding this issue. Fact of the matter is this:-
1) Independent midwives are 'private practitioners'
2) The insurance is sky high because so are the risks
3) There are many private practitioners - such as private GPs, private consultants. They pay additional insurance seperate from the NHS for their private work.
4) Private practitioners pass on the cost of their insurance to their private patients.
5)Obviously these private patients are prepared to pay that much extra for the service.
ERGO:-
6) If people rate the service of indepedent midwives then they should be prepared to PAY for it themselves. If not then they will disappear. Thats capitalism and economic darwinism baby!
James
Clearly the subject of your photo is completely barking ! If I were an underwriter I wouldn't offer cover at any premium.
James.....
Nail on head.
I tip my hat :P
Dr. Thunder
www.twoweeksonatrolley.blogspot.com
If a parent chooses to have a child at home and is making an informed decision - it is THEY who are taking the risk, not the clinicians.
If they choose to have a home birth with no intervention at all, then yes. If they choose a home birth, with an attending midwife, then the expectation should of course be on the clinician - by dint of their training and expertise - to take charge of the process and therefore to take charge of the risk.
I think this post mixes the issue of home births with that of independent midwifery.
The majority of homebirths (I would think) are carried out on the NHS, with a small number being carried out by the private sector.
Like it or not, people are entitled to choose to go private if they wish to (although I would agree that they should pay the full cost of this). I would think that private midwives who regularly attend home births are probably more experienced than NHS community midwives (for whom attending deliveries is not their main job), and they are certainly just as well trained.
If they're not as well equipped then that is a matter for negligence, but you could equally say that a surgeon carrying out an operation at a private hospital is not properly equipped because her hospital doesn't have a blood bank to deal with unanticipated emergencies.
The only issue here is that of insurance - practising without it is, I agree, indefensible. The NMC have just rewritten their code of conduct, which becomes active this week, and have kept the clause allowing people to practice uninsured (so long as they tell their patients), presumably to pander to this small group of professionals. It seems to me that it was a wasted opportunity - I'm sure that private midwives provide an important and obviously highly valued service, but they need to be able to provide the full service, which includes compensation if they fuck up (which we all do from time to time). Until they can do that, they have no place delivering care in this way.
In the Netherlands we have a lot of home-births. Trained midwives know when to send a mother to the hospital. About 30% of the mothers is being send to hospital during labour. Midwives don't take too high risks, why would they? Even with insurance, if a child dies and you could have prevented it, it's not something you would like to live with. Our independant midwives are insured, by the way.
Yes, in the Netherlands home births are much more practical. You are geared up to it and, I believe, you have excellent obstetric flying squads. We do NOT have those in the UK. If we DID have them, I would be more comfortable with home births.
++++++
And, for once, I am not writing about home births. I am writing about INSURANCE.
If commercial insurance companies will not provide cover, there is only one conclusion as James above clearly describes
JOhn
James, you say that the insurance is sky high but if parents/independent midwives want the service they should be willing to pay for it. James, they were willing to pay for it and paid up to £15,000 p.a. for insurance, WHEN IT WAS AVAILABLE. The problem now is that no insurance company offers insurance for independent midwives in the UK.
Dr C seems to believe that this is because they are a much greater risk than NHS midwives. My argument is that it has more to do with economies of scale. With only about 150 independent midwives and the possibility that a single claim could run to millions, it's just not cost effective to offer the insurance even if their risk is identical to NHS midwives and obstetricians. If all medical insurance were private it might be different but the NHS provides it's own insurance for obstetrics. Presumably there are enough independent midwives in the Netherlands for it to be economical for insurance companies to offer insurance.
Jane,
Doesn’t that just mean that the demand isn’t there?
If the service they offer isn’t sufficiently popular to sustain the business, then, sadly, the business isn’t viable.
rob clark, that may be true, but that's not what the blog article is about, is it? Dr C is saying that independent midwives cannot get insurance because they are dangerous. I'm just saying that this isn't the only explanation.
At the moment, it's still possible to get much of what an independent midwife offers for free from the NHS, especially if you opt for a home birth (continuity of care with the same midwife present throughout second stage and delivery as a minimum). But if NHS obstetric services continue to deteriorate at the same rate more people may opt to employ an independent midwife for anti and post-natal care with a planned hospital birth. According to the first link I gave, "a survey by the National Perinatal & Epidemiology Unit found that a fifth of all mothers who have given birth recently in UK hospitals did not have a midwife or doctor with them".
A proportion of independent midwife births are already planned for hospital delivery though I don't know if the independent midwife is able to deliver the baby or if they are just there for support. I'm sure I read somewhere that independent midwives can still get insurance for anti and post-natal care but can't find the link now.
jane_t
If you have a home birth with an NHS midwife, she will be insured by the NHS litigation authority, same as an NHS doctor.
Why should the NHS cover the fuckups of private homebirth midwives who are absolutely coining it in? £5000 for a delivery; 1 delivery/week = £1/4 million/yr.
They should pay the going rate for their insurance which would be at least £100K as long as they practiced safely. Of course, most take appalling risks, so are uninsurable even at £100K/yr.
If, to argue the point, there were 150 indie midwives paying £100K/yr each, that makes £15 million /yr which would cover 3 brain damaged babies/yr. This blows your "theory" out the water - if they were insurable they could get insurance eg. through a Lloyds of London syndicate.
But they aren't insurable. Their risks are too high. They are deadly "practitioners". Babies regularly die or are brain damaged because of their incompetence.
