The Independent Midwives of Kent
One of the many commentators under Madwife goes for a swim says the following:
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.That is correct. Let me explain why. To do so, I am going to take you through a birth supervised by the Kent Midwifery Practice, which is run by aquanaut Virginia Howes. I would not normally comment on a real case in a public forum, but this case is prominently and proudly displayed, under the title
on the front page of the Kent Midwifery Practice website. Apologies in advance for the length of this post but it would not be fair only to quote extracts. I therefore print it in full, with all the grammatical mistakes. It is entitled “Sharons Birth Story”. I am sure that the use of apostrophes is not part of midwifery training but you would have thought they might do better on an important promotional website. I do not know which midwife was taking responsibility for this birth, so we will call her “Mary”. A second midwife, Kay, was also present. Presumably this is Kay Hardie.“Unusual normal birth stories”read the amazing story of the 12 pound baby born at home.
Since I published this article, Sharon's story has mysteriously disappeared from the Kent Midwifery Practice website. I have already printed it verbatim below and fortunately the original story as seen on the website is still available from Google cache here. It is not easy to rewrite internet history. (Saturday 3rd May 2008)Sharons Birth Story
I remember the first words I heard when Sharon rang me at the beginning of her pregnancy “I would like a home birth but my husband wouldn’t like it”. Well I hear that a lot and feel that is only a minor hurdle to cross. If a woman really wants a home birth then getting husband on board is usually easy. I went to visit Sharon and Paul and gave them a DVD of another client of mine who had recently been featured on the Home Birth diaries series on the Discovery Channel. I chatted to them about the safety of home birth, risk factors and Sharon’s previous 3 hospital birth.
Sharon and Paul felt that the births of their first two daughters although medicalised, with induction of labour, continous monitoring, episiotomies, managed third stage etc were ok, but the birth of their last daughter and then the poor treatment they received during a late miscarriage made them loose their faith and belief in the local NHS maternity services.
We had hours and hours of discussion. Sharon had so many questions. We discussed every aspect of normal and abnormal birth. We discussed the whys and wherefores, the if and might be of every test and possible happening imaginable. We discussed the medical model of care, the history of childbirth even evolution and natural selection. Sharon was taking an anatomy and physiology course and so the physiology of birth was of great interest to her. Sharon was like a sponge and soaked up everything we discussed. I never at any time felt that Sharon was not making a truly informed choice about any aspect of her care.
At 34 weeks I concluded that once again Sharon was growing a large baby and had gallons of liquor on board. The baby was also breech.
As the story progesses, note Mary’s eclectic use of the word "medicalised". Medical procedures are only OK when carried out by Mary.Sharon had birthed 3 big babies; the largest was the second baby at 9lb 13oz. The third baby had been induced at 37 weeks following a diagnosis of polyhydramnios and an estimated weight of nearly 10 lbs. The actual weight at birth was 9lbs. There had never been any diagnosis of diabetes or any other maternal or fetal problems.
We don’t know the maternal age, but already we do know this is not a normal risk pregnancy. Three previous big babies and an induction at 37 weeks for polyhyrdamnios.We deduced that Sharon therefore grew big babies as normal for her. We decided that we would expect a big baby and not be concerned. Easier said than done during the first trimester!!
A gauche way of confirming the obvious and yet glossing over the dangers of large babiesAll went well. Ultrasound scans and routine bloods all showed a normal pregnancy.
Already Mary is “medicalising”. Ultrasound and blood tests. There is no test that shows a normal pregnancy.Sharon had some episodes of dizziness that were unrelated to anything.
Mary is a doctor now. Does she know the differential diagnosis of dizzyness?Her observations and haemoglobin all remained normal and the dizziness stopped with rest. I continued to advise her about diet and encouraged her to reduce her carb intake and increase her protein, calcium vitamins etc.
We had hours and hours of discussion. Sharon had so many questions. We discussed every aspect of normal and abnormal birth. We discussed the whys and wherefores, the if and might be of every test and possible happening imaginable. We discussed the medical model of care, the history of childbirth even evolution and natural selection. Sharon was taking an anatomy and physiology course and so the physiology of birth was of great interest to her. Sharon was like a sponge and soaked up everything we discussed. I never at any time felt that Sharon was not making a truly informed choice about any aspect of her care.
At 34 weeks I concluded that once again Sharon was growing a large baby and had gallons of liquor on board. The baby was also breech.
Now we are moving into high risk territory. Large baby and GALLONS of liquor. In other words, polyhydramnios again. The lie of a baby is not easy to determine when there is polyhydramnios, and in a fourth pregnancy a breech at 34 weeks may well turn spontaneously. But it is a large baby. Does Mary know where the placenta is?We discussed a scan and other investigations and Sharon declined as she wanted to stay away from the hospital as much as possible in order not to “open a can of worms” (her words) as had happened before.
So, no scan. We don’t know where the placenta is. We don’t know if the polyhydramnios is caused by foetal abnormality.I asked my partner Kay to visit Sharon at 36 weeks to assess presentation and overall health. I had always visited Sharon in the calmness of morning when the children were at school however Kay’s visit was in the evening on a particular stressful day. It was not surprising therefore that Kay found Sharon with an elevated blood pressure. She was also unsure of the presentation and therefore a referral was made to the local hospital.
Ah! So, now we are going to open the “can of worms” and do a little medicalising. Better late than never, but it is late. It may not be suprising that Sharon’s BP is raised but that does not mean it is not significant. I wonder if she had protein in her urine?While at the hospital Sharon had blood taken to assess for pre-eclampsia as we expected.
Why had Mary not already taken a blood test if this is what she expected?”However they also had her previous history did a blood glucose which was normal.
Mary should have checked Sharon for diabetes already on this historySharon had taken our notes with her and so the midwife who cared for her could read them and was well aware of the amount of discussion we had over the previous weeks. Despite this midwife felt the need to shroud wave and talk about the risks of big babies and advise against a home birth. She said that babies who have large volumes of liquor needed to be in hospital in order to be suctioned. In fact she went on so much that in the end Paul had to tell her to be quiet as she was upsetting his wife!
So, warning a mother with a now high risk pregnancy of the dangers of large babies and polyhydramnios is “shroud waving”. Has Mary considered that an experienced hospital midwife, reading Mary’s notes, might have been anything but reassured?I happened to call the hospital to find out how Sharon was and the midwife caring for her spoke to me. She said that Sharon’s bloods were normal but they had advised her to stay as she was “tightening”. I think I laughed and said I hardly think that was a reason to keep a woman in hospital especially in view of the fact that she was having a home birth and it was probably Braxton Hicks contractions anyway.
Let’s think about that. A mother in her fourth pregnancy, with a huge baby whose head (on the history) is probably not engaged, with polyhydramnios starts to get contractions. Has Mary not heard of prolapsed cords? Does she not know anything of the dangers of polyhydramnios? They probably were Braxton Hicks contractions, but Mary was not on site palpating Sharon’s abdomen, she was on the telephone. Why will she not take advice from a colleague who is with the patient?The midwife then went on to tell me she had looked up Sharon’s history and between baby 1 and baby 2 an incidental swab had detected group B strep and therefore they recommend a hospital birth with IV antibiotics. I quoted the Green Top guidelines to her that this was not a risk factor and said Sharon had not had IV antibiotics during her last labour.
Very controversial area this. Take a look at the Green Top guidelines from the RCOG. Mary is right that, on this history, it is not currently recommended in the UK that the labour is conducted under antibiotic cover. The practice in other countries is different. It is a difficult area. What is indisputable however is that the previous history of beta haemolytic strep, incidental or not, should not be ignored.Later Sharon told me that the same midwife had tried to undermine her confidence in me by asking Sharon if “her midwife” knew what to do if her baby’s shoulders got stuck. She also scared them about cord prolapse.
Shoulder dystocia is scary. It makes doctors concentrate. Remember we are dealing with a huge baby, which makes the possibity of a difficult delivery all the more likely. I would be scared of cord prolapse too. In a home environment it is a likely death sentence for the baby. Regular readers will recall the tragedy of the midwife whose own baby had a cord prolapse at homeShe “informed" Sharon and Paul that I practice without insurance.
Why is the word “informed” in inverted commas?The insurance issue is something I discuss at the consultation visit long before I book clients and so they were fully aware of all the issues.
Who knows what goes on in these “long consultations” but I somehow doubt that a mother with no medical training can really understand all the issues. Maybe Sharon did.I was very offended by the midwifes comments and angry at her scaremongering. I wrote to her asking for an explanation, quoted our Code of Conduct about respecting our colleagues and asked for an apology. I did not get an answer.
But Mary, you have already made serious disparaging remarks about your colleagues management of the patient and accused her of “shroud waving”. Respect is a two way trackSharon stayed in overnight and had a scan the next day. The baby was cephalic and an estimated weight showed between 8-9 lbs her blood pressure settled and she came home. She was asked to return for a consultant assessment and GTT test which she declined.
And did Mary support this advice? A high risk pregnancy like this should be assessed by a consultant obstetrician.She accepted however a repeat scan one week later which estimated the fetal weight as between 9-10lbs. They also diagnosed polyhydramnios. No surprise there then! The baby was cephalic with the head deep in the pelvis. The Sonographer concluded no abnormality seen to account for the increased fluid. A second opinion agreed and concluded that it was probably due to the size of the baby alone.
OK. So far so good. No evidence of foetal abnormality is a great relief. Note it took two ultrasound specialists to arrive at that conclusion.Despite the reassurance that all was normal and despite me knowing that 40% of babies with shoulder dystocia are less than 4 kg I could not stop all the shroud waving of that hospital visit having an effect on me and against my usual practice I suggested membrane sweeps prior to 40 weeks to encourage labour and planned to ask Kay to attend the birth.
I don’t understand the first sentence. Is Mary saying that 60% of shoulder dystocias are in babies weighing more than 4Kg? And this is not “shroud waving”. It is appropriate medical concern for a high risk pregnancy. Mary seems to be getting frightened now. She starts trying to induce the labour even though that is against her beliefsA membrane sweep on the due date had the desired effect and Sharon called me to report ruptured membranes 24 hours later.
Most doctors would prefer a women at term in a fourth pregnancy with a huge baby and polyhydramnious to be in hospital for any sort of manoevure that might induce labour. The baby’s head may well not be fully engaged and the rush of fluid from the polyhydramnios can bring an umbilical cord down.She laboured normally and well. She asked me to examine her after 5 hours and again against my usual practise I agreed. Normally I would reassure women that this was an intervention unproven in its benefits but that shroud kept rearing its ugly head and influencing my practice.
Dear God. She has not checked even once to make sure there is not a complex presentation.Sharon was 8 cms and the head was low. A couple of hours later and Sharon was pushing. The head was large and Sharon was having difficulty pushing it out underwater and so I suggested she stood up for gravity to help. This was all it took and the head was born. The body was born with the next contraction with absolute ease. However because she was now standing in the pool I had to lean over the pool to catch the baby. As the baby rotated I called Kay closer to help I said “don’t worry the shoulders are free I just need help in case I drop it”! Both of us caught this huge beautiful baby girl and passed her to her brave confident mum.
The story does not end there.
Forty minutes later Sharon birthed the placenta with quite a huge blood loss. All was well at this point so we all went into the lounge and Sharon breast fed her baby.
An extraordinary story. Mary’s management of Sharon’s labour was idiosyncratic and ignored a lot of standard medical practice. It gets worse. Had Sharon died at home of a post-partum haemorrhage, the fact that Mary had “lost” her BP machine might well have turned a civil case into a criminal charge of manslaughter.
But there is something even more extraordinary about the story. Mary’s blithe, gauche attitude to normal medical practice. She will not even take advice from her hospital colleagues. Experienced NHS midwives will be as horrified by this story as am I. We can all at least now understand why insurance is a problem.
Forty minutes later Sharon birthed the placenta with quite a huge blood loss. All was well at this point so we all went into the lounge and Sharon breast fed her baby.
All is not well. Sharon has had a “huge blood loss” after a difficult delivery of a very large baby. Has Mary taken any action? Has she even checked Sharon’s BP? Seems not. Please call an ambulanceShe had not breast fed any of the others and really wants to succeed this time. About an hour after her birth Sharon had another large blood loss and felt slightly clammy so I lay her down on the sofa gave her some syntometrine and looked for my blood pressure cuff. It was no-where to be found! I had it during labour but now it was lost.
The story is now moving from idiosyncratic to dangerous. There are two midwives present (remember, Kay is there as well) treating a woman with a serious post partum haemorrhage who is showing signs of shock. Two midwives and no BP machine. Please, please call an ambulanceTo date on day 3 it is still not located. I was concerned that I might have a woman who was compromised and so I called a paramedic.
Finally, Mary sees sense. Her patient is indeed compromised. She has had a post partum haemorrhage, she is clammy and Mary is not able to take her BP. So she dials 999.They arrived within 3 minutes and were the best guys I have ever met in the job. They got their BP machine which recorded observations at 5 minute intervals. Sharon’s observations were all normal. She then vomited and at the same time passed a huge amount of blood and clots.
The post partum haemorrhage continues and Sharon now vomits. She is critically ill and needs to be in hospital. PLEASE take her to hospital.I felt it was appropriate to give ergometrine IM and commence 500ml gelifusin and then 1000 saline.
Mary is now putting up a drip, giving plasma expanders and normal saline. One and a half litres in total. Over what period of time? Did she take blood for a group and cross match? I doubt it. Sharon needs to be in hospital. Please please take her to hospital.Sharon felt fine and all her observations were fine. The Paramedics remained for nearly 2 hours. They helped without taking over and were a pleasure to have around.
We have to take Mary’s word for the fact the Sharon now felt fine. A high dependency para-medic ambulance has now been tied up for two hours. I am sure the paramedics did not want to take over. I am sure they stayed as they realised the gravity of the situation.I felt that Sharon did not really need to transfer and instinctively felt that the large loss which in all I estimated at 1500mls was due to the large placental site and yet again normal for her as she was not compromised.
Bonkers. Utterly bonkers. Nothing more to be said on that.However having discussed it with my supervisor I transferred her. I think covering ones behind was discussed!!!
Is Mary frightened by now. Why else would she call her supervisor? Thank goodness she did.When we arrived the same midwife was on duty and Paul quite firmly ordered her out of the room! Sharon was then cared for by a lovely midwife. However yet again that medical model reared its ugly head and they wanted to do tests on the baby. Blood sugars and IV antibiotics!
The "lovely midwife" wanted to do tests on the baby, such as blood sugars. Mary does not approve so once again it is the pejorative “medical model”. It is indeed the medical model. Checking the blood sugar on a new born 12 pound baby is entirely sensible.Sharon declined and stated that she had come in to be checked over not the baby and please hurry up as she wanted to go back home. She was all perfectly normal with a well contracted uterus, normal observations and lochia. She had a couple of hours of syntocinon as a precaution and then we all went home.
The way Mary glosses over standard medical treatment is breathtaking. Why was Sharon’s uterus now contracted down? Two hours of i.v. syntocinon might explain it.She has a haemoglobin of just under 10 (so probably a bit lower in reality) but is feeling great and tucking into steak and broccoli. Her big beautiful baby is named Tulah and weighed in at a whopping 12lbs. Tulah is feeding on demand 3-4 hourly. Perfect. Sharon is giving up having babies now.
+++++++++++
An extraordinary story. Mary’s management of Sharon’s labour was idiosyncratic and ignored a lot of standard medical practice. It gets worse. Had Sharon died at home of a post-partum haemorrhage, the fact that Mary had “lost” her BP machine might well have turned a civil case into a criminal charge of manslaughter.
But there is something even more extraordinary about the story. Mary’s blithe, gauche attitude to normal medical practice. She will not even take advice from her hospital colleagues. Experienced NHS midwives will be as horrified by this story as am I. We can all at least now understand why insurance is a problem.