With a damage or death rate of 1/100 (see published stats eg. in Western Australia), you'd need to provide around £2.5million / cover per 100 babies delivered (if everyone sued and could prove negligence).
If the rate of successful lawsuits were 50% you'd need to therefore provide £12.5K per baby just for the insurance. If the chance of a legal win was overall 25% then over £6K per baby - just for the insurance.
These creatures should pay the going rate like everyone else. They'd then have to practice safely to everyone's benefit, especially the infants of the deluded women who employ them.
Sure. And, wise or not, that is their right. But why don't they use a midwife working within the NHS who is properly trained, has the proper kit, and is insured?
Because in many areas, the NHS actively discourages home birth due to staff shortages. if you do get them on board, you have no idea who will turn up when you're ready to give birth. I suspect that continuity of care is the biggest driving force behind independent midwives, and it's why demand for them is growing. The women I know who hired IMs could have had NHS home births, even under the strict criteria many trusts use.
Anonymous 4.36pm,
Where have I said that the NHS should pay? I've merely pointed out that there may be other reasons for the lack of available insurance policies beyond independent midwives being a greater risk than NHS midwives.
One delivery a week doesn't sound likely, and it you had bother to read what's gone before you would know that it's not the cost of the insurance that's the problem. IT DOES NOT EXIST. They cannot buy the insurance because no insurance companies offer it.
Please provide links for the 1/100 damage or death rates you mention as I've been unable to find them.
If independent midwives are so dangerous, why are they insured without problem in other European countries?
"The problem now is that no insurance company offers insurance for independent midwives in the UK"
Jane_t you keep banging on about economies of scale with absolutely no evidence whatsoever. Its your guess, and its way off the mark.
Insurance companies don't trust independent midwives and rightly so. By way of thier far looser connection to the service than nhs midwives they are always going to be higher risk. THey won't have the same formal ties, the same 'chains of command', the same multi disiplinary teams. None of it.
I really resent the idea frankly that in a day when I on a yearly basis have to have a whole host of peer review and supervision of my clinical skills, and provide evidence of my 'good practice' that there be a group of 'health care professionals' who put themselves outside the nhs block, outside its area of assessing and skill maintenance, so far outside that insurance companies are unwilling to take the risk, and then bemoan their situation.
The NHS is crying out for decent midwives. THese independent midwives could easily find jobs in the NHS. But they don't want to because they take issues with the NHS practices - as evidenced by the lady in the article above this.
Insurance companies and the actuaries who dictate to them know a bad risk when they see it.
When i was a student way back when and did my training in tommies one of the midwives made a statement to me I'll always remember (alongside the consultant obstetricians offhand comment afterward).
"Midwives are better than doctors at dealing with the client on a during a normal birth but the doctors are better at the complex and problem labours."
The consultant retorted "yes, and Tiger woods finds putting from 30 yards easier than putting from 2..."
James
"We hope that the Primary Care Trusts will buy our services in the same way they do for GP services."
Accurate comparision! After all, we do the same job.
anonymous 8.51pm said:
"jane_t you keep banging on about economies of scale with absolutely no evidence whatsoever. Its your guess, and its way off the mark."
It's also the reason given by independent midwives who have presumably negotiated directly with insurance companies. http://www.saveindependentmidwifery.org/content/view/20/38/
"Insurance companies don't trust independent midwives and rightly so. By way of thier far looser connection to the service than nhs midwives they are always going to be higher risk. THey won't have the same formal ties, the same 'chains of command', the same multi disiplinary teams. None of it."
Proof please. If independent midwives are intrinsically dangerous, how do they manage to buy insurance in other European countries?
anonymous 8.51pm said:
"I really resent the idea frankly that in a day when I on a yearly basis have to have a whole host of peer review and supervision of my clinical skills, and provide evidence of my 'good practice' that there be a group of 'health care professionals' who put themselves outside the nhs block, outside its area of assessing and skill maintenance..."
If it makes you feel any better, midwives are not completely unfettered.
http://www.nmc-uk.org/aArticle.aspx?ArticleID=2098
Supervision of midwives is a statutory system (required by law, through an Act of Parliament) that increases protection of the public from poor midwifery practice - by monitoring midwives’ practice and providing support and guidance to every midwife in the UK.
Supervision of midwives is achieved through experienced midwives who undertake further training to become eligible to be appointed as a supervisor of midwives.
All midwives, whether practising in hospitals, the community or self-employed have a named supervisor of midwives and are required by law to participate in the supervision process.
Supervisors of midwives provide support, advice and guidance to individual midwives on practice issues whilst making sure the midwife complies with the Midwives Rules and encouraging further development of skills and knowledge. They also provide professional leadership in a variety of arenas.
http://www.nmc-uk.org/aArticle.aspx?ArticleID=2101
In order to maintain your midwifery registration, you must:
* Submit an annual Intention to Practise form
* Complete a Notification of Practice form every 3 years
* Pay your annual fee of £76
Post Registration Education and Practice - PREP
In order to renew your midwifery registration every three years, you will need to provide a signed Notification of Practice (NOP) form. The NOP asks you to declare that you have met the PREP requirements (see below) and are of good health and good character. If you do not meet the PREP requirements, you will need to undertake an approved return to practice course before you can renew your registration.
Meeting the Practice standard
* submit your annual Intention to Practise form
* practise as a midwife for a minimum of 450 hours during the three years prior to your renewal of registration
Meeting the CPD standard
* at least 35 hours of learning activity relevant to your midwifery practice during the three years prior to your renewal of registration
* maintain a Personal Professional Profile (PPP) of your learning activity
* comply with any request for the NMC to audit how you have met these requirements
One, independent midwives in other countries are all on a level playing field; there isn't a small group operating outside the constraints of normal practice and often with higher risk patients. (I know 2 women who hired independent midwives for VBAC because they encountered resistance from the local NHS. In practice they could have demanded a home birth, and one of the pro-HB sites tells you how to go about doing so, but they found it easier to pay £3000.)