Private midwives have been working without indemnity insurance since 2002, when the last company willing to provide cover pulled out. Despite this, their numbers have grown from about 40 in 2002 to 200 at present, with up to 4,000 babies a year delivered privately. (The Times)But is seems the lack of insurance is only a problem for the patients and the babies. The independent midwives exibit "la belle indifference". Annie Francis, spokeswoman for the Independent Midwives’ Association said:
“Most clients understand you can’t insure against things going wrong during childbirth, only against negligence, and negligence is not really an issue for us”
That's all right, then.
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: independent midwives, Kent midwifery practice, madwives
201 Comments:
You can always tell when a delivery is starting to go tits-up. It's when "my client" magically becomes "your patient".
This poor woman, who has been woefully managed by the midwitches should have been in hospital from the outset. I'm suprised that she even had a Venflon in.
There are no obstetricians, paediatricians, anaesthetists, ODAs, blood bank or anything at home for that moment when your "client" doesn't play by the rule book and ends up being a "patient".
They spend 3 years training to monitor an entirely normal process only to f**k it up when something happens.
Dangerous. Very dangerous.
Hi - you need to do a proof read of your comments if you are to critisize their grammar. I spotted a forth instead of fourth and a too instead of two.
Good stuff though.
OT, sorry; anyway; shortage of junior doctors, not MMC/MTAS related -- insofar as I can tell:
http://icwales.icnetwork.co.uk/news/wales-news/2008/05/01/hospitals-hit-by-junior-doctor-shortage-91466-20846958/
Claire said...
Hi - you need to do a proof read of your comments if you are to critisize their grammar. I spotted a forth instead of fourth and a too instead of two.
Hi Claire - you need to do a proof read of your comments if you are to critisize their grammar. I spotted a critisize instead of criticize ....
Glass houses / stones ?
As an experienced NHS community midwife there is no way I can endorse Mary and Kay's actions. The patient was clearly high risk from the start and not suitable for a home birth. As you say, John, Bonkers.
L.
Leicester
So one bad example proves they're all bad? That rules out the NHS for deliveries then since there are hundreds of bad examples, many of them actually ending in death or injury to mother or baby. Not very scientific for a doctor.
claire said...
Hi - you need to do a proof read of your comments if you are to critisize their grammar. I spotted a forth instead of fourth and a too instead of two.
Good stuff though.
+++++
I am well rebuked. In mitigation a "forth" for a "fourth" and a "too" for a "two" are more typos or spelling mistakes than grammatical errors; and I am writing a blog, not design a web site to sell things. And I had to mention the fact that the madwive's copy is riddled with errors or I would have been accused of sloppiness.
But, mitigation, not an excuse. A prick in the balloon of pomposity.
So I will forgive your criticise with a "z". You probably have an American spell checker
John
jane_t said...
So one bad example proves they're all bad? That rules out the NHS for deliveries then since there are hundreds of bad examples, many of them actually ending in death or injury to mother or baby. Not very scientific for a doctor.
Thursday, May 01, 2008 7:06:00 PM
+++++
Oh dear, JaneT, you don't get it, do you. These Kent Midwives are holding themselves out to be paragons of obstetric virtue.
Yes, lots of mistakes in NHS obstetrics. BUT everyone is properly insured, so at least anyone sustaining damage will get proper compensation. You won't get that from the independent madwives. Sue them, and they just go bankrupt and walk away.
What I would like to see the the Royal College of Midwives stepping in to stop these absurd practitioners. A doctor behaving like this would be up in front of the GMC before you can say writ.
Finally, if you are right, we can expect lots of independent madwifes to write in and say that they don't agree with "Mary's" management.
Don't hold your breath
John
"Yes, lots of mistakes in NHS obstetrics. BUT everyone is properly insured, so at least anyone sustaining damage will get proper compensation. You won't get that from the independent madwives. Sue them, and they just go bankrupt and walk away."
Oh dear, John,
I've never said that I agree with midwives practising without insurance.
"Finally, if you are right, we can expect lots of independent madwifes to write in and say that they don't agree with "Mary's" management."
If I'm right about what?
They would have to read this blog to be able to respond. There are only about 150 of them, after all. Probably best not to hold your breath.
I helped our MP deal with a case where a local woman delivered in our local DGH Maternity Unit, she was left physically and mentally permanently and severely damaged by kackhanded intervention, in a wheelchair for life etc, her husband had to give up work to look after her, the older child and the new baby and it took more than 5 years of endless fighting and persistent effort to get proper compensation from the NHS.
To be fair, the RCM did withdraw insurance from independent midwives. The NMC, though, failed to finish them off by making insurance a requirement for registration -- I take it the Government's new guidelines, in effect, do that.
(My 'finish them off' is not a personal attack on these women, it's an objection to their working for fees but relying on the NHS for various tests etc.; of course, they aren't the only such practicioners in the UK)
Jayann,
Surely it's the mother's that are making use of the NHS and they have paid for that benefit with their taxes? If the midwives had to pay for the tests themselves the cost would just be passed on to the customer.
The midwives argument is weak.
Just because there is demand for it, doesn't mean the taxpayer should subsidise it.
There would probably be a demand for cheap hernia ops at home done by nurse practitioners, some people are stupid.
The government should tell them to swivel.
I don't know anything about giving birth, but I do know a thing or two about critically ill patients.
I'm not sure what to make of this blood loss. If it was 1500ml, then surely that combined with the diluting effect of 1500ml IV fluid, would have led to a Hb drop to well below 10? This has certainly been my experience in ICU/A&E. So it seems someone's overestimating either the amount of blood loss or the Hb.
Loss of the sphyg is concerning, although shouldn't have made a difference. A drop in BP is a very late sign of shock, and one would hope that other factors (such as tachycardia, tachypnoea, prolonged CRT, dizzyness, paleness, coldness, clammyness, nausea etc.), combined with a good history of a major bleed (which this patient clearly had), would trigger the midwife to realise that the patient was critically ill. At this point, hospital (IMHO) is the only way to go, regardless of the blood pressure.
So, from a critical care nurse's point of view, not great. I don't feel qualified to comment on the management of the labour overall, but if you think it was so concerning, why do you not send the midwife's account in the direction of the NMC?
jane_t, yes, I agree; but normally if a patient chooses a private practicioner, they pay for tests.
-- this annoyed me:
"Bloods tests were taken as planned but a community midwife wasn’t forthcoming so we had to ring round for a taxi to take them to the hospital.
---
Virginia and I were angry about this and felt we were being bullied and speechless that Jane had had to pay £30 for a taxi to take her blood tests to the hospital as a midwife couldn’t come to collect, yet it was ok to send a midwife now with an instruction letter after the event!"
http://www.kentmidwiferypractice.co.uk/2006/birthstories/janebykay.htm
I hope it's clear I object to all instances of private practice being parasitic on the NHS (while also seeing it as pretty inevitable given the system we have now).
Scary scary stuff John!
Hi jayann,
Plenty of people pay for an early consultation with a specialist but then go on to have the treatment on the NHS. This obviously saves the NHS money but they also probably jump ahead of others, which is another issue of course. I can't see what's wrong with using the NHS after paying for consultations or some of the treatment privately. It saves the NHS money and the patient is entitled to use the NHS anyway. How are they parasitic on the NHS when the patient is entitled to get all of their treatment on the NHS but take less?
Thirteen years ago my youngest son was born. He - like the baby referedto was a huge (13lb) baby. He was born (section) in hospital and frankly I feel my wife would have died if she had she had been anywhere else. Following the birth she had a massive postpartum bleed which required an immediate transfusion and intense care. Please stop these dangerous lunatics.
Absolutely appalled especially by the whole IV infusions part.
Dealing with a lot of acute surgical patients and traumas the big thing i was taught from day one was that you should only use Gelo as a stop gap to transfusion. Gelo breaks down within 30mins, you give it to cover the period in which you crossmatch some blood units.
But the community madwife didn't go to that session.
What really blinkers me is how completely disrespectful and blase she is about the opinions of the hospital midwives.
Fact is the hospital midwives see more cases in a month than she probably does in a year. THey also see the ones that do go wrong, and benefit from greater support (and ergo teaching) by both other midwives and senior obstetricians.
The sheer arrogance is mindboggling.
OT: Is Labour abolishing illness?
K
anonymous said...
I helped our MP deal with a case where a local woman delivered in our local DGH Maternity Unit, she was left physically and mentally permanently and severely damaged by kackhanded intervention, in a wheelchair for life etc, her husband had to give up work to look after her, the older child and the new baby and it took more than 5 years of endless fighting and persistent effort to get proper compensation from the NHS.
Thursday, May 01, 2008 7:32:00 PM
++++
Sad, interesting and irrelevant to the question of the questionable practices of some independent midwives
John
anonymous said...
I helped our MP deal with a case where a local woman delivered in our local DGH Maternity Unit, she was left physically and mentally permanently and severely damaged by kackhanded intervention, in a wheelchair for life etc, her husband had to give up work to look after her, the older child and the new baby and it took more than 5 years of endless fighting and persistent effort to get proper compensation from the NHS.
Thursday, May 01, 2008 7:32:00 PM
++++
Sad, interesting and irrelevant to the question of the questionable practices of some independent midwives
John
jane_t, I know people see consultants privately first then jump the NHS queue, and I am opposed to that.
How are they parasitic on the NHS when the patient is entitled to get all of their treatment on the NHS but take less?
they are parasitic in that they could not practice their (fee-based) practice without the NHS. They are no more parasitic than many others, but still, they are parasitic.
Well said Anon re the abolishing illness! Come on now "DR?" C - it is National Blogging Against Disablism day today - look the word up carefully and do not be rude or the people who know about illness eg not you will be there to read and comment and publish the comments of a "DR" as widely around the world as they can!
Interesting again that you moan abut your "colleagues"! What sort of job do you really have? A stay at home search of how to be rude on a blog one? !
This account beggars belief, I'm not a midwife or a madwife. I am an ex-A&E senior nurse and I would have been very concerned at this amount of blood loss in a patient whom I could monitor carefully in a resuscitation room. To allow this woman to bleed to this extent, without immediate removal to hospital is lunacy, sheer, swivel-eyed lunacy. No wonder these wretches can't get insurance.
By the way, like the use of the term 'ultrasound specialists' to describe sonographers. Not going soft on quacktitioners are you?
Or did the missus proof read this for you and tell you to be nice to them?
By the way, like the use of the term 'ultrasound specialists' to describe sonographers. Not going soft on quacktitioners are you?
Or did the missus proof read this for you and tell you to be nice to them?
++++++++
Hoisted on my own petard! Yes, my wife trains the ultrasonographers.
For once, this is not a quacktitioner rant. I have just increased my medication. This is a serious look at obstetric care by people who work outside the NHS because they would not be tolerated within it
John
These midwives do have insurance.
It's called the NHS. Did the 'nice' paramedics charge them for 2 hours of their time and for saving their ass?
“Most clients understand you can’t insure against things going wrong during childbirth, only against negligence, and negligence is not really an issue for us”
Breathtaking arrogance. Makes your 'carry on doctor' sound like a new age hippy.
Absolutley, totally, irrevocably fucking bonkers.
And all done in a paddling pool, to boot.
I could weep, I really could.
'jane_t, I know people see consultants privately first then jump the NHS queue, and I am opposed to that. '
They may have a consultation privately, but if they need NHS Rx they go on the waiting list like anyone else. Anything else and the consultant plus the hospital would face disciplinary action. So the only queue they have jumped is to see the consultant originally.
And I don't blame them. I would do the same. I want to see a doctor when I am ill.
There is something rather ideological about the whole thing. Firstly the aggressive attitude towards the 'medical model' and secondly the protest involving ducking as a reference towards medieval witches suggests that there is perhaps something of the anti-male about it.
Sorry crippo, I was sure I'd heard people had jumped the queue for treatment.
So the only queue they have jumped is to see the consultant originally.
I am really not happy about that either (particularly when -- as was the case in Wales, as I think it may still be despite offical statements -- the original NHS queue is months-to-years long). And in effect, if an NHS list is unreasonably long, someone who sees a specialist privately and is referred immediately for NHS treatment *is* jumping the queue.
I'm not saying I wouldn't do that, I might well do it. But it's still bad.
Dr C said:
"Sad, interesting and irrelevant to the question of the questionable practices of some independent midwives
It's only irrelevant if you are not using the example of some independent midwives who are bad at their jobs to argue that all independent midwives are therefore bad at their jobs. As you appear to be making this argument, then it follows that the existence of 'bad' NHS obstetric staff must mean that all NHS obstetric staff are also bad. So where do women go?
Crippo said:
"'jane_t, I know people see consultants privately first then jump the NHS queue, and I am opposed to that. '
They may have a consultation privately, but if they need NHS Rx they go on the waiting list like anyone else. Anything else and the consultant plus the hospital would face disciplinary action. So the only queue they have jumped is to see the consultant originally.
And I don't blame them. I would do the same. I want to see a doctor when I am ill."
Exactly, my thoughts too, and as you point out, I did mean that they jumped the queue for the first consultation, not the queue for NHS treatment later. But I still struggle with the idea that this will delay appointments for people who cannot afford to pay. The consultant only has so much time. If he sees more private patients he will have less time for NHS patients and someone who really could do with a more urgent appointment may be delayed as a result.
Almost too terrified to leave a comment in case I spell something wrong but good lord, this is indefensible surely?
Where's the NMC?
Have they read this?
Do they read blogs?
Inside the NHS most of this would incur disciplinary action but beyond that I'm trying and failing to figure out how anyone who holds legal registration and is therefore duty-bound to uphold the principles of the profession laid down by the NMC can actually work like this and sleep at night?
This makes a mockery of the NMC as much as anything else.
Dr C, here's the page you need, http://www.nmc-uk.org/aArticle.aspx?ArticleID=2667
If this example is as bad as you claim, and not being medically trained I've no way of judging, you are morally obliged to report this midwife.
A blood loss of 1500ml? Nearly 3 pints!! Considerably more than an armful I would say.
Its not so much providing the service of a home birth that horrifies me, it is the sheer arrogance that she showed in her continual refusal to concede to standard medical tests/procedures..
It might be my own prejudice here, but I tend to picture home birth mums and midwives as new agey hippy types. More concerned with
"the birth experience" than real potential dangers to their child.
Dear John,
Knowing no other way to contact you, I append this to the many previous posts in the hope that you all read it, and perhaps, you Cripps, might post a new thread, in praise of unsung heroes.
I was unfortunate enough to be called to Frimley Park Hospital today, because my eldest heroin-addicted son had had a massive bleed from his femoral artery caused by sepsis in an injection site.
As I write this, and having held my son's hand prior to entering theatre for the vascular surgeons to weave their magic on what must seem like a lost (junkie) cause, I have to tell you that the front-line staff were brilliant.
My son's operation will have started around 22:00. The vascular surgeon(s) involved will have been 'called-in' and arrived.
Thank you!
There will also have been a call-out for an urgent cross-match of blood. To you, dear Biomed Scientist:
I thank you equally!
This is what the NHS is all about John. Please continue to do your best to preserve it.
Fingers crossed, I'll see my son awake tomorrow. I am writing this (close to midnight) as a cathartic exercise. I gave my son a hard time for being a junkie.
It's looking like I over did things.
Yrs
Anon
Christ on a F***ing bike - not only are these two women grossly negligent, but they publicise their negligence on a website.
I am an anaesthetist, I mange sick and critically ill patients on a daily basis and even with a full obstetric theatre team, ICU back up and a well stocked blood fridge I would be concerned about a woman with symptomatic Post-Partum Haemorahge (PPH) -this kills and it kills rapidly. the closest I have ever seen a fit young mother to death was following a PPH, which had occured in the community with an independent madwife in attendance. Anyone who doesn't believe me should spend a few weeks doing obstetrics in a third world country, the standard of care provided in this case would have been unacceptable even in most of those places.