That said, independent midwives are not doing so only because they disagree with NHS rules, but because there's a bloody good market for it. And until the NHS sorts out maternity services, there will continue to be one and they should be insured.
So, alexis and jane_t, how much money should the NHS divert from its own maternity services / frontline services per year to pay for insurance cover for NON-NHS WORKERS?
£10m a year? £30m?
When did I say that independent midwives shouldn't have to buy coverage, or that the NHS should insure them? Yes, insuring independent midwives would require government intervention, but that doesn't necessarily mean they'd just be covered like NHS midwives.
I've heard independent midwives say they'd be happy to buy insurance if it were offered; it would be interesting to put that to the test.
Listen jane-T.
Do insurance companies insure people who've been banned due to drunk-driving and lots of accidents?
No.
It's the same thing.
They used to insure these fruitcakes for 15K. Now they don't. Because they are beyond coverage. They would not buy insurance because they couldn't afford it. Hence it isn't offered.
Other European countries? Homebirth midwives are mainstream - not dangerous morons who are anti-establishment and would rather see babies die than their mothers receive the correct care.
And the rates for death at homebirth in WA were recently pulished - use Google, or is your internet knowledge as good as your healthcare knowledge?
“The report found six unexpected deaths in planned home births during 2000-2004 which is a term perinatal death rate of 6.7 per 1,000 home births compared with 2.1 term per 1,000 in planned hospital births in the same period,” he said.
http://www.health.wa.gov.au/press/view_press.cfm?id=756
To finish off:
http://news.bbc.co.uk/2/hi/health/340399.stm
This is the most influential and highly respected independent midwife in the UK. Read & weep readers....
Comparisons with insurance in other health services are completely inappropriate - different systems, different groups, different insurance systems. The 'critical mass' argument is nonsense as no insurance company insures only one group - there are very few private paediatric cardiologists in this country and yet they can all get insurance. No private hospital in the UK would dream of having uninsured doctors working there, and NHS doctors have private insurance on top of the NHS CNST scheme.
No, these people cannot get insurance because the risk is very high - and sadly the tales written on this website clearly illustrate this well. Of course it is easy to dismiss this as a few bad apples, but when your barrel is very small even a few bad apples will significantly skew your risk profile.
Home births are riskier than hospital delivery - both epidemiology and common sense demonstrate this. Assuming all goes well, and maternal anxiety is not a major problem, I'm sure it is a more pleasant experience than giving birth in hospital - hospitals are not nice places, I know I work in one. However one is trading ones safety and the safety of the newborn for a 'pleasant birth experience'. If risks are minimised then this may an acceptable trade off (personally I don't think so, but thats my value judgement). However failing to act to minimise or mitigate risk is unacceptable. The NMC should simply not permit people to practice without insurance.
anonymous 11.02am said:
"Do insurance companies insure people who've been banned due to drunk-driving and lots of accidents?
No.
It's the same thing."
http://www.drinkdriveinsurance.co.uk/
"They used to insure these fruitcakes for 15K. Now they don't. Because they are beyond coverage. They would not buy insurance because they couldn't afford it. Hence it isn't offered."
Evidence please.
"Other European countries? Homebirth midwives are mainstream - not dangerous morons who are anti-establishment and would rather see babies die than their mothers receive the correct care."
Opinion or based on evidence?
"And the rates for death at homebirth in WA were recently pulished - use Google, or is your internet knowledge as good as your healthcare knowledge?
“The report found six unexpected deaths in planned home births during 2000-2004 which is a term perinatal death rate of 6.7 per 1,000 home births compared with 2.1 term per 1,000 in planned hospital births in the same period,” he said.
http://www.health.wa.gov.au/press/view_press.cfm?id=756"
This will hopefully provide some useful evidence when it's finished, though, why do you think it's OK to use information from Australia but not europe? You've just discounted my comparison to European independent midwives and straight away quote Australian research.
They are in the process of commissioning an independent professional review of home births but, “A preliminary review of medical records by the Department indicates that it is likely that the setting of the birth did not affect the outcome in at least five of the six deaths.”
"To finish off:
http://news.bbc.co.uk/2/hi/health/340399.stm
This is the most influential and highly respected independent midwife in the UK. Read & weep readers...."
Using a single example to write off a whole group again. Anyone can do that but it doesn't really prove anything:
http://www.leighday.co.uk/doc.asp?cat=848&doc=1124
http://news.bbc.co.uk/1/hi/england/wiltshire/7226836.stm
http://www.ireland.com/newspaper/breaking/2008/0418/breaking75.htm
http://www.examiner.co.uk/news/local-west-yorkshire-news/2008/04/10/couple-s-agony-at-baby-millie-s-tragic-death-86081-20744870/
http://news.bbc.co.uk/1/hi/wales/1861761.stm
http://news.bbc.co.uk/1/hi/health/1157966.stm
http://www.independent.co.uk/life-style/health-and-wellbeing/health-news/mothers-at-risk-britains-urealu-labour-crisis-761779.html
http://www.timesonline.co.uk/tol/news/uk/health/article1037007.ece
http://www.highbeam.com/doc/1G1-95892019.html
http://news.bbc.co.uk/1/hi/health/194854.stm
http://www.ealingtimes.co.uk/news/localnews/display.var.891587.0.why_did_no_one_stop_this.php
angry gasman said:
"Home births are riskier than hospital delivery - both epidemiology and common sense demonstrate this."
I agree that common sense seems to suggest that hospital will be safer than home birth. But then, lots of supposedly sensible ideas have been proved wrong by research, otherwise why bother doing any research?
I ran a search in PubMed and came up with the following studies into home birth. I've included all of the studies that appeared in the first two pages (ran out of time for more and don't think most people will bother to read what I have found anyway). I've only quoted conclusions because of space but the links are there for anyone interested in reading more. I agree that more research is needed, but I can't see why there are such strong feelings against home birth for low risk pregnancies. The research done so far doesn't seem to support the common sense idea that hospital is better than home.
BTW, I don't feel that strongly either way, I'm just trying to understand why others do.
http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&uid=9271961&cmd=showdetailview&indexed=google
Meta-analysis of the Safety of Home birth
"CONCLUSION: Home birth is an acceptable alternative to hospital confinement for selected pregnant women, and leads to reduced medical interventions."
http://www.ncbi.nlm.nih.gov/pubmed/11868639?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum
Outcomes of planned home births versus planned hospital births after regulation of midwifery in British Columbia.
INTERPRETATION: There was no increased maternal or neonatal risk associated with planned home birth under the care of a regulated midwife. The rates of some adverse outcomes were too low for us to draw statistical comparisons, and ongoing evaluation of home birth is warranted.
http://www.ncbi.nlm.nih.gov/pubmed/8942694?ordinalpos=3&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum
ome versus hospital deliveries: follow up study of matched pairs for procedures and outcome. Zurich Study Team.
CONCLUSION: Healthy low risk women who wish to deliver at home have no increased risk either to themselves or to their babies.
http://www.ncbi.nlm.nih.gov/pubmed/7639843?ordinalpos=5&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum
A matched cohort study of planned home and hospital births in Western Australia 1981-1987.
KEY CONCLUSIONS: Planned home births in WA appear to be associated with less overall maternal and neonatal morbidity and less intervention than hospital births. IMPLICATIONS FOR PRACTICE: whether these observed differences in intervention and morbidity have any relationship to the small, non-significant increase in perinatal mortality could not be determined in this study. Continuing evaluation of home birth practice and outcome is essential.
http://www.ncbi.nlm.nih.gov/pubmed/15961814?ordinalpos=6&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum
Outcomes of planned home births with certified professional midwives: large prospective study in North America
CONCLUSIONS: Planned home birth for low risk women in North America using certified professional midwives was associated with lower rates of medical intervention but similar intrapartum and neonatal mortality to that of low risk hospital births in the United States.
http://www.ncbi.nlm.nih.gov/pubmed/10796198?ordinalpos=7&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum
Home versus hospital birth.
REVIEWER'S CONCLUSIONS: There is no strong evidence to favour either planned hospital birth or planned home birth for low risk pregnant women.
http://www.ncbi.nlm.nih.gov/pubmed/1895169?ordinalpos=12&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum
Birth setting for low-risk pregnancies. An analysis of the current literature.
Despite the methodological limitations, nontraditional birth settings present advantages for low-risk women as compared with traditional hospital settings: lower costs for maternity care, and lower use of childbirth procedures, without significant differences in perinatal mortality.
http://www.ncbi.nlm.nih.gov/pubmed/15015990?ordinalpos=13&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum
Does a pregnant woman's intended place of birth influence her attitudes toward and occurrence of obstetric interventions?
CONCLUSIONS: A large proportion of women desire a home birth. The impact of that choice demonstrated a smoother course of the birth process, compared with women who desired to deliver in the hospital, as measured by fewer obstetric interventions. We suggest that psychological factors (expectation and perceptions) influence both a woman's decision of birthplace and the actual birth process.
http://www.ncbi.nlm.nih.gov/pubmed/9137308?ordinalpos=22&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum
Home birth in New Zealand 1973-93: incidence and mortality.
CONCLUSION: Home birth was a safe and increasingly popular: though minor, option for New Zealand women from 1973-93.
http://www.ncbi.nlm.nih.gov/pubmed/1536368?ordinalpos=23&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum
The safety of home birth: the farm study.
the results suggest that, under certain circumstances, home births attended by lay midwives can be accomplished as safely as, and with less intervention than, physician-attended hospital deliveries.
http://www.ncbi.nlm.nih.gov/pubmed/18333936?ordinalpos=24&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum
An estimation of intrapartum-related perinatal mortality rates for booked home births in England and Wales between 1994 and 2003.
CONCLUSIONS: The results of this study need to be interpreted with caution due to inconsistencies occurring in the recorded data. However, the data do highlight two important features. First, they suggest that IPPM rates for home births do not appear to have improved over the study period examined, even though rates did so overall. Second, although the women who booked for home births and had their babies at home seemed to have a generally low IPPM rate, those who required their care to be transferred to hospital did not. Women who book for home births should be offered comprehensive evidence-based information about the potential benefits, risks and uncertainties associated with their choice of birthplace by the healthcare professional responsible for supporting their decision. It is of considerable concern that the data recorded nationally in England and Wales do not provide accurate information about when and why a transfer from home to hospital booking occurs and about their outcomes.
http://www.ncbi.nlm.nih.gov/pubmed/3933717?ordinalpos=27&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum
Five year prospective survey of risk of booking for a home birth in Essex.