Having recently become a father I was pleased that my usual anaesthetic antagonism towards our midwifery colleagues was proven misplaced when on the other side of the drapes. They were nothing but lovely, professional and excellent. As a bunch midwifes tend to be anti-interventionist, so when even a hospital based midwife starts saying 'time to think about an interventional, hospital based labour' then it is time to take that suggestion very, very seriously. To describe this advice is 'shroud waving' simply shows the depths of this woman's ignorance.
I also find her attitude towards 'medicalisation' amusing (well actually I find it F***ing scary, but amusing in a black way). When she infuses 1.5 litres of boiled cow solution then this is not 'medicalised'! presumably when I do it is. When she gives synthetic uterine contractors this is not 'medicalised', presumably when an obstetrician does it is.
This case proves one thing, humans are resilient - we survived as a species for millenia without modern medical intervention as we can compensate for significant injury. However whilst at a population level this is sufficient, it does not mean individuals can't die. This madwife came close to leaving several children without a mother, that she is proud of this fact suggests she should be removed from the NMC register forthwith.
Anon 11:59 - thanks for posting something positive about NHS emergency care, we seldom get much thanks in the wider world or recognition that we do generally do a good job (its different from patients, who are generally thankful for the care they recieve).
I hope your son recovers, both from his acute illness and also from his more chronic one.
Keep strong.
This story is paradigmatic of the ignorance, magical thinking and ideology characteristic of direct entry midwifery in the US and independent midwifery in the UK.
These midwives are ignorant of the most fundamental principle of caring for pregnant women: Childbirth is dangerous. It is one of the leading killers of young women and babies in every time, place and culture. Without a basic understanding of the inherent dangers of childbirth, these women are very dangerous.
Belief in magical thinking and "intuition" (a fancy way of saying ignorance) is also endemic to direct entry midwives and independent midwives. Magical thinking is believing that your own thoughts can exert power over outcomes. Hence the emphasis on positive thinking and birth "affirmations".
The touching belief in the power of magical thinking is yet another reason for the condemnation of "shroud waving" (in addition to the fundamental ignorance about the incidence of complications). These midwives actually believe (on the basis of no evidence, but then they don't understand evidence) that thinking about complications causes complications.
If anyone needs further proof, they should read the recent paper in the Australian midwifery journal Women and Birth. The paper is entitle Including the nonrational is sensible midwifery. The paper is mind boggling and ends with this flourish of outright stupidity:
"For example, when a woman and midwife have agreed to use expectant management of third stage, but bleeding begins unexpectedly, the expert midwife will respond with either or both rational and nonrational ways of thinking. Depending upon all the particularities of the situation the midwife may focus on supporting love between the woman and her baby; she may call the woman back to her body; and/or she may change to active management of third stage. It is sensible practice to respond to in-the-moment clinical situations in this way... Imposing a pre-agreed standard care protocol is irrational because protocols do not allow for optimal clinical decision-making which requires that we consider all relevant variables prior to making a decision. In our view all relevant variables include nonrational matters of soul and spirit."
These midwives are dangerous and proud of it.
I'm from Japan.
Glad to meet you.
Please link to this site.
Keep it up please♪
John, as a specialist physician/pathologist from Oz, with a strong interest in patient safety, this article is disturbing on so many levels, I am simply flabbergasted.
The I read Dr Tuteur's post, and am now offically purple-headed and apoplectic with rage.
These people are willing to sacrifice the health, safety and lives of others for their beliefs . Not only that, they appear proud of their "outlaw" status. have never seen such a staggering display of arrogance in a healthcare worker.
Unfortunately, it will almost certainly take a preventable maternal death, maybe more than one, to stop them.
Someone in the UK must submit a complaint to the appropriate regulatory authority and demand action be taken.
Good grief.
I am only a lowly med student here and I cannot believe this article. I have had the good fortune of having quite a bit of obstetric exposure and I cannot get over how blase this nutter is.
A month or so ago we had a ruptured ectopic where the Pt lost 1.5L. And despite being in a well stocked OT with x-matched blood on hand and 2 senior OBs everyone was still very, very catious about her management.
This cowboy almost takes delight in her ignorance and is unbelievably aggressive to other health professionals.
She has got to be struck off surely.
"Dr C said:
"Sad, interesting and irrelevant to the question of the questionable practices of some independent midwives"
It's only irrelevant if you are not using the example of some independent midwives who are bad at their jobs to argue that all independent midwives are therefore bad at their jobs. As you appear to be making this argument, then it follows that the existence of 'bad' NHS obstetric staff must mean that all NHS obstetric staff are also bad. So where do women go?"
Jane t, he is not making the argument that ALL independent midwives are bad at their jobs in that literal a sense!
The above illustrates a high risk pregnancy that ran into potentially life threatening complications. The woman herself wanted a home birth-because that is what she just plain wanted. She obviously didn't have enough knowledge about her health or the health of her baby to make a sensible, informed decision. (Or if she did, she didn't give enough of a fuck about her baby to do the sensible thing.) These independent madwives are in a position to exploit that lack of knowledge as the basis for their career.
"Sharon had birthed 3 big babies; the largest was the second baby at 9lb 13oz. The third baby had been induced at 37 weeks following a diagnosis of polyhydramnios and an estimated weight of nearly 10 lbs. The actual weight at birth was 9lbs. There had never been any diagnosis of diabetes or any other maternal or fetal problems.
We deduced that Sharon therefore grew big babies as normal for her. We decided that we would expect a big baby and not be concerned. Easier said than done during the first trimester!!"
Note how she reassures her "ah sure all this completely abnormal stuff that could cause serious damage is just normal for you love, it's nothing"
Yes, it's EXACTLY what the woman wanted to hear. So fucking what? She and her baby were at risk and it was not brought to her attention. This is not condemning ALL independent midwives. But their existence at all, the fact that they are even there, means that the potential for more situations like this, and worse, is alive, well, and flourishing. Yes, there are bad NHS staff too. But at least you're in a hospital. Chances are, when you haemorrhage, somebody else might be around who remembers where the sphyg is. And someone might even give you some blood and like, bad medical stuff and save your life. Fuck me.
The mortality rate in Britain in the first half of the 20th century was approx 1/250.
Since "medicalising" childbirth, it is almost unheard of for women to die in childbirth. Yes, evil bad horrible doctors and NHS midwives, giving you IV fluids, blood transfusions when you haemorrhage, C-sectioning when your baby is in distress, CTG monitoring to ensure foetal wellbeing, controlling BP to avoid pre-eclampsia, treating you with exnoaparin when you get your PE/DVT, antibiotics for your infections, etc etc etc.
"They arrived within 3 minutes and were the best guys I have ever met in the job. They got their BP machine which recorded observations at 5 minute intervals" - I don't think she would have had the same opinion of me as I put her patient on the ambulance and blue lighted her to hospital!
I'm guessing her "paramedics" weren't. Technicians (or, god forbid) ECAs would have found it very difficult to have a discussion (or should that be multi-disciplinary team meeting ;-) about the patient's condition.
What a useless, dangerous waste of blood and organs this woman is.
'But I still struggle with the idea that this will delay appointments for people who cannot afford to pay. The consultant only has so much time.'
Very true. And this is part of the problem. What would you do if you were a consultant? Flog your guts out in the NHS hospital run by the clipboard wielding numpties with the protocols and the under valued ward nurses, or a private hospital where you can put the patient first?
Just to clarify, consultants do thier private practice in non-contracted hours, ie in their spare time. We have time sensitive job plans. The problem is, consultants are now reducing the time on these job plans, for less pay of course.
I don't do any, by the way.
So, who's going to be the first to report the loonies then? I've downloaded the PDF but I'm in New Zealand & don't think it would carry much weight from here. Here's hoping that they just made all this up.... it reads like a boy racer moaning about how he can't afford car insurance then going on to describe how he beat his mate drag racing around the M25. Truly scary people.
Here's the real kicker, for me: "However yet again that medical model reared its ugly head and they wanted to do tests on the baby."
They want to run tests on the baby! ...those bastards! Medical know-it-all scum all of them.
So she's already put the baby at risk and damn near killed mummy.
The truly worrying thing about this, is that this woman does not, even on a basic level, realize that she was at fault here.
It is only a matter of time before she kills somebody.
I wonder if Sharon is happy...?
Jane_t
Do you support this negligent & wicked practice?
Is there a way of formally complain against this midwife? I think she is too dangerous to be allowed to work as a midwife. She even don't recognizes herself how dangerous she is.
However yet again that medical model reared its ugly head...
Incredible. Am actually lost for words.
The husband’s cognitive behaviour in all this is a bit puzzling. She seems to be using him as a cat’s paw in her fight with the hospital midwives, that, after he was initially against a home birth. I wonder what she said to him.
If he had just jotted down a few points on the back of an envelope such as:
Home:- cost/risk
1) No back up.
2) No insurance,
3) Costs,
Benefits:-
1)Well being feeling from a home delivery.
Hospital: Cost/risk
1) Risk of picking up some infection in hospital.
Benefits:-
1) Free at point of delivery.
2) Full back up of a general hospital.
3) Unlimited liability
It would have been a no brainer. Should Mary cease practicing midwifery I can see a shining career ahead of her as an independent financial advisor.
http://news.bbc.co.uk/2/hi/africa/7377707.stm
Seems like they have independent fuckwit midwives killing babies and using herbs in the third world also...
Jane_T said...
So one bad example proves they're all bad? That rules out the NHS for deliveries then since there are hundreds of bad examples, many of them actually ending in death or injury to mother or baby. Not very scientific for a doctor.
When the NHS obstetrics teams make mistakes that result in bad outcomes, the staff concerned will be scrutinised, adverse clinical incident forms will be written, disciplinary proceedings may be considered and the doctors and nurses may end up being referred to their respective professional bodies. Here, when an independent midwife has made a catalogue of errors and has demonstrated poor judgement and even criminal negligence, their body uses the case account with pride to advertise their services. Can you appreciate that there is a slight difference here?
jane_t
Where do you practise. I'd like my wife to be well clear of you!
As an NHS community midwife I attend homebirths, and sometimes not just for those women assessed as 'low-risk' as we cannot refuse to attend a homebirth. We can give information, we can advise strongly against but we have a legal obligation to attend, and the Trust has to provide the midwives, few women are aware of this (thank heavens).
I cared for a friend, also a midwife, through her 3 pregnancies. The first was uneventful, in the second, planning a homebirth, she developed polyhydramnios. I referred her in for a scan, yes polyhrdramnios, no cause seen. Her labour was induced at term, flooded the room, continuous CTG, all well. Normal birth, 7lb baby born, first breath his chest recessed deeply, and continued to do so. Paeds called, he was transferred to a major London Hospital where a congenital diaghragmatic hernia and severely under-developed lungs were diagnosed and he died 2 days later. Until the diagnosis was made I beat myself up, what had I missed, what had I done wrong? The sonographers had missed the anomaly, nothing is perfect but, we could have gone ahead with the homebirth. However, we were aware and concerned about the possible risks associated with polyhydramnios so decided an obstetric unit was best. Thank heavens we did as, if I was distressed when baby was able to have immediate care, imagine how my friend and myself would have felt at home with a baby struggling to breathe.
I am not sure what sort of site this appeared on but my biggest worry is it sounds like it was written by a work experience student rather than a clinician. I wouldn't insure any of these people they sound like a f'ing liability. They seem to 'wing it' and in doing so risk peoples lives. Bunch of nobs.
Gentleben
p.s. what is shroud waving, sounds a bit pagan to me
1500 ml blood loss, is a lot. When I did my OB rotation I remember, that anything over 1000 ml was written up as a "serious incident" and an investigation was carried out.
I can't rationalise how she could remain so unfazed by the seriousness of the situation. I was at a birth where the mother lost about 750ml and everyone was very concerned.
What scares me more than anything else about these independent midwives is what would they do if they had that nightmare situation of a PPH and a baby who needed resus. At the above mentioned birth we had both despite it being a low risk pregnancy, but we had so many extra hands to help out. The minutes following the baby's birth were probably not the quietest ever, but the parents were grateful for the 6-7 people who were in the room within 50 seconds and able to help mother and baby survive.
I am not sure what sort of site this appeared on but my biggest worry is it sounds like it was written by a work experience student rather than a clinician. I wouldn't insure any of these people they sound like a f'ing liability. They seem to 'wing it' and in doing so risk peoples lives. Bunch of nobs.
Gentleben
++++
You can click on the site Kent Midwifery Practice above the article and the url is here as well;
http://www.kentmidwiferypractice.co.uk/
John
anonymous said...
There is something rather ideological about the whole thing. Firstly the aggressive attitude towards the 'medical model' and secondly the protest involving ducking as a reference towards medieval witches suggests that there is perhaps something of the anti-male about it.
Thursday, May 01, 2008 10:26:00 PM
I think anonymous @ 10:26 has a point.
I am a retired Nurse/Midwife/Health Visitor and I found myself more and more appalled as I read through your post. When I trained as a midwife, and when I practised, we had to provide home deliveries where the mother insisted on them, but none of us wanted them.
This was particularly the case as they were usually booked in the back of beyond and a time when the snow could be a foot deep.
I cannot understand the arrogance of these 'madwives', and the case quoted just illustrrates why Dr Johgn Crippen calls them Madwives.
I wish to dissociate myself from them.
All independent midwifery is a farce. I'm not saying that all independent midwives are bad, I'm saying that any system that condones the concept of encouraging and facilitating something as dangerous as giving birth outside a hospital is ridiculous. People can do whatever they want to themselves, but to put another's life at risk out of hippyish sensibilities is literally unbelievable. It should be a criminal offence to practice midwifery outside of a hospital in non-emergency settings or for financial gain. As a society we are being irresponsible and betraying our most vulnerable citizens (neonates) by condoning the horseshit that is homebirthing. I'm not a nutter or a hardliner paternalist, I'm someone who cares deeply about human rights and I believe that an innocent child's right to be born safely trumps a woman's "right" to give birth at home without things being "medicalised"(i.e. safe) every time. These weirdos always fight back by saying "women have been giving birth for millennia with no help", which omits the fact that peripartum dead was also the greatest mortal risk for both childbearing women and babies for millennia. I'm normally slow to take conservative lines on legislation, but to encourage or even allow independent midwifery to exist is a shameful indictment of our attitude - when we forget that being PC about someone's "birthing experience" is never going to be as important as providing the greatest possibility for both mother and child to be alive and well.
dr.janedoe said:
"Jane t, he is not making the argument that ALL independent midwives are bad at their jobs in that literal a sense!"
He does. He believes that they cannot get insurance purely because they are too high risk and does not accept the possibility that it may have more to do with the need for insurance companies to make profit and lack of economies of scale. He ignores the fact that independent midwives in other European countries are able to get insurance because it doesn't fit with his view of home births and independent midwives.
Here are some of his comments about independent midwives:
"Dr C seems to believe that this is because they (independent midwives) are a much greater risk than NHS midwives.
That is correct"
"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?"
"They will never accept that home births are dangerous and that they, indeed, are dangerous."
anonymous 11.28am said:
"Do you support this negligent & wicked practice?"
I'm undecided through lack of evidence. I'm looking forward to seeing the results from the major study currently being carried out into safety in the UK (sorry, can't find the link atm). This seems to be the current 'official' opinion on home birth:
http://www.rcm.org.uk/info/docs/Home%20Births_Joint%20Statement_1.pdf
"The Royal College of Midwives (RCM) and the Royal College of Obstetricians and Gynaecologists (RCOG) support home birth for women with uncomplicated pregnancies. There is no reason why home birth should not be offered to women at low risk of complications and it may confer considerable benefits for them and their families. There is ample evidence showing that labouring at home increases a woman’s likelihood of a birth that is both satisfying and safe, with implications for her health and that of her baby."
dimer said:
"When the NHS obstetrics teams make mistakes that result in bad outcomes, the staff concerned will be scrutinised, adverse clinical incident forms will be written, disciplinary proceedings may be considered and the doctors and nurses may end up being referred to their respective professional bodies."