The results of this study showed no evidence of an increased risk associated with home confinements but indicated that there were fewer problems than were encountered in the deliveries in mothers confined in hospital.
http://www.ncbi.nlm.nih.gov/pubmed/9107116?ordinalpos=34&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum
Physician- and midwife-attended home births. Effects of breech, twin, and post-dates outcome data on mortality rates.
Although the data are more than a decade old, they support the premise that outcomes for low-risk home births are comparably good whether attended by physicians or midwives. However, the findings do raise questions about the safety of attending high-risk births at home.
Jane_t
(I don't think you're a layperson at all, BTW)
The reason, we hate independent midwives is because, as a rule, they're man & doctor-hating and all of us involved in labour care, especially in London, have a long experience of their demonstrably poor standards. I can think of several examples that I've experienced that left me astonished at the lack of awareness of their negligence. See the Doc's latest post for a similar example.
The reason we're against home-birth is not because of home-birth perse. For low-risk women with good midwives near to a hospital it can be a good option. Unfortunately most women who are very pro homebirth have good reason to be afraid of hospitals - they are high risk and have had difficult experiences in the past. They are fundamentally unsuitable for home birth. Unfortunately there is a high-profit making group of midwives who will cater for these poor women and offer inappropriate choice.
Most women will get away with their gamble becuase babies are tough and built to withstand incidents. The bottom line is though that they're making a selfish gamble of their baby's life for a single day or two's experience, and are being abetted in their crime by these so-called professionals.
It's society's problem becuase society has to pick up the pieces.
You quote hospital problem births. In every study the risk of death in a hospital (despite including their large numbers of highest risk babies) is lower than at homebirth / in a birthing centre.
So, sensible homebirth is probably OK if slightly more risky. Independents are not sensible and attract distressed women who should know better but don't. In society the state makes decisions for those who cause themselves and society harm through ignorance, maliciousness and lack of judgement. Here this is happening and therefore these independents should be outlawed, as they cost lives.
jane_t - thank you for taking a moment to flag up the studies.
Research data vs personal experience, always difficult when they appear contradictory.
I've heard it said that we (humans) go mad in herds and only recover our senses one by one - am I thinking about the midwives or their detractors ?Well, I honestly don't know when it comes to the homebirth debate (or peripheral issues such as insurance arrangements, the question raised in the original post, of course).
The Dutch and Americans have a far bigger pool of indies, and I understand that they are safe clinically (according to the research evidence).
I wonder what they are doing that the indies here aren't - presumably they have all obtained insurance, at least ?
anonymous 3.50am:
Thank you for your considered and moderate response.
"Jane_t
(I don't think you're a layperson at all, BTW)"
Why do you say this? My current work involves paperwork, web site design and maintenance (our own, not for others - I'm not that good) and cleaning (not in a hospital!). I've never worked in a hospital, a GP practice or anywhere remotely medical. I've worked in the offices of a market research company, a library and a textbook distributor before my current work.
"The reason, we hate independent midwives is because, as a rule, they're man & doctor-hating and all of us involved in labour care, especially in London, have a long experience of their demonstrably poor standards. I can think of several examples that I've experienced that left me astonished at the lack of awareness of their negligence. See the Doc's latest post for a similar example."
As I've never met one it's interesting to hear from someone who regularly does. Do you report their poor standards and negligence?
"The reason we're against home-birth is not because of home-birth perse. For low-risk women with good midwives near to a hospital it can be a good option. Unfortunately most women who are very pro homebirth have good reason to be afraid of hospitals - they are high risk and have had difficult experiences in the past. They are fundamentally unsuitable for home birth. Unfortunately there is a high-profit making group of midwives who will cater for these poor women and offer inappropriate choice."
It's very sad if this is the case and another good reason to improve NHS offerings.
"Most women will get away with their gamble becuase babies are tough and built to withstand incidents. The bottom line is though that they're making a selfish gamble of their baby's life for a single day or two's experience, and are being abetted in their crime by these so-called professionals.
It's society's problem becuase society has to pick up the pieces.
You quote hospital problem births. In every study the risk of death in a hospital (despite including their large numbers of highest risk babies) is lower than at homebirth / in a birthing centre."
Please, please, please provide links to evidence. I would love to take your word for it but I don't know you or what qualifications or experience you have. If people like you provide evidence rather than opinion (it's all it is without evidence), maybe you will save a high-risk-birth mother from making the wrong choice. The type of ranting we have seen in these comments just polarise opinion, pushing people further into their corners and people are less likely to change their mind on the issue.
"So, sensible homebirth is probably OK if slightly more risky. Independents are not sensible and attract distressed women who should know better but don't. In society the state makes decisions for those who cause themselves and society harm through ignorance, maliciousness and lack of judgement. Here this is happening and therefore these independents should be outlawed, as they cost lives."
The research I've found seems to suggest that the risk is similar for low risk mothers and risk of intervention is less with home birth. You seem to be linking home birth to independents but of course many home births happen on the NHS. Please provide evidence that home birth itself is dangerous for low-risk mothers and I will change my mind.
It sounds as though you are in a position to reduce risk to future mothers and babies by reporting malpractice and negligence. How many times have you done this?
the a&e charge nurse said:
"jane_t - thank you for taking a moment to flag up the studies.
Research data vs personal experience, always difficult when they appear contradictory.
Yes, I agree but research is important. If people see a report of death or injury to a mother or baby in the paper, caused either in a hospital by NHS staff or at home by NHS staff or an independent midwife, it's important that they realise the difference. Anecdotal evidence cannot be relied upon when making important decisions, unless of course you will be receiving care from the same midwife or obstetrician!