All midwives, including independents, are supervised, http://www.nmc-uk.org/aArticle.aspx?ArticleID=2098
"Here, when an independent midwife has made a catalogue of errors and has demonstrated poor judgement and even criminal negligence, their body uses the case account with pride to advertise their services. Can you appreciate that there is a slight difference here?"
If you believe this and know what you are talking about (I'm not medically trained so find it difficult to judge), follow the link I posted earlier and report her. If you truly believe the above and fail to report her, you (and any other medics who believe the same) will be partly responsible for any damage done to mothers and babies at her hands in future.
anonymous at 3.09pm said:
"Where do you practise. I'd like my wife to be well clear of you!"
What makes you think I practise? Can you read? If you'd bothered to read what's gone before you will have seen that I'm not medically trained.
and sometimes not just for those women assessed as 'low-risk' as we cannot refuse to attend a homebirth. We can give information, we can advise strongly against but we have a legal obligation to attend, and the Trust has to provide the midwives, few women are aware of this (thank heavens).
This sounds ridiculous. It should be counted as a criminal offence when you want to attend high-risk home-births. Who is responsible for this policy and who can change this?
I was making the point that it is very difficult, and heartbreaking stressful to try and extract 'proper compensation' from the NHS - they will lose the files, alter the records (oh yes they do), refer the case back to umpteen committees, etc etc.
Jane t, I- I- (shakes head) you seem to know little about BOTH medical matters AND financial matters.
What on EARTH do you think private insurance companies are in business for if not to make a profit? They're, um, not charities!
Why do you think the insurance companies won't insure them then? I'm interested to hear it.
The situation is what is dangerous-not so much the individuals. However-again-common sense-people who recognise that this is a dangerous situation and one with lots of potential problems may be less likely to get involved with it. Hence the not so good or downright stupid midwives may be more likely to go "independent", as it is arguably the Darwin awards candidate choice! Maybe they shouldn't be allowed to call on the NHS to bail them out-all this would resolve itself pretty quickly then!
btw I'm joking in the above comment. But I think in the event of having to get bailed out , the indy midies should have to pay back the associated charge to the NHS.
In my large experience, the independent midwives are the least clinically skilled of all midwives.
They're less clinically skilled than experienced NHS midwives, know it and are pissed off that everyone else does too and don't let them manage pregnant women to the low standards they'd like, so they've got out and espouse "new age" philiosophy to cover their lack of ability.
They're less clinically skilled even than newly qualified midwives who know when to ask for help & support ie. they lack the clinical skill of judgement.
Their practice involves sitting back and doing nothing as a response to virtually every situation in labour. Not examining, not making judgements when concerning findings are observed. They just sit & coo and tell the woman to go into different positions etc. and make cups of tea.
It's sickening that they can get away with it. Roll on the UK homebirth study. Every other study ever done has shown there is an excess mortality in home birth, even in low-risk planned homebirths. The good studies on birth centres run by midwives vs. hospitals consistently show a doubling in mortality for the little ones in the "low risk" birth centres (see Cochrane database). Sick.
I have no medical experience, and can only judge from my two experiences giving birth (in hosptal). After having my second baby (who had some sort of cord-in-the-wrong-place problem), I was so scared of cord prolapse that it put me off birth completely, hospital or no hospital! Both my babies were delivered by hospital midwives, and I have great respect for midwives who work in hospitals or who deliver babies in settings where there are no hospitals, or where the mother cannot or will not go into hospital, etc...
I understand from the above comments that NHS midwives must attend home births (even high-risk ones) in situations where the mother refuses to go to hospital. Do NHS midwives also do planned home-births? Just curious.
The article you featured today was appalling... as I understand it, the gist of it was:
- Mother with extreme dislike of hospitals is determined to give birth at home, at all costs.
- Said mother finds semi-trained woman (also with extreme dislike of hospitals) who will deliver the baby at home, despite the fact that it is a high-risk birth.
(and general chaos ensues...)
This "midwife" should lose her license. She is clearly irrational and dangerous.
I found it interesting that the "midwife" has "hours and hours" to spare to talk about all topics under the sun with the mother. I was wondering what her point was... to me it just seemed strange that she had so much time to spare. Then it turned out she was trying to use this to prove that the mother was making an "informed decision". Deluded thinking...
I see now why you call them "madwives"!
Dear Jane_t,
Perhaps there are good independent Midwives out there, but while people like these are allowed to continue practise no Insurance company in their right mind would insure them at any price.
If these independent midwives get insurance via the Govt as they desire I look forward to sending my £10 000 Malpractice Insurance bill to the government for payment. This covers my private practice in a non obstetric low risk speciality for a year, and I have never had a claim atempted in 18 years of practise.
This is one of the reasons private practise is expensive, I see no reason why Independent Midwives should be differrent.
Just writing a blog post on this myself, and noticed that the link to this story from their website has dissappeared (unless I'm just being thick?).
here it is, northern nurse
http://www.kentmidwiferypractice.co.uk/2006/birthstories/sharon.htm
Nope, it's gone, although it does say "this story will be returning soon" in its place.
No doubt it will have passed through the hands of a lawyer when it returns.
Looks like the author(s) are running scared.
Those in the UK, please keep the pressure up!
I see their fee for a full package is £27OO.
Tell you what, front up with a grand and I'll come round your house, drink tea all day, draw some runes on your forehead and do an incantation.
It would be safer than this bunch.
KENT MIDWIFERY PRACTICE has now taken down Sharon's Story without comment or discussion, though they say "it will be back"
Whether it will be back in the same form, I rather doubt.
The account I gave of it was a verbatim copy with no alterations at all.
Furthermore, the original is still available via Google cash.
Full details :
http://nhsblogdoc.blogspot.com/2008/05/kent-midwifery-practice-now-you-see-it.html#links
John
The remaining birth story...how they delivered a grand multip, with 2 previous sections and renal failure at home...sounds like a bitter rant against NHS midwives and obstetricians.
Rather than talk about anything constructive/interesting, they just moan about the NHS midwives and obstetricians and a £30 taxi bill. It is a very bizarre birth story.
Penny
Can't be bother to answer the last posts aimed at me. The writers either haven't bothered to read the previous posts or have trouble understanding English as they are querying points I've not even made. Others seem happy to make judgements without providing evidence. Anonymous at at 3.33am says see Cochrane database. A search for 'Cochrane home birth' brings me to this page and statement:
http://www.cochrane.org/reviews/en/ab000352.html
"Summary
No strong evidence about the benefits and safety of planned home birth compared to planned hospital birth for low-risk pregnant women
In some countries almost all births happen in hospital, whereas in other countries home birth is considered the first choice for healthy and otherwise low-risk women. The change to planned hospital birth for low-risk pregnant women in many countries during this century was not supported by good evidence. Planned hospital birth may even increase unnecessary interventions and complications without any benefit for low-risk women. The review found only one small trial, which provided no strong evidence to favour either planned hospital birth or planned home birth for low-risk pregnant women."
I'm assuming this isn't what you wanted us to read? Maybe you can be more specific with your 'evidence' and actually provide links. Then we may end up reading what you intend us to read.
I am shocked that so many supposedly medically trained people are willing to make such strong statements with so little evidence. If you hope to persuade those sitting on the fence (like me), please provide some evidence. Random rants do not work.
Has anyone reported this midwife to the NMC yet? If not, why not? If she is as dangerous as you say and YOU fail to report her, YOU will be partially responsible for any death or injury she causes in future.
jane_t:
"A search for 'Cochrane home birth' brings me to this page and statement"
That paper is out of date.
It is important that people understand that all the existing scientific evidence to date shows that homebirth has an increased risk of preventable neonatal death in the range of 1-2/1000. There are papers that CLAIM to show that homebirth is as safe as hospital birth, but they do so by comparing homebirth of low risk women to high risk hospital birth or to hospital birth in previous decades. Indeed, the paper most widely quoted by homebirth advocates, the Johnson and Daviss BMJ 2005 paper ACTUALLY shows that homebirth has a rate of neonatal death TRIPLE the hospital rate in the same year. You won't find that mentioned in the paper itself. That's because the authors conveniently left the low risk hospital death rate in 2000 out of the paper entirely (Johnson is the former Director of Research of the Midwives Alliance of North America; Daviss, his wife, is a homebirth midwife).
Homebirth advocacy is based in large part on mistruths, half truths and outright deceptions. Women who want to have a homebirth need to know the truth about the risks. Otherwise, they cannot make an informed decision.
Christie
"I understand from the above comments that NHS midwives must attend home births (even high-risk ones) in situations where the mother refuses to go to hospital. Do NHS midwives also do planned home-births? Just curious".
Yes we do attend planned homebirths. Currently the government is encouraging homebirths and there is also a study underway to assess and compare the safety of homebirth/birth centre/obstetric unit births, it's called Birthplace. http://www.npeu.ox.ac.uk/birthplace
Anon - Re - Obligation to attend a homebirth. It is part of the Midwives Rules/Code of Practice. Explanation of how stuffed a midwife could be is here http://www.homebirth.org.uk/law.htm
midwifemuse:-
Could you tell us what sort of criteria you use these days for advise re:home births?
Back when iw as a student the area i was in advised all first time mothers to havea hospital delivery, all 'complicated' births, and all births where the mother has had 5+ children previously.
Is that still the case?
James
James - "Could you tell us what sort of criteria you use these days for advise re:home births?"
Primips - yes, if low risk i.e no medical conditions which may complicate the labour, over 17 years old, height over 1.53m, under BMI 30/100Kgs but over 19, aged under 40.
Multips - Advised against if previous section, PPH, over 5 previous births, previous babies over 4 Kgs, difficult instrumental birth, shoulder dystocia, 3rd/4th degree tear.
In current pregnancy if PIH, polyhydramnios, malpresentation, multiple pregnancy, gestational diabetes, term + 12, prolonged rupture of membranes, known strepB or other 'deviation from the norm, complication'.
Basically everything about them has to be straightforward. Homebirths have the same criteria as stand-alone midwifery units. I may have left something out, and units do differ but NICE have a guideline - http://www.nice.org.uk/nicemedia/pdf/IPCNICEGuidance.pdf , pages 13 - 16 are quite definitive!
amy Tuteur, MD said...
"Homebirth advocacy is based in large part on mistruths, half truths and outright deceptions. Women who want to have a homebirth need to know the truth about the risks. Otherwise, they cannot make an informed decision."
I agree completely with the need to make an informed decision. To help with this, please can you give links to the research that shows that home birth in low-risk pregnancies are more dangerous than hospital births.
it was still there when I posted the link, dr rj (alternatively, my browser cache held it!) -- sorry, northern nurse.
(Dr jr: 'jane's story', still there, annoys me too.)
jane_t
You really are a useless load of rubbish.
Try this
http://www.cochrane.org/reviews/en/ab000012.html
Read the 2nd last sentence in main results about risk increasing to 1.83.
Now shut up and go away. It's clear you haven't mastered Google yet, so how can you comment on such a complex subject as home birth.
Anonymous (at 5:52PM).
Does the (Cochrane) data pertain to planned homebirths ?
CEMACH found that the majority of homebirths in the UK were, in fact, unplanned.
I don't pretend to be a research guru but I could no figure detailing ARR (on the link you provide) I would have though this is an important bit of info ?
By the way please share you thoughts concerning who should or shouldn't permitted to express opinions on a public blog about this emotive topic.
I'm sure you've already noticed that commentators in the research field have noticed how views are often polarised.
The original birth story is back up on the site. On initial skimming it appears unchanged. I read the other birth story and was struck by this phrase:
'Jane went into labour 4 days after her due date. As soon as she rang me to say her waters had gone, I was on my way green light on!'
Does she mean a green light as in warning beacon? If so, this is illegal use as they are only to be used by regsitered medical practitioners i.e. not independent madwives.
This is explicit in the Road Vehicle Lighting Regulations 1989
Warning beacon emitting green light:
Used so as to be lit except whilst occupied by a medical practitioner registered by the General Medical Council (whether with full, provisional or limited registration) and used for the purposes of an emergency.
Doesn't appear to cover the earnest madwife attending a home birth.
anonymous 5.52pm
We are talking about home birth, not home-like birth. Maybe you should learn to read before you criticize others.
Jane_T:
"To help with this, please can you give links to the research that shows that home birth in low-risk pregnancies are more dangerous than hospital births."
All the existing scientific evidence shows that PLANNED homebirth in low risk women has an increased rate of preventable neonatal death compared to low risk hospital birth in the same year. To my knowledge, there is not a single scientific paper that shows that homebirth is as safe as hospital birth for COMPARABLE risk women in the SAME YEAR. If you know of one, please cite it.
amy tuteur, you keep saying that all the existing scientific evidence shows that planned homebirth in low risk women is dangerous but you still haven't given me any links. It should be easy. I'd love to just take your word for it, but I don't know you and have no idea of your qualification, etc.
As I don't have access to medical libraries I can usually only read summaries of research and they don't always mention when the data was collected. This study appear fit your requirements for the same year. Unfortunately, as often seems to be the case, it's not large enough to come to firm conclusions.
http://www.bmj.com/cgi/content/full/313/7068/1313
"This study does not have sufficient power to exclude differences in rare events. The probability of these events concerns both sides--for example, the rare complications of interventions in hospital as well as unmanageable bleeding at home. However, most indicators suggest that home delivery does not pose a higher risk than hospital delivery and that it reduces some of the additional risks of interventions."
BTW, how do you justify the fact that the move of low-risk births to hospital from home was not evidence based?
BTW, how do you justify the fact that the move of low-risk births to hospital from home was not evidence based?
The move of ALL births from home to hospital WAS evidence based.
It wasn't until birthing moved into the hospital that evidence was collected to show which were risk factors for problems in birth, and hence enabled us to differentiate LOW RISK from HIGH RISK.
Do you think research just magically happens?
Medicine is a complex thing, and it must not be assumed that a change from one line of established thought to another indicates failure on those who followed the former.
We use the best information to hand to make the best possible choices.
At least thats how medicine (and indeed midwifery) should work.
James
James
Hi James,
I can see how this might happen. They find that some births are safer in hospital and from that concluded that all births are safer in hospital. But if this is how it happened, it can't really be called evidence based. I must admit to having read somewhere today that the move wasn't evidence based but couldn't find the page again. I would be interested in any links to the research that underpinned the move from home to hospital research.
Of course research doesn't magically happen. But how do medical procedures start to be used before research proves they are effective and why are they allowed to become so widespread before research is carried out? Examples might include shaving before birth, 100% fetal monitoring in some American hospitals, 20+% caesarean rates, etc.
amy tuteur:
You may also be interested in this piece of research, Safety of Alternative Approaches to childbirth, http://vbfree.org/docs/schlenzka.htm
The following are quotes from the full dissertation available from a link on the above page with an extra link of mine added to the end in brackets. Sorry it's so long, I'm too tired to trim and organise it. In my defence, the original is 225 pages long.
The large sample size of more than 1,000,000 California births provides sufficient power for the analysis of perinatal mortality, despite the low perinatal mortality rate and the small percentage (1%) of out-of-hospital births.
The core of this study is the test of the hypothesis, that the natural approach to childbirth (birth setting Home+Center) is as safe, i.e. has the same perinatal mortality, as the hospital-based obstetric approach (birth setting Hospital) for low-risk pregnancies.
the study is limited to perinatal mortality as the outcome measure, because of its dominant role in preventing an open discussion of alternative approaches to childbirth.