"I've heard it said that we (humans) go mad in herds and only recover our senses one by one - am I thinking about the midwives or their detractors ?Well, I honestly don't know when it comes to the homebirth debate (or peripheral issues such as insurance arrangements, the question raised in the original post, of course)."
I'm also undecided on the home birth issue. I had a home birth with my third child but this was after two normal deliveries (though the first involved an extended 2nd stage, probably exacerbated by poor management), we lived literally 5 minutes away from the hospital and opposite the ambulance station. However, I was booked for a hospital delivery for my recent pregnancy because we are an hours drive away from the hospital. The NHS midwife seemed quite keen on the idea of home births and said they are quite common in this area but it's not a risk I would be prepared to take here.
I'm also undecided on the insurance issue. I would never consider employing an independent midwife anyway, just as I would never consider going private for other medical care, or even employ a cleaner for our house, probably a result of my working class background! It's highly unlikely that birth will ever to be a personal issue for me again so it's all an academic argument to me now (except maybe grandchildren, but not too soon I hope!). Many people have to raise a handicapped child without the benefit of a payout for negligence. I am close friends with one family and know another fairly well. It is a stuggle. They have been applying for home extensions and alterations for a wheelchair for nearly 3 years and don't seem any closer, the dates keep being moved back as the council and landlord argue about who is paying for what. I can see that a payout for negligence, even if it took a couple of years to come through, would make a massive difference to them. But balanced against that is the relatively low numbers involved.
"The Dutch and Americans have a far bigger pool of indies, and I understand that they are safe clinically (according to the research evidence).
I wonder what they are doing that the indies here aren't - presumably they have all obtained insurance, at least ?"
Yes, it would be good to know if there is any difference. I had always had the impression that midwives in America had less training than UK midwives and that obstetricians were the norm. UK independent midwives have the same initial training as NHS midwives and are also governed by the same bodies.
"As I've never met one it's interesting to hear from someone who regularly does. Do you report their poor standards and negligence?"
Yes.
""As I've never met one it's interesting to hear from someone who regularly does. Do you report their poor standards and negligence?"
Yes."
That's good to hear. Can you give me the names of some of the midwives so that I can request details of the decision made by the NMC?
Thanks
The evidence is there, this is why those people (doctors) who can understand the hints contained within the better studies, despite methodological difficulties and lack of power, are anti-homebirth.
Those who just read the conclusions, which are always bland & non-committal as scientifically required given the problems with creating true randomised trials, will not have their untutored minds opened by arguments on the internet.
The studies you link to are very poor quality, and you don't have the skills to analyse their shortcomings unfortunately.
There will be a better study along in a couple of years that will help demonstrate some more what's obvious to doctors & the vast majority of our sensible mothers and fathers, but in the meantime some babies will end up dead and maimed because of the silly decisions of some women.
Those who can't see the obvious, that a few babies will die because of accidents outside hospital, lack common sense. What a rejection, the gift of safe childbirth!
So you're saying that it's impossible for patients to make an informed choice and we should just shut up and listen to our doctors like good children? I should listen to professionals like the doctor that who told me I would bleed for 2 days after my miscarriage (it was 2 weeks) and told me to flush my foetus down the toilet. If he lacks a basic understanding of miscarriage but talks with certainty about it and can't even be bothered to read guidelines on the disposal of human tissue, do you really think he has read the studies you say 'hint' at the dangers of childbirth?
Interesting piece on unpublished research here, SAFETY OF ALTERNATIVE APPROACHES TO CHILDBIRTH, http://vbfree.org/docs/schlenzka.htm I'm reading the full dissertation at the moment and find this comparison between the natural birth methods used by Odent in Pithiviers to US hospitals interesting. All maternity patients attending the public hospital in Pithiviers were included in these figures, so it covers all levels of risk because high risk pregnancies were not screened out. This allows a direct comparison with US hospital figures. Odent introduced the concept of “the undisturbed birth” and ruled out any oxytocin for induction or augmentation of labor. The protocol had no place for routine or elective analgesia or epidurals. There was no use of forceps, just vacuum extraction. When the midwives could not manage the complications, the surgeon Odent stepped in.
Here are the figures in %, first figure for Pithiviers, second for US hospitals:
Ultrasound - 0 63.9
Induction - 0 16.9
Augmentation - 0 16.9
Fetal monitoring - 0 82.5
Analgesia - 0 missing
Epidural - only for cesarean 60.0
Episiotomy - 6 43.1
Cesarean - 6.6 20.7
Forcep - 0 3.2
Vacuum - 5.2 6.2
Infant transfer to Neonatal care 1.5 missing
Perinatal Mortality - 0.71 1.08
He concludes from these figures:
"From all the above data we conclude that there seems to be sufficient evidence to suggest that when low-risk women in the United States choose to have their birth managed by an obstetrician/physician, they subject themselves to a significant probability of unnecessary obstetric interventions. The next chapter suggests that these interventions might not just be unnecessary but to a large degree ineffective or harmful."
Enkin seems to be a well respected researcher connected with the Cochrane project. He summarizes the Cochrane project's position as follows:
"As technical advances became more complex, care has come to be increasingly controlled by, if not carried out by, specialist obstetricians. The benefits of this trend can be seriously challenged. Direct comparisons of care given by a qualified midwife with medical back-up with medical or shared care show that midwifery care [the natural approach to childbirth] was associated with a reduction in the range of adverse psychosocial outcomes in pregnancy, and with reductions in the use of acceleration of labour, regional analgesia/anaesthesia [epidural], operative vaginal delivery, and episiotomy. No differences have been demonstrated in the rates of labour induction, pharmacological analgesia, or caesarean section. Midwifery care also resulted in fewer babies weighing less than 2500 grams, needing resuscitation, or needing admission to special care units.
and he concludes:
It is inherently unwise, and perhaps unsafe, for women with normal pregnancies to be cared for by obstetric specialists, even if the required personnel are available (Enkin et al. 1995, p. 15)."