In the US, home birth occurs outside the mainstream maternity care system, with non-regulated selection criteria (if any), and a questionable availability of backup services for intrapartum transfers.
The scope of this study is not the entire population of births in California in 1989 and 1990, but rather that population of low-risk women for whom birth at home or in a birth center could be considered an option.
the “Study Population”, then has 815,927 births. The perinatal death rate for the Study Population is now significantly smaller (from 1.16% down to 0.56%) since we excluded 65.8% of the perinatal deaths because these cases belong to a population not considered eligible for the natural childbirth approach in birth centers or at home, or are considered not preventable or independent of the type of maternity care the women received.
Our first major finding is that only 11% of all perinatal deaths occur in the 68% of all pregnancies – those that can be considered low-risk and are considered candidates for the natural approach to childbirth.
The perinatal mortality is actually slightly lower for the natural childbirth approach, although not significantly so. This result holds, no matter which exclusion criteria are applied for identifying the low-risk pregnancies. And whether we use indirect standardization or logistic regression, we arrive at the same results. It should also be kept in mind that the assumptions we made in setting up the database generally favor the obstetric approach (hospital setting) - thus having the potential for strengthening our findings rather than weakening them. Our conclusion is that this consistent pattern of findings is a very strong suggestion that natural childbirth, including the problems that seem to be associated with intrapartum transfers in today’s childbirth system in the United States, is as “safe” with respect to perinatal mortality as obstetrician-managed hospital birth for low-risk women.
Under no circumstances do the California data for 1989 and 1990 allow the obstetric profession to uphold the claim that for the large majority of low-risk women hospital birth is “safer” with respect to perinatal mortality. Our data also suggest that even for the high-risk levels of our Study Population the natural approach (including transfers) produces the same perinatal mortality outcomes as the obstetric approach.
Comparing the use of cesarean sections between the natural approach and the obstetric approach for our California Study Population (the 71% of all California pregnancies eligible for the natural approach), we find an overall cesarean rate of 6.3% for the natural approach caregivers and 22.1% for the obstetricians.
(http://www.greenjournal.org/cgi/content/abstract/108/3/541
Postpartum Maternal Mortality and Cesarean Delivery
CONCLUSION: Cesarean delivery is associated with an increased risk of postpartum maternal death. Knowledge of the causes of death associated with this excess risk informs contemporary discussion about cesarean delivery on request and should inform preventive strategies.)
"CONCLUSION: Cesarean delivery is associated with an increased risk of postpartum maternal death."
Well of course it is. It's a bloody (literally & figuratively) operation. Operations carry a risk, both immediate & delayed; I'm not here to educate Jane_T on them because I would hope she would read both sides of an argument. And by her own admission is not medically trained. And the comments page of a (popular) medical blog is no substitute for MB BS FRCOG. So the conclusion is totally meaningless. Obstetricians do this every day - they will only intervene with a procedure that contains risk when the risk is deemed greater if they don't.
THIS IS THE BASIS OF ALL MEDICAL INTERVENTION. I fail to understand how non-medics continually rally against this basic principle of common sense (including Primum Nocere). But then they are never in that situation.
Doctors know that Caesarean's are bad for people.
Doctors still do them.
Therefore Doctors are evil.
Christ I wish my life was that simplistic.
Medical Research for Simpletons:
Doctor has idea.
Doctor tries idea.
Doctor notices good result.
Doctor wonders whether good idea produced good result (we call this correlation) or whether it was co-incidence.
Doctor does small trial (we call this a Pilot Study) to see if good idea works on some more people.
Doctor applies for funding from large multinational corporation/Medical Resarch Council/Government body to try idea in lots of different people but some of them will get the old idea (current best practice) and some of the will get the new idea. Doctor tries to match the people in these two groups so they are the same.
Doctor measures the results of treatment with old idea & new idea in the two groups.
Doctor compares these groups.
Doctor takes all this data to a statistician who sticks it into a computer.
Statistician tells Doctor that he/she should have used more people to detect the difference & if he/she had asked the statistician for advice at the start then he/she wouldn't have just wasted a year of their life.
Doctor goes back to start with more people.
Doctors finds good idea is better than old idea.
Doctor publishes good idea in peer-reviewed journal.
Doctor is soundly criticitsed by some doctors who prefer the old idea & find faults in the way he/she measured the difference.
Or Doctor is soundly praised for his/her miraculous breakthrough that will save countless lives.
Doctor can now spend the next few years travelling from conference to conference prosletysing about the good idea he/she had.
Now - some ideas are too good to be researched because common sense says they will. There are no randomised control trials looking at the difference in patient outcome with measurement of oxygen saturations under general anaesthesia. Yet if you gave one without SpO2 monitoring and something went wrong, you would be considered negligent. There is very little evidence supporting the CPR recommendations (ILCOR) but we know if we don't do it then people die (or rather don't survive, as asystole is pretty much dead anyway).
So, Jane_T, question asker, this is how research works. Sometimes it doesn't. But its still the best there is. Perhaps you have an alternative?
Jane_T:
"This study appear fit your requirements for the same year. Unfortunately, as often seems to be the case, it's not large enough to come to firm conclusions."
It's not large enough to come to ANY conclusions and the authors should be aware of that. Neonatal deaths are measured per thousand. Any study that has less than 500 per arm is meaningless.
"BTW, how do you justify the fact that the move of low-risk births to hospital from home was not evidence based?"
Of course it was evidence based. Just because you aren't aware of the evidence does not mean that evidence does not exist. Indeed, the shift from homebirth to hospital birth has been one of the greatest public health advances of all time. In the past 100 years in the US birth shifted from 5% in the hospital to 99% in the hospital. During that time period neonatal mortality dropped by 90% and maternal mortality dropped by 99%.
"You may also be interested in this piece of research, Safety of Alternative Approaches to childbirth, http://vbfree.org/docs/schlenzka.htm"
I do not get my information about obstetrics from an unpublished PhD thesis in sociology.
"Cesarean delivery is associated with an increased risk of postpartum maternal death."
The Denaux-Theraux study to which you refer looked at 65 maternal deaths that occured in France from 1996-2000 and compared them to a control group of 10,244 women who had vaginal deliveries looking for differences. It is hardly a surprise that more women in the group that ultimately died had C-sections since those women were the sickest, most complicated pregnant women in the country.
In contrast, studies that compare large numbers of women who had elective C-sections with large numbers of women who had vaginal deliveries show that the risk of mortality is no different.
From Elective primary cesarean delivery, Minkoff H, Chervenak FA, N Engl J Med. 2003 Mar 6;348(10):946-50:
"In the most recent British survey, a new classification of cesarean delivery permitted an assess-ment of the risks for women undergoing scheduled cesarean deliveries. Such women actually had lower mortality than did those having a vaginal delivery, with only one death occurring among 78,000 women who had a scheduled cesarean delivery. Similarly, data from Israel demonstrated that mortality associated with elective cesarean delivery was lower than that associated with vaginal delivery. Furthermore, all these analyses may understate the risks associated with not undergoing an elective cesarean delivery, since a woman who elects a trial oflabor cannot be guaranteed a vaginal delivery. If a woman eventually requires an emergency cesarean delivery, she will face a risk of death several times as high as that faced by women who have a scheduled cesarean delivery."
From the CMAJ in February 2007 on low-risk planned cesarean delivery versus planned vaginal delivery at term:
"The ... study groups comprised 46,766 women who underwent a planned cesarean delivery for breech presentation and, as the reference group, 2,292,420 healthy women who had a planned vaginal delivery with labour that was either spontaneous or induced...
No mothers died in-hospital in the planned cesarean delivery group, whereas 41 women died in the planned vaginal delivery group."
As I said above, homebirth advocacy is largely based on mistruths, half truths and outright deceptions. You've just offered four separate examples to support my claim.
Jane_T
You're falling into the trap that many members of the public fall into when having medical debate on the internet.....Basically...
1) Just because something is "research" doesn't make it correct. Whether it is published in a reputable journal, or is someone'r unpublished PhD thesis.
2) Just because something is on the internet also doesn't make it true.
3) Just because something was once published, doesn't mean it's currently up to date.
It's very hard to argue about the medical evidence if you're just googling "evidence for homebirth safety" or whatever. you're going to miss swathes of up to date research by doing that. Most of it isn't published online in enough detail that you can work out if it's good quality or not, unless you have a subsciption or other access to the journal.
I just thought, from reading your posts, that you should bear that in mind.
Dr. Thunder
www.twoweeksonatrolley.blogspot.com
two weeks on a trolley team - you seem to be suggesting that only doctors are capable of evaluating (clinical) evidence ?
I'm not sure I agree with that - we certainly seem to be wasting £1billion plus on statins (to take just one example, of so called evidence based practice gone horribly wrong) - there is certainly a fair amount of literature debunking the entire cholesterol hypothesis, yet prescription rates rise inexorably.
And as you know there are now significant doubts about the scatter gun approach to SSRIs as well.
Amy Tuteur clearly thinks ALL births should take place in hospital - I dare say that if the entire population of sick adults moved into hospital as well there might be a few less deaths (providing they can all dodge c-diff spores/MRSA, etc).
The fact is a percentage of women will always prefer home births.
Is the end point (of the home birth detractors argument) that this choice will be removed, perhaps following the introduction of legislative measures ?
So, how should the risk (of homebirth) be presented to mothers - clearly many doctors don't trust the "madwives", while other doctors claim the public are unable to grasp the significance of research findings ?
jane t
Read the original statement by anonymous.
"The good studies on birth centres run by midwives vs. hospitals consistently show a doubling in mortality for the little ones in the "low risk" birth centres (see Cochrane database). Sick."
It says "birth centres"
The Cochrane review was about birth centres.
It was to show midwife care by itself is associated with increased risk - these birth centres are attached to hospitals and babies can be delivered quickly if need be. Just the fact that it's midwives doubles the risk.
Don't you fucking understand that?!
You're so ignorant and blind.
Unpublished sociology PhD on an unrelated subject!?
You tit!
Richie, I'm going to copy that adn give it to my students, excellent summary! Perhaps some of them m ight actualy read it, as it comes from the 'net.
COI Peer reviewer for a major journal, so far have accepted 2 papers (with revisions) from the last 23 I have read. Guidance is needed.
Okay - you have all shown very well that medical research is confusing and very open to argument! As a layperson, what I take from this whole discussion is:
- There is probably some amount of increased risk in low-risk home birth vs. low-risk hospital birth. The cause of the danger will be different -- if you are unlucky enough to have a big post-partum bleed, you will obviously be better off in a hospital (can I say this? It seems like common sense, anyway!). But in a hospital you may possibly be in slight danger in other ways (I don't know how, but might guess hospital bacteria, being left alone, etc...?). I would choose the hospital in any case... another mother with a low-risk birth might want to gamble on not needing fast access to the hospital. I don't really have a problem with that (and remember I am not a medical person at all!!).
However, the Kent Independent Midwives appear to pride themselves on offering home birth even to those the NHS has decided are too high-risk for home birth. The other story, Jane's story, is still available to read, at:
http://www.kentmidwiferypractice.co.uk/2006/birthstories/janebykay.htm
a quote:
"Jane certainly had an interesting previous birth history including 2 caesarean sections and 2 induced labours. It was the on-going kidney disease that was the most concerning however and how pregnancy and birth might adversely affect her. Jane could most certainly be considered ‘high risk’ which is why she was unsupported by the NHS in her wishes for a home birth."
However, the Kent independent midwives offer home birth even to higher risk mothers -- after all, at the top of their webpage it says, "Supporting *Women's* choice", with "Women's" in very large letters! I.e., even if the (scare-mongering?) NHS midwives tell you you are not suitable for a home birth, you still have a choice as the independent midwives will be happy to take you on! Good news for any mothers who have been turned down by the NHS midwives!!
- Christie
I began anaesthetics in 1971,a time when the UK had many small GP run maternity units + home deliveries were common. As an SHO I was part of the Ob Flying Squad which sent an Ob registrar,gasman and madwife to bail out any untoward event in the delivery suite/bedroom. Having seen several episodes of inversion of the uterus as a flying squad member and now having 35+ years of
Ob anaesthesia behind me I feel that Home Delivery is best left to Domino and his Pizza team.
"So, Jane_T, question asker, this is how research works. Sometimes it doesn't. But its still the best there is. Perhaps you have an alternative?"
Richie, why would you think I would have or want an alternative? This is how I thought it should work, I was asking why it isn't always used.
Amy tuteur,
you seem happy to rubbish any research I offer without reading it but have still not been able to give me any links to research to support your views. You've managed to find some research to quote on a side issue, so how about providing evidence on home birth. You say they all show it's dangerous so it shouldn't be difficult. Until you do, it's not worth bothering to talk.
Dr Thunder,
"1) Just because something is "research" doesn't make it correct. Whether it is published in a reputable journal, or is someone'r unpublished PhD thesis."
Obviously. But maybe others with more knowledge could look at the figures and say why it's incorrect.
"2) Just because something is on the internet also doesn't make it true."
Well dohh, I'd never have guessed that. Yet most medical people here seem to expect me to take their word for it. I don't know them, I don't know their qualifications, but they continue to say 'home birth is dangerous' without providing any evidence.
"3) Just because something was once published, doesn't mean it's currently up to date.
"It's very hard to argue about the medical evidence if you're just googling "evidence for homebirth safety" or whatever. you're going to miss swathes of up to date research by doing that. Most of it isn't published online in enough detail that you can work out if it's good quality or not, unless you have a subsciption or other access to the journal."
That's why I keep asking for evidence - still nothing. How do you suggest patients make an informed choice on this issue? I don't believe for a minute that most doctors keep up with the research (it would be unreasonable to expect them to) so it's not worth asking them. It seems reasonable to believe that the majority of people who carry out research have more knowledge of the subject than me or my GP.
anonymous 8.02am
"Unpublished sociology PhD on an unrelated subject!?"
How is a comparison between home birth and hospital birth involving over 800,000 births unrelated?
a & e charge nurse:
"you seem to be suggesting that only doctors are capable of evaluating (clinical) evidence?"
I would go much farther than that. I would state as fact that only people who understand science, and statistics, and have formal training in obstetrics are capable of evaluating the evidence.
I would make a further, more basic claim. Only people who have actually READ the scientific papers from start to finish (not the abstracts, not the "explanations" of other homebirth advocates) are capable of evaluating the evidence. Let us be honest here. How many homebirth midwives and homebirth advocates have read even ONE scientific paper? Virtually none. Homebirth advocates are constantly congratulating themselves on being "educated". In reality, they are among the least educated people around on the subject of childbirth. Most of what they think they "know" is actually false, and they don't have a clue.
"Amy Tuteur clearly thinks ALL births should take place in hospital - I dare say that if the entire population of sick adults moved into hospital as well there might be a few less deaths (providing they can all dodge c-diff spores/MRSA, etc)."
I am stating an empirical fact. All the existing scientific evidence to date shows that homebirth has an increased rate of preventable neonatal death compared to hospital birth for comparable risk women in the same year. Even when you include iatrogenic illness in the hospital population, even when you include malpractice in the hospital population, the hospital population STILL has a lower rate of preventable neonatal death. There is simply no question that the hospital is the safest place to give birth. The only people who appear to be unaware of this fact are homebirth advocates.
Women are entitled to make whatever choice they wish, but they cannot possibly make an informed choice when homebirth advocate prattle an endless stream of factual misinformation, distortions and outright lies.
jane_t:
"you seem happy to rubbish any research I offer without reading it"
What makes you think I haven't read it? Just because you haven't read it and simply parrot the claims of other homebirth advocates does not mean that I haven't read it.
Go Amy.
Most of these reading have seen your (correct) posted analyses of the "seminal" homebirth studies and support your views on the dangers.
I love how they say "show us the research", "give us the links". And you do, but they ignore them and your commentary!
Oh well, they know that very few people support their crackpot views, hence their frustrating, repetitive & brainless posts.
Go Amy.
Most of these reading have seen your (correct) posted analyses of the "seminal" homebirth studies and support your views on the dangers.
I love how they say "show us the research", "give us the links". And you do, but they ignore them and your commentary!
Oh well, they know that very few people support their crackpot views, hence their frustrating, repetitive & brainless posts.
Thank you, Amy Tuteur - if you think only those with 'formal training in obstetrics' are capable of evaluating evidence, then you effectively preclude MOST doctors (from having a meaningful opinion)since they will not have rotated to this specialty after qualifying.
If even the doctors cannot understand the evidence (based on the standard you suggest) then who does this leave to present the numbers to the now rather worried mothers ?
a&e charge nurse:
"if you think only those with 'formal training in obstetrics' are capable of evaluating evidence, then you effectively preclude MOST doctors"
What are you talking about? All doctors receive formal training in obstetrics in medical school.
The point is that homebirth midwives and homebirth advocates are not qualified to evaluate the evidence; they don't even bother to read the actual papers in any event. Therefore, they must either acquire more knowledge or consult those who have more knowledge. It is irresponsible of them to offer medical advice and opinions when they have no idea what they are talking about.
Amy Tuteur - you mean medical students then, sorry, I thought your comment implied doctors with hands on experience, and post-reg training in the O&G specialty (such doctors are a statistical minority, of course).
Are you seriously suggesting that midwives should not have opinions (due to lack of knowledge) ?
In what way does this type of polemic advance the possibility of finding common ground between the various parties ?
A&E Charge Nurse: Statins useless? Pah! They are making an Aspirin-like comeback. In my speciality (ICU) they are rising Phoenix-like from the hypercholesterolaemic flames).
Coming to you soon:
Statins in SAH preventing delayed vasospasm:
http://www.bestbets.org/cgi-bin/bets.pl?record=01142
Statins in severe sepsis:
Lancet. 2006 Feb 4;367(9508):413-8
And so much more. RCT results pending for both.
Start taking your statins (again) now....
Crippo - thanks for the appreciation of the study explanation. Built on bitter experience unfortunately.
Jane_T - don't let the ruder members of this faculty beat you down
Is this the longest running comments thread ever? Everyone loves a Madwife!
a & e charge nurse:
"Are you seriously suggesting that midwives should not have opinions (due to lack of knowledge)?"
Yes. Are you seriously suggesting that midwives should have opinions without bothering to learn the scientific evidence as they are ethically required to do? Are you actually suggesting that anyone should take midwives seriously if they think their opinions about topics on which they are ignorant are of any value to anyone?
Isn't the answer that "expertise" is a sliding scale?
Real experts know what they are experts in, and what they are not. And part of learning to be an expert in your chosen field is to recognise when someone else knows more than you. And also to know where you are likely to find real experts giving real expert opinions (like Cochrane reviews).
PS In the specific example of childbirth our local household hierarchy of expertise goes (bottom to top)
- social worker neighbour who had primip home birth aged 43 after reading multiple mad articles in the Guardian
- me (bioscience academic w PhD)
- Mrs Dr Aust (hospital doc w MRCP)
- our consultant obstetrician at the local hospital where Mrs Dr Aust gave birth
PPS I'm finding reading all this very educational - really. And I second Crippo's comments about Richie's step-by-step account of the medical research process
amy tuteur,
"What makes you think I haven't read it? Just because you haven't read it and simply parrot the claims of other homebirth advocates does not mean that I haven't read it."
If you've read it, can you say where he went wrong in his analysis of birth records in California? I must admit that I didn't read every word of his dissertation but I read most of it. As you don't even seem to be aware that it's available for me to read and believe I could only have been parroted the claims of home birth advocates I suspect you didn't even follow the link. I didn't see the research mentioned on a home birth web site because I've not read any home birth advocate web sites. I've purposely limited myself to respected web sites like PubMed and BMJ and have followed some links from these sites.
"I would go much farther than that. I would state as fact that only people who understand science, and statistics, and have formal training in obstetrics are capable of evaluating the evidence."
But you seem to rule out all of the people who understand science, and statistics and have a formal training in obstetrics if their research findings disagree with your opinion.
anonymous 7.09pm
"I love how they say "show us the research", "give us the links". And you do, but they ignore them and your commentary!"
Well I've just gone through all of amy's posts in this thread and still haven't found this research you mention. Can you repeat the link for me?
Maybe she should pass on these links to the Birthplace in England Research Programme (http://www.npeu.ox.ac.uk/birthplace), she might save them some money. They seem under the misapprehension that "research reviews have identified major gaps in the evidence including whether there is a difference in the rate of any good or bad outcomes for mothers or babies depending on where birth is planned" and are spending lots of money on more research. If amy is to be believed, they are mistaken and are wasting taxpayers money.
PS Dr C, have you reported Mary to the NMC yet?
PPS thank you, Richie.
I have reported them to the RCM and the RCOG.
I think their unrelenting rants against colleagues and NHS procedure is extremely unprofessional and is not giving women the supportive informed environment that they claim.
As for their obstetric knowledge in dealing with high risk/emergency cases...they seem positively dangerous...but then we only have their word on that matter.
Penny
Thank you Penny. Losing a baby at 12+ weeks gestation is bad enough. I can't begin to imagine what it's like to lose a baby at term. You may want to consider reporting them to the NMC as they can strike them off. Don't know if the RCM or RCOG can as one is a trade union and the other is for Obstetricians and Gynaecologists. Check this page, http://www.nmc-uk.org/aArticle.aspx?ArticleID=2667, for further information.
Hi Jane_T here's two that are freely accessible (I could find more but only through my hospital intranet library which, unless you personally subscribe to JAMA or The Lancet would be difficult to access)
One is peer reviewed & published in a (decreasing in importance since they started getting populist) medical journal; against it is its 10 years old & the lead author is a 'consumer advocate' - I've no idea what that is & the reason it counts against the study purely reflects my prejudice; I tend to like studies in medical journals to be lead-authored by doctors.
http://www.bmj.com/cgi/content/full/317/7155/384
And another is here:
http://www.greenjournal.org/cgi/content/full/100/2/253
This is retrospective which also counts against it but is fairly alarming in the finding that those born at home were twice as likely to die and these were low-risk pregnancies. It does contain the interesting statement that analysis of the mothers showed them to be 'better educated'; presumably not against the risks of home birth though...
To obtain the information you request would seem to be ethically problematic. Ideally you would prospectively take mothers presenting to GP/midwife/obstetric clinic for their first antenatal appointment & randomise them to home birth or hospital birth, matching each group for age/parity/gestation/maternal pathology etc.
Then you let them give birth. Then you measure how many babies/mothers died or suffered significant morbid events. You don't need to be an ethicist to see that this might be somewhat problematic. So it seems that retrospective audit & the flawed data that produces will probably have to do.
I hope you understand some of the frustration of the medical profession surrounding lay interpretation of specialist papers. Medical journals are written for medical specialists; the media merely report the conclusion of the abstract (& often incorrectly interpret it). Your questions are as valid as anyone's but there are some things that Google can't answer & context is the key. I realise that Guardian readers demand their specialists interpret everything for them; in the old days this was taken on trust. If I spent every family meeting explaining the mechanics of dialysis or ventilation or the pharmacology of inotropes I would never get my job done (and sometimes people have asked me to - "so Doc, how does this machine actually work?")
I view this approach to medicine as the equivalent of refusing to fly anywhere until the pilot has explained to most of the passengers how the airplane actually works. I don't need to know that. I just trust the system has trained him/her to the safest standard necessary & that they will do their best to get me to where I'm going.
So why does the public expect differently of doctors? (Are there any 'Pilot Practitioners?')
jane_t:
"If you've read it, can you say where he went wrong in his analysis of birth records in California? I must admit that I didn't read every word of his dissertation but I read most of it."
Let us be honest here. You haven't read even one scientific paper on homebirth from start to finish, have you? So why do think you know anything about this topic? Why do you think anyone should pay attention to anything you say? More importantly, why do you suggest to other women that they should ignore what doctors say in favor of your uneducated, entirely fabricated "opinion" on the topic?
"But you seem to rule out all of the people who understand science, and statistics and have a formal training in obstetrics if their research findings disagree with your opinion."
Really? How would you know that? You haven't read the research, and you lack the formal training to evaluate it in any case.
Richie, thanks for the links. I've had a look at the first study and would be greatful if you or anyone else with knowledge in this area (and the time, of course) could look through and critisize my thoughts on the research.
"Overall, information was available for 7002 planned home births during 1985-90. Information came from individual notification forms in 5052 (72%) births, from summaries in 1372 (20%) births, and from home birth support group newsletters in 576 (8%) births. Two additional births resulting in deaths were identified from other sources; these were confirmed by state perinatal data collections."
Unsure about the appropriateness of including the two additional births resulting in deaths from other sources. Wouldn't this bias the results as they were not random selections? It would be easy to prove something is unsafe by searching out the problem cases and loading the results with them.
The sources of information on deaths seem strange, they included an newsletter, for example.
Causes of death included lethal malformation, SIDS, Postviral cardiomyopathy and chromosomal abnormality. Could these have been caused by the place of birth?
"Of 43 deaths with known birthweight, 11 (25.6%) were less than 2500 g of whom four were malformed. Of 44 deaths of known gestational age, eight (18.2%) were preterm (<37 weeks) and seven (15.9%) post-term (>= 42 weeks)"
"Recognisable risk factors in pregnancies resulting in 23 deaths from intrapartum asphyxia" (included breech presentation, twins, Intrauterine growth restriction)"
Wouldn't these have been counted as high risk births in the UK and not been considered suitable for home birth?
"In most cases there had been warning signs during labour. Often these occurred early enough to have allowed timely transfer. In seven cases, meconium or bradycardia, or both, were noted several hours before fetal death. In some cases, risk factors and warning signs accumulated without prompting effective action. In none of the intrapartum asphyxial deaths was the fetus alive on arrival in hospital
Two deaths occurred in water births (n=344); in both cases the fetal heart had not been listened to during second stage labour."
This suggests lack of training rather than an intrinsic danger in home birth. I've read elsewhere that in Queensland, registered midwives can, and do, go into independent midwifery practice after the basic 12 months' training and 20 normal deliveries. Although the College of Midwives has rigid criteria, they are neither enforced nor policed. Is this similar to the UK?
"A search of the literature during the 1980s and 1990s identified seven studies with definitions and criteria that permitted comparison with the national Australian data. These studies were from Australasia, Europe, and the United States. Australian planned home births had a perinatal death rate about twice as high as these countries."
"Australian home birth practitioners might differ from home birth practitioners elsewhere. Home birth practice in Australia is nearly 100% private practice and characterised by low caseloads. On average during 1985-90, 53% of practitioners attended less than five home births a year, and only 13% attended more than 20 home births a year. This contrasts with the Netherlands, for instance, where home midwifery caseloads of more than 100 births a year are common."
Is it appropriate to compare between countries? How important is it to compare like with like?
Part of the conclusion:
"A fourth, and more compelling explanation, is that some home birth practitioners in Australia no longer offer home birth to women at low risk. At least 18 deaths (36%) in this study occurred in twins, post-term and preterm infants, and breech presentations, which would be contraindications for home birth elsewhere. Post-term births had a death rate twice that of other home births, and home birth mortality was 1 in 14 for breech presentation and 1 in 7 for twins. The two largest contributors to the excessive mortality were an underestimation of the risks of perinatal asphyxia in such births and, more generally, underestimation of the significance of fetal distress. This raises questions about other effects of prolonged asphyxia that were not addressed in this study."
I would conclude from this study that it's very important for the level of risk to be established before birth and during the early stages of labour and high risk mothers strongly discouraged from having a home birth. Without re-working their figures to correct for this (I haven't got the necessary skills or information to do this) I've no idea what the situation would have been if only genuinely low risk births had happened at home. Would you agree?
Amy, still on evidence? Do you think it appropriate for me to take the word of stranger on the internet?
Jane_T:
"I've had a look at the first study and would be greatful if you or anyone else with knowledge in this area (and the time, of course) could look through and critisize my thoughts on the research."
Hilda Bastian set out to show that homebirth is as safe as hospital birth. Her homebirth advocacy credentials are impeccable. She gave birth to her own children at home; she was a leader of a Homebirth Australia (prior to engaging in research); became active in consumer affairs because of her unsatisfactory experiences with the medical profession; and whe was member of the Cochrane Review board.
Here is how Bastian described the results of her study:
"The comparison of home and hospital births showed categorically that the rate of death for normally formed, reasonably sized babies was significantly higher in home births ... The principal source of this excessive rate of death was a very high rate of intrapartum deaths. Such a high rate of death in labor must always raise questions about the adequacy of care around birth. The conclusions of the study are not at all surprising. With many high risk home births, and many long delays to transfer (or no transfer at all) after fetal distress, babies needing intervention to survive were inevitably dying.
It is true that these outcomes may not reflect current practice. While death rates in hospital are decreasing, in home births they have actually increased."
In other words, the deaths occured because the midwives did not understand which patients were high risk and which patients needed to be transferred.
Figures recently released by the Department of Health of Western Australia confirm these findings.
"The unanticipated perinatal deaths at homebirth in 2002-2004 followed on the heels of unanticipted perinatal deaths at homebirth from 2000-2002. Accordingly, the Department of Health attempted an in depth review as part of its 12th Report of the Perinatal and Infant Mortality Committee of Western Australia:
There were a total of six unexpected term perinatal deaths amongst planned home births recorded in the five years Jan 2000 – Dec 04. The six deaths occurred between 38 and 41 weeks gestational age, and involved singleton pregnancies with no overt congenital abnormalities. Two deaths were antepartum and four were the result of an intrapartum complication (two stillbirths and two early neonatal deaths). Three of the deaths occurred at home and three occurred in hospital. One of the six babies delivered at home, and five delivered in hospital. Four of the six cases had low-level medical preventability scores (2 or 3) and two cases had no evidence of preventability.
The term perinatal mortality rate was 6.7 per 1,000 total births, compared with a term perinatal mortality rate of 2.1 per 1,000 total births in the planned hospital births in the same period, which was a statistically significant difference (Fisher Exact p=0.013)...
Trend data show that the proportion of planned home births has remained fairly stable at between 0.4 – 0.7% of all births over the past 15 years."
The Committee reached the following conclusions about homebirth:
"A small but significant number of women choose a planned home birth. Ideally that choice would be 'informed choice'. The current risks and benefits of home birth in Australia are not well understood, due to low numbers and lack of recent research. However, there was an increased risk of perinatal mortality in planned home births compared with planned hospital births in a large Australian study of home births where analysis of births in the four years 1985-1988 for which the most comprehensive data were available showed that in babies of at least 2500g birthweight there was a perinatal mortality rate of 5.7 deaths per 1000 births in planned home births compared with 3.6 deaths per 1,000 planned hospital births. Intrapartum death not associated with congenital malformation or extreme immaturity was three times as frequent in planned home births than it was nationwide...
... Whilst there have not been any maternal deaths in planned home births in WA in recent years, there may be concern about the potential risk of maternal death, particularly due to postpartum haemorrhage in the home setting. There was a significantly increased risk of third stage complications in planned home births in WA 1981-1987.
The information presented from the WA 2000-04 analysis shows that the choice of home birth would appear to have put 'low risk' women into a 'higher risk' category of perinatal death,.."
No Jane,
It would be appropriate that you take the word of your specialist who knows your individual medical history, has a knowledge of the (flawed) research done on this topic and has years of experience of dealing with the major emergencies that can happen very quickly without warning in the lowest risk women. It would be helpful if you stopped writing on this website about something you have no knowledge of, no training or experience in and therefore no valid opinion.