It sounds as though much more research needs to be carried out into interventions in childbirth. The benefits of a medical approach compared to a natural approach certainly don't seem as clear cut as some here seem to believe. The transfer of births of low-risk mothers from home to hospital was NOT evidence based.
"and told me to flush my foetus down the toilet."
So this is why you're here. You have issues surrounding medical advice and loss of control. The vast majority of miscarriages settle in a day or two. Yours didn't - so your doctor was wrong. He wasn't - he was giving you a likely outcome. Even most women with very late miscarriages go home the day after, the bleeding having settled. And what do you think most women do when they have a miscarriage at home? Where do you think it goes? Do you think they come in to the hospital with the products? Why are YOU so out of the ordinary. Why do you think that your amateurish googling of irrelevant and useless "research" studies will change the minds of people who have dedicated their professional lives to these issues of safety, and have had independent midwives bring in situations beyond belief. You lack any sort of judgement on these issues and have significant problems and really need to let the past go.
anonymous 8.10am
"and told me to flush my foetus down the toilet."
So this is why you're here."
No, I was here before and while it happened.
"You have issues surrounding medical advice and loss of control. The vast majority of miscarriages settle in a day or two. Yours didn't - so your doctor was wrong. He wasn't - he was giving you a likely outcome."
Wrong again. I rang him to tell him that I had had a miscarriage. I'm not sure what you mean about loss of control?
"Even most women with very late miscarriages go home the day after, the bleeding having settled. And what do you think most women do when they have a miscarriage at home? Where do you think it goes? Do you think they come in to the hospital with the products? Why are YOU so out of the ordinary."
I had an earlier miscarriage a few years ago and the GP came out, checked I was OK and took the foetus away. This was after a miscarriage that seemed much like a heavy period, so not that traumatic apart from the loss of a baby. This time I was given no guidance on what to expect or what was normal. It happened at home and it was late enough for me to go through a form of labour, with contractions over 8 hours that needed breathing through towards the end, waters breaking, lots of blood, etc. I passed a tiny, perfect baby. I could see the outline of it's head and back through the amniotic sac and it's little legs and feet sticking out of the bottom. Do you really think it's OK for a doctor to say I should flush it down the toilet with the turds? If he had any idea of what a 12+ week foetus looks like he must have known it looked like a baby.
I Googled then too, to find out what was normal and what I should do because I hadn't been told by the medical profession. All of the information says to save what you lose so that the medical profession can check that it's all there. There are dangers involved with retained products of conception apparently. When I asked what to do with the foetus it was because of this information. The nurse at NHS direct who called the doctor seemed to expect him to come out and check me too. Luckily it's three weeks later, everything is fine and I've had no problems with infection, etc. The bleeding lasted 2 weeks in all which, according to Google, is normal. If I'd believed the doctor I would have been worrying that something was wrong. In case you're interested, we buried the baby/foetus in the garden.
" Why do you think that your amateurish googling of irrelevant and useless "research" studies will change the minds of people who have dedicated their professional lives to these issues of safety, and have had independent midwives bring in situations beyond belief. You lack any sort of judgement on these issues and have significant problems and really need to let the past go."
The medical profession supposedly relies on these useless research studies, it's called evidence based medicine. I would rather rely on research than GPs who has made obviously incorrect statements with conviction; coeliac disease is not linked to type 1 diabetes, some children grow out of type 1 diabetes, women who have miscarried will bleed for two days, etc. A simple Google search will prove all of these are incorrect. I have asked the medical profession taking part in this discussion for evidence that home birth is dangerous. As you imply, I would be stupid just to take their word for it, I don't know them or their qualifications, etc., but no evidence has been given.
Why are you so upset and wound up by this, by the way? You seem to feel very strongly that I should trust these 'dedicated professionals' who I don't know and may be shop assistants for all I know. You seem to think I should ignore the evidence of people who are interested enough in the subject to carry out and publish research. Presumably we can be certain that they are qualified doctors of a reasonable standing or they wouldn't have been able to carry out the research in the first place? I'm obviously not talking about the unpublished dissertation here before you bring that up, but I expect he has had training in collating and interpreting data which is all he did and which anyone can check for themselves.
The fundamental problem comparing home births with hospital births is that we are not comparing like with like, even if we use the fairly simplistic dichotomy of 'low' and 'high' risk patients the effects of patient and health professional selection mean that we are not comparing two similar groups - if we add to this the frankly poor nature of many of the studies into this area then sadly claims one way or the other are hard to substantiate. Of interest a recent study in the British Journal of Obs and Gyn http://www.blackwell-synergy.com/doi/full/10.1111/j.1471-0528.2008.01669.x
showed that those who are transfered to hospital having planned to have a home birth have a higher perinatal infant mortality - the study again isn't perfect, but it does fit with the thought that delay in accessing medical care leads to mortality.
The only real way to settle this would be to conduct a randomised trial, but that is simply not feasible.
Thank you, angry gasman, a calm post and a link to research - at last. BTW, the link didn't work but I think I found the right research by searching for 'home birth'. I am assuming you mean this study, 'An estimation of intrapartum-related perinatal mortality rates for booked home births in England and Wales between 1994 and 2003'. Please correct me if I'm wrong.