Spending hours of your time reading a large unpublished (for a reason - it's crap) study and other flawed research isn't good. You've wasted all that time without realising the research was rubbish (because you haven't the training) and still you go on!
Points:
The definitive study on homebirth will NEVER be done for ethical reasons.
There is a consistent theme in most (flawed) studies that home birth doubles (or more) the risk in low-risk women.
All obstetricians and most midwives recognise that they deal with horrible emergencies in low-risk women on a regular basis that takes all their training and a large amount of help to safeguard women & babies. All recognise that at home, these would be difficult or impossible to manage, even if the midwife were good.
Most midwives who do home births have attitudinal or political or clinical-ability problems which is why they're working independently, away from scrutiny of their practice.
Many independent midwives practice without insurance, which is unethical.
The much touted Netherlands homebirth system, is becoming a lot less popular as women move to hospitals. The women know the score. The perinatal mortality rate is high in this country, despite not counting 24-28 weekers like in the UK for instance. This would make their rates even higher.
The Swedish homebirth study demonstrated a six-fold increase in mortality, despite great resources and a healthy population.
Cheers
Ritchie
"THIS IS THE BASIS OF ALL MEDICAL INTERVENTION. I fail to understand how non-medics continually rally against this basic principle of common sense (including Primum Nocere). But then they are never in that situation. "
If only it really were that simplistic.
Unfortunately, you see very different rates of intervention/procedures depending on the way that doctors are recompensed.
So, in a health system where docs get an inclusive salary - guess what? they do less procedures. Then introduce a system where docs get paid per procedure - guess what? more procedures. It's simple economics of health care systems. Add into the mix the fear of litigation, and you can see why the c-section rate in the US is far higher than in other countries with no concomittant improvement in outcomes.
Docs aren't evil, of course not. But they're not saints either. And (this may surprise you) they are subject to the same economic/social influences as the rest of us mortals.
Amy said,
"In other words, the deaths occured because the midwives did not understand which patients were high risk and which patients needed to be transferred."
So lack of training and selection of unsuitably high-risk pregnancies for home birth, as I concluded and not a study into low risk home birth. Is training in Australia comparable to the UK? Can midwives in the UK go into independent midwifery practice after the basic 12 months' training and 20 normal deliveries? Are midwifery policies routinely ignored or not policed?
You go on:
"There were a total of six unexpected term perinatal deaths amongst planned home births recorded in the five years Jan 2000 – Dec 04."
You fail to mention that these results have not yet been fully reviewed and that:
“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.”
and:
"Dr Towler said the Department had worked closely in the past two years with the CMWA to enhance the standards, protocols and governance of the service and was pleased with the progress that had been achieved. To date there have been no perinatal deaths in the program in 2007."
http://www.health.wa.gov.au/press/view_press.cfm?id=756
http://www.health.wa.gov.au/publications/documents/mortality.pdf
In the report it states:
"Four of the six cases had low-level medical preventability scores (2 or 3) and two cases had no evidence of preventability."
What does low-level medical preventability score mean?
They also state:
"Advocates of home births have often quoted ‘safety data’ from international studies, but it is difficult to extrapolate from international data to the situation in Australia where there are differences in many respects, including training and experience of midwives, and geography. The difficulty of emergency transport services to offer safe retrievals in WA is a major consideration."
This is presumably true also when making the comparison in reverse.
They conclude (partially quoted previously by you):
"The information presented from the WA 2000-04 analysis shows that the choice of home birth would appear to have put ‘low risk’ women into a ‘higher risk’ category of perinatal death, although possible demographic differences in the group of women who chose home birth compared to those women who chose a hospital birth have not been examined. In addition, there is no information available to the Committee regarding morbidity outcomes for women who had a home birth. A formal review of home birth outcomes in WA may answer some of these questions."
Hopefully the review will further improve home birth risk which already appears to be improving. I'm still not convinced their situation is comparable to the UK, but I'm willing to be persuaded that this is the case.
Sorry, another study as recommended by Richie:
This study is much more convincing.
"Because Washington State birth certificates do not identify which home births are planned, we defined planned home births as those singleton newborns of at least 34 weeks’ gestation who were delivered at home and who had a midwife, nurse, or physician listed as either the birth attendant or certifier on the birth certificate (if an attendant is not listed on the birth certificate, then the person listed as the certifier attended the delivery)."
So some unintentional home births may be included. It's possible that the patient's midwife, nurse or doctor arrived after a quick, unplanned home birth and were recorded as a certifier on the birth certificate as a result. The unpublished California study sounds very similar to this, though it used all births during the study years and the information they used included details of the planned place of birth.
To be fair they do attempt to correct for some unintentional home births,
"To minimize misclassification of intended and unintended home births, the main analysis was confined to births in which there were no recorded pregnancy-related complications (6133 home births, 10,593 hospital births), because it is unlikely that women with one or more of these complications actually intended to deliver at home."
"The safety of intended home births remains controversial. In one population-based cohort study of 3067 intended home deliveries in Missouri, there was a twofold increase in the overall risk of neonatal death in babies delivered at home compared with hospital deliveries attended by physicians. Providers of all levels of training attended the intended home deliveries, with higher risk estimates associated with lower levels of attendant training. A second cohort study of 934 home deliveries in North Carolina observed that the risk of neonatal death was four of 1000 live births in planned home deliveries attended by lay midwives, 30 of 1000 live births when the home delivery was attended by a provider other than a physician or lay midwife, and 12 of 1000 live births that took place in hospitals. Thus, there was a suggestion in both studies that the level of training of the home birth attendant may partly determine the outcome of the birth."
It's important to know how training in the UK compare to the US.
"A fourth study comparing 6456 out-of-hospital births attended by licensed midwives to 23,956 hospital births attended by physicians in Washington State during 1980–1990 observed that out-of-hospital deliveries were associated with a comparable rate of neonatal death as hospital deliveries. This study addressed possible confounding by maternal age, ethnicity, marital status, occupation, parity, adequacy of prenatal care, classification of residence, and pregnancy-related complications on neonatal mortality in both groups. However, information allowing more accurate determination of the intended location of delivery became available from Washington State birth certificates only at the end of the period included in this study, limiting the ability of the authors to remove potential bias from the misclassification of infants of planned home deliveries who were born after transfer from home to medical facilities as hospital births."
They would also not have been able to recognise unintended home births (presumably precipitous births) which are known to have higher rates of bad outcomes. We don't know if one group would have cancelled out the other.
"The proportion of physicians attending home births in this cohort was too small (7.6% of all home births) to examine pregnancy outcomes for this group alone. Unlike the previous study done in Washington State, ours did not address the influences of different types of non-physician attendants in the outcomes of home delivery because we could not readily verify this information on the Washington State birth certificates. A study done by Myers et al showed that birth certificate data correctly identified attendant type for out-of-hospital births 30% of the time. The major source of attendant misclassification was between the various types of midwives. The proportion of misclassification between professional and nonprofessional providers was not assessed."
So we have no idea of the training received (or not received) by the attending midwife and it sounds as though it's legal for non-professional providers to attend births. Again, not really comparable to the UK.
They conclude:
"The results of our study suggest that planned home births are associated with an increased risk of adverse neonatal and maternal outcomes, particularly among nulliparous women. Nonetheless, more light needs to be shed on this controversial topic before practitioners and expectant parents can be fairly counseled about the safety of planned home births. Future observational studies using a study design that accurately assesses the intention to deliver at home, adverse pregnancy outcomes, and relevant confounding factors are needed."
This sounds a fair summary for parents in Washington State, taking into account the poor information available to them in some areas of significance. Not sure how relevant it is to the UK. We would need to know how comparable midwifery training is for a start and also if I'm correct in believing that it's legal for non-professional provides to added births there. Again, more research is needed.
The 'Collaborative survey of perinatal loss in planned and unplanned home births' took place in the UK and involved all 558,691 registered births to women normally resident in the former Northern Regional Health Authority area during 1981-94. A bit old now but at least it's the UK and large numbers.
http://www.bmj.com/archive/7068pr2.htm
I haven't had time to read it properly yet their conclusion includes:
"During that time the death rate in labour or the neonatal period in non-malformed babies of normal birth weight born to women booked for a home delivery (those deaths most capable of reduction by high quality care during labour) was as low as the regional figure for all other such losses (0.05% v 0.11%)."
and
"Perinatal loss is only one issue that needs to be taken into account when considering home birth, and the fact that very few babies died does not of itself show that arrangements for home birth were necessarily safe. Nevertheless, women wanting a home birth will take heart from these figures. Such results were achieved only by vigilance, ready access to hospital services, appropriate and timely transfer when problems arose during either pregnancy or labour, and by the readiness of both midwives and mothers to contemplate transfer promptly once problems were identified."
Their key points are:
"Key messages
# Perinatal mortality in babies born outside hospital was four times higher than the average for all births in the Northern region between 1981 and 1994
# Only three of 134 deaths were associated with planned home birth
# Over three quarters of the perinatal deaths associated with planned home birth occurred in hospital
# The hazards associated with planned home birth are quantifiable only when death is classified according to the original planned site of delivery
# Perinatal mortality in the few (<1%) pregnancies in which home birth had been planned was less than half the average for all births, and few of these deaths were associated with substandard care"
Petra:
"Docs aren't evil, of course not. But they're not saints either. And (this may surprise you) they are subject to the same economic/social influences as the rest of us mortals."
Again, this generic lumping together. Please don't patronise me ('may surprise you'). This is a UK NHS-based blog; I am a UK-trained, southern-hemisphere working doctor. The systems I trained & currently work in (and this may surprise you) fall under the schemes of 'socialised medicine' (as the opponents of Michael Moore choose to call it). So the economic/social influences do not apply as to whether a C-section is more expensive than a PV delivery. I don't have an HMO deciding how much money I will get for my procedures or telling me what I can & can't do for my patients. I am paid a fixed salary by a district health board. My pay is not performance related. I also work in a system that is 'no blame' with no ability for patients to seek legal recompense against individuals or hospitals as the state has an all-inclusive insurance policy that covers your care should you be unfortunate enough to suffer at the hands of incompetent staff or equipment failure. Again, I chose to work in this system. So your comments about American healthcare do not apply to the statement I made.
The economic factors you allude to are instrumental in 20-30% of American citizens having no healthcare insurance. And why I would never choose to work in America where financial considerations outweigh patient care.
So, yes, at this level, it really is that simplistic.
Please don't apply North American (sorry Canadians) prejudice to a UK forum.
In view of several comments and a large number of emails, I have now passed on the details of the Kent Midwifery Practice to the regional midwifery supervisor and also the NMC.
Helen O'Dell 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.
If anyone wishes to make their views known, the relevant email addresses are:
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
jane_t:
"So lack of training and selection of unsuitably high-risk pregnancies for home birth, as I concluded and not a study into low risk home birth."
You seem to have missed the point entirely. The midwives did not understand that they could not manage those situations, AND they often did not understand that complications were occurring even in the midst of the complication. Most importantly, they did not know how to manage those complications, which can occur also occur in low risk women.
The bottom line is pretty straightforward. Even the lowest of low risk women can and will have life threatening complications. If a life threatening complication occurs at home, and if immediate C-section or expert resuscitation (intubation) is needed to save the baby, the baby will die. The only way that homebirth could even be as safe as hospital birth is if the preventable homebirth deaths were offset by preventable hospital birth deaths. That does not happen. Contrary to all the prattling of homebirth advocates, there is no evidence that hospital "interventions" cause preventable neonatal death and a massive amount of evidence that hospital interventions prevent massive amounts of neonatal death.
jane_t,
"I haven't had time to read it properly ..."
Then why are you commenting on it?
Why do you keep making claims about studies that you have not read? Read the actual study. Analyze the actual data. Do not tell us about the abstracts. Do not copy the claims of other homebirth advocates, which impress you because you haven't read the papers and don't understand the actual paper.
Amy said:
"You seem to have missed the point entirely. The midwives did not understand that they could not manage those situations, AND they often did not understand that complications were occurring even in the midst of the complication. Most importantly, they did not know how to manage those complications, which can occur also occur in low risk women."
Yes, exactly, lack of training. It doesn't follow that every midwife in every part of the world is similarly lacking the appropriate skills and training, just as the examples of poor performance by obstetricians resulting in death and injury doesn't mean that all obstetricians will perform badly.
"The bottom line is pretty straightforward. Even the lowest of low risk women can and will have life threatening complications. If a life threatening complication occurs at home, and if immediate C-section or expert resuscitation (intubation) is needed to save the baby, the baby will die."
And absolutely no low-risk women and their babies die or are injured as a result of interventions that may not have been necessary? Every single intervention in UK hospitals is necessary? The huge differences between intervention rates used by Odent without increases in morbidity or mortality suggest that many interventions in UK hospitals could be avoided and often are avoided with home births. Interventions such as forceps and c-sections do cause morbidity and mortality. They are probably necessary when they are carried out in UK hospitals, but could a different approach to birth from the start avoid the need for the intervention? When UK hospitals are able to match Odent's success rates, maybe women will not feel such a need for home birth and they will also benefit from the brilliant backup provided by a hospital when things do go wrong. How do you explain Odent's low intervention rates? If you believe that c-section rates of about 20% are necessary, why didn't more women and children die or suffer injury with Odent's rate of 6.6%?
For those that missed it on the other thread I've repeated the part about Odent below.
"Then why are you commenting on it?"
I didn't comment on it. I quoted parts and intended to ask how the study is regarded in medical circes but forgot to add that bit.
Odent
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."
Amy, sorry missed this bit.
"Why do you keep making claims about studies that you have not read? Read the actual study. Analyze the actual data. Do not tell us about the abstracts. Do not copy the claims of other homebirth advocates, which impress you because you haven't read the papers and don't understand the actual paper."
I have read the studies I've discussed in detail. You've obviously not read my previous posts well enough because I've already said that I haven't read home birth advocate web sites and have quoted directly from the papers. Of course I don't understand everything I've read. That's why I've asked for clarification and asked if my understanding is correct.
"Please don't apply North American (sorry Canadians) prejudice to a UK forum."
Ummm. OK. COnsidering that I'm British, I guess it'd be a bit difficult to do in the first place.
My US example was illustrative. Even under socialised medicine systems, doctors are recompensed in different ways - and the system of compensation changes the types and amounts of interventions/procedures that are carried out. You, personally, may indeed be above such materialistic interests. Many of your colleagues are not.
Wow, to be accused of being patronising by a doctor!! What was the title of this tread again???
Jane T seems to be a bit of an idiot.
She quotes passages without understanding that they are a) not relevant or b) actually harmfull to her argument.
She also seems to be under the influence that forceps/ suction delivery or C-section is a simple choice of "why not" in hospital rather than a serious intervention that is not taken lightly.
The constant reply of "i'm not trained/ i don't understand/ i want YOU to tell me what to make of this study" is fucking silly.
I do wonder what you do Jane t as in my mind you would be dangerous shelf stacking.
Go away ready the papers, appraise the stats and then come back without quoting passages and debate your side.
Otherwise shut up and realise you sound like a moron
Tell us how many of the kids who had no monitoring/ interventions/ go so fucked up that the surgeon eventually stepped in ended up havig problems long term?
Tell you what, i have been in an environment where birth is low intervention. I have seen women torn in pregnancy with no analgesia (for fuck sake does this sound cruel to anyone else?) due to lack of availability.
Lets all go back to third world medicine and tell the unlucky women ...well sorry your baby died/ is damaged but you know its all about "natural birth".
anonymous 1.58pm
What well reasoned, constructive arguments you put forward. 10/10 for effort. It must be so nice for you to have such good playing out weather today too! Hope you're making the most of it. Please don't listen to the kids in school who say that education and learning are uncool. There's nothing wrong with trying to learn and understand new ideas. You go for it!
Almost as good as your efforts Jane T.
At the end of the day i don't know why i am even directing comments towards you.