The problem I have with their figure for 'transferred to hospital from home', is that first of all it's an estimate (with quite a wide range of possible estimates given), and also that it doesn't say when the transfers happened. As far as I can tell it would include a transfer to hospital care a week after a home birth was booked. It certainly doesn't mean transfers during labour. I would expect a higher IPPM in this group because it will include mothers transferred to hospital care before labour for signs of problems like pre-eclampsia, breech presentation, down symdrome or spina bifida, etc. This is what they say about the transfer to hospital figures:
"Unintended home birth rates and transfer rates were taken from studies previously conducted in England and Wales. The range in these rates is large, and this implies that the studies applied different definitions of transfer and unintended home birth rates. However, the details of the definitions were not available. There were insufficient adequate reports to obtain more precise estimates for these rates, and they were considered the best available."
"Thus, although those women who had intended to give birth at home and did so had a generally good outcome, those requiring transfer of care appeared to do significantly worse and indeed had IPPM rates well in excess of the overall rate. It is not possible to tell from the available data when transfer occurred, that is during pregnancy or at labour onset."
The IPPM of planned, actual home birth was lower than the overall IPPM (0.48 compared to 0.79), but this is to be expected because of selection bias (high risk mothers are steered towards hospital), so we cannot draw much information from this figure.
They conclude:
"There are two main concerns. First, no improvement in the IPPM rates in booked home births was observed, whereas overall IPPM rates did appear to improve. Second, women who booked a home birth but required transfer had relatively high IPPM rates. This needs to be evaluated and investigated further.
"It is vital that data are collected prospectively so that an accurate picture can be established of both intended and unintended home birth rates, together with a clear indication about when and why a transfer to hospital care occurred. The fact that reliable data are not currently available to inform a key health debate is a matter of great concern."
This seems a reasonable analysis and confirms my impression of the current situation. Basically, they don't really know for sure and more research is needed. However, I don't think home birth can be as obviously dangerous as so many here seem to believe or the research that has been done so far would have picked this up.
Dr C said:
"Following numerous comments and emails, I sent details of Kent Midwifery Practice to Helen O'Dell who is the Midwifery Officer for South East Coast Local Supervising Authority... I have therefore also sent copies of the email to the NMC."
Thanks.
"Using a single example to write off a whole group again. Anyone can do that but it doesn't really prove anything:"
"So you're saying that it's impossible for patients to make an informed choice and we should just shut up and listen to our doctors like good children? I should listen to professionals like the doctor that who told me I would bleed for 2 days after my miscarriage (it was 2 weeks) and told me to flush my foetus down the toilet. If he lacks a basic understanding of miscarriage but talks with certainty about it and can't even be bothered to read guidelines on the disposal of human tissue, do you really think he has read the studies you say 'hint' at the dangers of childbirth?"
Jane, dear, pot and kettle? Aren't you just writing off the medical profession's abilities to analyse evidence and the training to know when to apply it just because you didn't like one of them?
Hmmm?
Dr.JaneDoe said...
Jane, dear, pot and kettle? Aren't you just writing off the medical profession's abilities to analyse evidence and the training to know when to apply it just because you didn't like one of them?
Well, I've said I'm not posting more on the home birth topic (I've covered your points in previous posts, anyway), but this is about my reasons for asking questions.
I liked the doctors, well, not sure about the one in the example you quote, but then I didn't meet him, he was just a voice over the phone, he may be very nice in person, but the others were certainly all very nice, it was just some of their knowledge that was suspect (did you read the other examples). I'm sorry if I've given the impression that I hate doctors, I get on fine with them in person.
I don't doubt they have the skills to understand and analyse the studies and guidelines, I just doubt they read them. Being reasonable, it would be impossible for a doctor keep up with all the research and guidelines for all the conditions they are involved in treating. And it would be unreasonable for me to ask my doctor to look into it specially for me. How many 10 minute appointments would that take? Many patients with chronic diseases or their carers know more about their condition (and in particular, how it works in them) than many doctors.
I don't feel like this because of one experience with one doctor, that would be stupid. It's happened over time and certainly, in my younger days, I believed every word they said. The personal examples included about 5 or 6 different doctors, the diabetic problems I've mentioned includes most children's diabetic clinics in the UK and most GPs. As a simple example, most children's diabetic clinics do not teach carbohydrate counting. We are lucky with our current consultant as he is very interested in current research and interested in learning more. They have even begun to teach carb counting in our clinic recently. But if we hadn't taught ourselves carb counting 7/8 years ago, my children's future health prospects would be much, much worse than they currently are.
We have to take responsibility for our own health. It's important to listen to our doctors, and it's the only reasonable thing to do in an emergency situation, but if there's time, why not educate ourselves if it's going to improve our future health?
The difficulty is often in sifting through the good and bad sources of information. I look for known reliable sites, Mayo, PubMed, NHS sites, BMJ, etc, I look for overviews of the condition first, then I tend to look for guidelines produced by the appropriate specialists organisations as they will have taken the research into account and will have the knowledge to analyse it correctly. I will then look at research overviews before looking at individual studies. I give preference to large, double blind studies, etc, etc. Then I might ask my doctor if he thought something is appropriate in my situation, though I'm more likely to say something if it's about my children. If it's for me, I'm more likely to just go along with what the doctor says unless I feel very strongly that they are wrong.
My argument is that it has more to do with economies of scale. With only about 150 independent midwives and the possibility that a single claim could run to millions, it's just not cost effective to offer the insurance even if their risk is identical to NHS midwives and obstetricians.
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