If you were a midwife or a doctor then i would be really scared, until then its just trying to make a dimwit see the light.
To be fair school age children would probably have less idiotic ideas than you.
At least i don't have to ask people to translate my posts and get bak to me with what they actually mean.
I kept it nice and simple for you, i'm a nice guy you see.
Jane_t - with all due respect, you're a batshit, agenda-pushing fool. Yeah we know all about your miscarriage, your bad experiences with the NHS etc. etc., but you're now just flailing about like a madwoman.
Firstly - you say that homebirths only fail due to 'lack of training or expertise'. This WHOLE debate has been about madwives who ARE trained, who HAVE NHS expertise, but decide that all medical intervention is bullshit, and that 'love' and 'woman-centered healing' can bring about the perfect birth. To me, knowing the facts and IGNORING THEM is far scarier that an untrained person, ignorant of medical facts, doing the same.
Secondly - If you are ill, do you chant to the Moon Goddess, and hope it will all be ok? If you had cancer would you leave it untreated, after all, that is the 'natural way'. 'Natural'=/='Good'. Belladonna is natural, as is tuberculosis.
You are the prime example of why these madwives and their ilk are so very dangerous. Uninformed, uneducated people like you Google "hospital birth+bad" and come to your own conclusions of "Oh well, homebirth MUST be better because blah blah blah.." without understanding any of the reasoning behind hospital births. You buy into the madwives' creed of "Mother knows best", and wallow in delusions of 'feminine intuition' and 'mama power'. I've seen this so many times, with HORRIBLE results.
These madwives are no better than UCers, but as I'm trying to stay roughly on topic, unlike you, I'll steer clear of that rant for now.
This debate is about loony New Age madwives (working solely to their own agenda) vs properly-trained, licensed, and insured medical professionals. Not "Wah wah hospitals are evil" or "All homebirths are bad". Keep OT or bugger off.
Petra:
"Wow, to be accused of being patronising by a doctor!! What was the title of this tread again??"
The Midwives of Kent. Not sure how this answers your question. Your US example is not illustrative in any way as it doesn't apply to public practice in socialised medicine. Which is what I was talking about. You have still failed to explain how an NHS obstetrician is 'rewarded' (your word) for performing a procedure that is not medically indicated.
Apologies for the American insult; that was unintended. The patronising accusation however was not. Please wear it as the badge you so wish it to be.
Ritchie:
Aaah, I was thinking more of the pot and the kettle thread that linked to this one.
Whether a health system is socialised or not is not the determining factor in how doctors are paid. In many socialised systems in Europe, for example, doctors are reimbursed after carrying out a procedure. Similarly, a US doctor could be directly employed by an HMO and receive a global salary, irrespective of the procedures carried out.
Anyway, coming back to your original comment that I was responding to, my point was that clinical indications are NOT the only factor in determining a C-section. There are many other influences, such as how a doctor is paid (probably decreasing the likelihood in the UK compared with other countries - which may or may not be a good thing, the jury's out on that - I guess it isn't if you are one of the unlucky women who did need one but didn't get one in time), the culture of litigation (pushing rates up in the US) and the medical culture and acceptability of c-sections.
So, yes, if I have a baby then I would be cognizant of all those influences. I am not a clinician and I have no obstetrical training. But I would expect those caring for me to allow me to make an informed decision and to provide me with the information to do so in all but the most emergent of situations.
I would expect those caring for me to allow me to make an informed decision and to provide me with the information to do
Petra - that is what they do do. I'm not saying this as a (medical) doctor, because I'm not one. I'm saying it as a person who has been through one pregnancy with my other half and is currently going through another. Obstetricians (especially) and hospital midwives will tell you what the relevant numerical risks are, and if they don't, you can ask them to. I can vouch for this having been there to see it (though not in the precise setting of c-section).
The story Dr C quotes shows that some of the madder "pro-woman" midwives do not present the dangers realistically, and seemingly do not understand them, either prospectively or when they are in the thick of it.
The "madwives" in Dr C's example seem to me, as an outside observer, to start from an ideological point of "we are the professionals, we can handle any birth as a homebirth, no worries, right to choose!" But -
- if they are the main ones delivering the information about risks, is it likely their patient really knows what the risks are both in terms of outcomes and of statistics?
- And if she doesn't, in what way is she meaningfully "fully informed and consenting"?
I have known two mothers (friends or neighbours) who opted for home birth squarely against the obstetricians' advice. But at least they were left in no doubt by the docs and midwives of precisely what risks they were taking.
dr aust:
"that is what they do do"
well, ideally. but that doesn't always happen and is filtered through a lens of social, economic and cultural influences. I'm glad that you do feel fully informed.
Anecdotally I cam attest to that from personal experience, having given birth in the US and the UK. Risk, and recommendations based on those risks, are presented very differently. Again, I'm not judging and have no a priori philosophical claims, but I just think interventions such as c sections are not objectively based on risk but influenced by subjective, possibly latent, factors.
And, yes, the same applies to independent midwives who seem to be more explicit in declaring their subjective evaluation of risk, and more extreme in their behaviour.
Best of luck to you and mrs dr aust!
Petra: I'm still not clear what the pot/kettle reference is unless the (blanket) implication is that all doctors are patronising? Or merely the ones on this thread that find themselves increasingly exasperated at being asked to explain complex studies & justify their practice to people with no training & no experience in either?
With reference to your 2 statements:
"I am not a clinician and I have no obstetrical training."
&
"clinical indications are NOT the only factor in determining a C-section"
I am perplexed as to how you are able to make the second statement with any confidence having made the first. As everyone here is now so keen on evidence based medicine, could you provide me with references to the appropriate studies that show this? Perhaps you could also let me know your area of expertise so that I can make uninformed statements relating to that.
I am also curious as to how much information you would require for an 'informed' decision. RCTs? A meta-analysis? A statement of financial declaration form the obstetrician that they do not own shares in the company that makes the drapes for C-sections? My point is that unless you have obstetric specialist training then you are not able to make an informed decision & that is not meant to insult your intelligence (although you may well take it that way). Any 'evidence' presented to you will only reflect the bias of the person presenting it (as there is obviously 'evidence' both ways). That is why we have experts; essentially to decide for you (and again, in a non-patronising way). And why I would only let one of them near my expectant partner. I refer to my airplane analogy in an earlier comment.
Informed consent is (in my experience) rarely that, however much the informer & informee delude themselves that it is. Listing potential complications is not fully informed consent however much the lawyers may say it is.
The key point of this thread, and a point that has been made much more eloquently by others, is that the midwives in this situation were blissfully unaware of the danger that 'Sharon' was in. They describe a post-partum haemorrhage as if it was a minor inconvenience, not a life-threatening event & not only that but they then display it on their website as a triumph of homebirth. And that is why they have been referred to the appropriate people.
Lets start with the fact that this is an English blog and most of the posters are in England it seems.
Doctors in the UK working in the NHS recieve a wage...if you do 20 C-sections or none you get paid the same.
So doing all those nice sections must be for fun.
Petra, the main point is that if an NHS doctor advocates a treatment here its based on clinical judgement (wherther good or bad) but not on financial grounds (getting turned down for a treatment is another thing but not the doctors decision).
Richie,
"Or merely the ones on this thread that find themselves increasingly exasperated at being asked to explain complex studies & justify their practice to people with no training & no experience in either?
Sorry for being so awkward, but it is our bodies and our babies we are talking about here. We will have to live with any consequences of unnecessary interventions on a day to day basis, possibly for the rest of our lives. Unless the obstetrician or midwife has been negligent (and a 20% c-section rate isn't considered negligent even though much lower levels appear to be safely possible) they will not have to live with it.
It's a bit like the diabetes consultants who don't believe it's necessary to count carbohydrates and that HbA1c levels of 9% are fine. By the time a child develops diabetic retinopathy and goes blind, develops kidney failure or one of the other complications of diabetes, as a direct result of these high blood glucose levels, they will no longer be treating the child, they would have moved on to the adult clinic and they will probably never even learn of the results of their poor care. Less than 15% of children in the UK meet the recommended targets for BG levels. These levels are recommended as those that give a good chance of avoiding complications.
Yes, I know it looks like I'm going off at a tangent to all those anonymous people out there, but it's another example of how patients have had to educate themselves to keep themselves or their children safe. Until recently diabetics were told to 'eat a healthy diet' and that carb counting is old fashioned and unnecessary. Yet without carb counting you might just as well dial up three different doses of insulin and inject one at random. Some mother's have even hide the fact that they carb count because they are made to feel as though they are being obsessive. Luckily it's beginning to change and some clinics are beginning to teach carb counting and course like DAFNE are being offered to adults (though not children or their carers).
"I am perplexed as to how you are able to make the second statement with any confidence having made the first. As everyone here is now so keen on evidence based medicine, could you provide me with references to the appropriate studies that show this? Perhaps you could also let me know your area of expertise so that I can make uninformed statements relating to that."
How about the low c-section rates achieved by Odent without increases in deaths and injury?
"The key point of this thread, and a point that has been made much more eloquently by others, is that the midwives in this situation were blissfully unaware of the danger that 'Sharon' was in. They describe a post-partum haemorrhage as if it was a minor inconvenience, not a life-threatening event & not only that but they then display it on their website as a triumph of homebirth. And that is why they have been referred to the appropriate people."
Yes, and as a result of the discussions here they have been reported to the relevant authorities which is a good thing. I don't recall a single person defending these midwives. But discussions evolve and naturally move on to include other issues. I haven't read any rules that say we must stick just to the issue raised in the blog and never drift onto other related subjects and it's especially likely when it's well know how strongly the blogger feels against certain issues (like home birth).
jane_t:
"How about the low c-section rates achieved by Odent without increases in deaths and injury?"
Since it has never been published in a peer reviewed scientific journal, it is irrelevant.
You keep trying, but you keep coming up empty handed. You have yet to find a single study that shows homebirth to have the same or lower neonatal death rate as hospital birth for comparable risk women in the same year. You have yet to present even a shred of information to support your claim that hospitals perform unnecessary interventions.
Since you are so sure that obstetricians perform unnecessary C-sections, please share with us exactly which criteria can be used IN ADVANCE to predict which C-sections are necessary. Unless you can provide definitive criteria that can be used by all providers in advance, you have no idea at all whether there are unnecessary interventions being performed. I recommend reading up on type I and type II error to understand how we determine what level of interventions is appropriate. You must demonstrate that your criteria minimize type I error, or your claims are meaningless.
Amy,
If you show me yours, I'll think about looking into what you are asking me for. I'm not wasting any more of my time talking to you until you attempt to give me some evidence to support your oft reapeated claims that all research proves that home birth is more dangerous for low-risk pregnancies than hospital. If all research proves this it shouldn't be hard to find, even if it's just the abstract. I've lost count of the number of times I've asked you for the evidence and you have avoided the issue. All I can conclude is that you are talking rubbish.
If what you say is true, why does the Birthplace in England Research Programme (http://www.npeu.ox.ac.uk/birthplace) believe that there is no evidence? Why are they being given taxpayers money to carry out the research? Or are they all also strange people who believe in magical thinking and "intuition" who have somehow hypnotised the department of health into giving them money?
jane_t:
"why does the Birthplace in England Research Programme (http://www.npeu.ox.ac.uk/birthplace) believe that there is no evidence?"
You have misunderstood (again). All the existing evidence shows that homebirth has an increased risk of preventable neonatal death. Despite this, the government is trying to promote homebirth as a way to save money. According to the NPEU: "Research reviews have identified major gaps in the evidence including whether there is a difference in the rate of any good or bad outcomes for mothers or babies depending on where birth is planned." In other words, the government has promoted homebirth despite having no evidence to show that homebirth is safe.
NICE recently undertook a comprehensive review of the homebirth literature and concluded that (1)most homebirth studies are poorly done and biased in favor of homebirth and (2) despite the bias in favor of homebirth, those studies STILL show that homebirth has an increased risk of preventable neonatal death compared to hospital birth.
The NPEU is gathering additional evidence because they are deeply concerned that the government has deliberately misrepresented the safety of homebirth in order to save money.
Ritchie:
"
""I am not a clinician and I have no obstetrical training."
&
"clinical indications are NOT the only factor in determining a C-section"
I am perplexed as to how you are able to make the second statement with any confidence having made the first."
Easy. When you look at c-section RATES for a whole population, you find a net association between c-section rates (or other interventions) and the way that they are recompensed.
The dissonance between the statements would be true if I were clinically evaluating an individual case. I am not, nor am I attempting to do so. In such cases, I defer to your expertise. However, at a population level, you can clearly see an effect. Quasi-experiments also indicate changes in procedures when doctors are recompensed differently This means that the way doctors are paid does have an effect - more incentive in the US, less incentive in the UK.
Regarding my qualifications to make such statements: I am writing up my dissertation on the social determinants of maternal health for a PhD in social epidemiology. I also have an MPP (Masters of Public Policy), focusing on health and health policy. The statements regarding the behaviour of doctors under different health systems came from papers that I read for a compulsory course on the political economy of health systems (taught by a leading health economist) for my MPP. It is not my main research focus so I can't remember the exact cites. You can take my word for it, or not, as the case may be. I guess you have to take my credentials at face value as well. Unfortunately, I don't have the time right now to dust off my old folders and find the exact cites that were used in the course (fascinating stuff, by the way, if you do want to follow it up and look things up yourself).
" I refer to my airplane analogy in an earlier comment."
I saw your airplane analogy and I thnk it is false. A far better one, in my opinion, is a teacher making a decision about my child's education without consulting me. But they are the experts? Yes, that's true but it's my child and, at the end of the day, I make the decision. I am the one who, ultimately, has to bear the consequences of any decision. It is incumbent upon you to do your utmost best to inform me of the options open in a fair and unbiased manner. I had a hiccup in my last pregnancy and the midwife who counselled me regarding the best course of action told me "I can tell you the pros and cons but I cannot make a choice for you, you are the one who has to bring up a brain-damaged baby, or even deal with a dead one, if you make the wrong decision". I thought that was wise counsel, yet respectful of my autonomy.
"The key point of this thread, and a point that has been made much more eloquently by others, is that the midwives in this situation were blissfully unaware of the danger that 'Sharon' was in. They describe a post-partum haemorrhage as if it was a minor inconvenience, not a life-threatening event & not only that but they then display it on their website as a triumph of homebirth. And that is why they have been referred to the appropriate people."
I completely agree. As I said, I'm not a clinician, but even as a lay person with a non-clincal background in maternal health, I was absolutely shocked. I'm not against home births, per se, especially since in my part of London women have the wonderful choice of Northwick Park Hospital and Barnet Hospital (so home births are probably far safer), but it needs to be done properly!
anon 10.43:
"Lets start with the fact that this is an English blog and most of the posters are in England it seems.
Doctors in the UK working in the NHS recieve a wage...if you do 20 C-sections or none you get paid the same.
So doing all those nice sections must be for fun.
Petra, the main point is that if an NHS doctor advocates a treatment here its based on clinical judgement (wherther good or bad) but not on financial grounds (getting turned down for a treatment is another thing but not the doctors decision)."
Well, actually, I think that there is a tendency in the UK to undertreat. But, yes, I would feel secure in the UK that having a C-section is not being motivated by financial incentives, which is certainly a good thing.
However, i still disagree that it is fully based on clinical decision alone. Amy Tuteur has just mentioned type I and type II errors. Your clinical judgment is affected by your risk preference. You may intervene when there is no need or, altenatively, not intervene when there was a need. Clearly, the midwives of Kent show a preference for type II error but a regular hospital ob or mw in the UK would likely have a preference for type I errors and a US ob an even stronger preference. The clinical indications are the same. The final DECISION as to whether to intervene or not is socially and cultually mediated.
Amy,
Nice conspiracy theory (which doesn't mean it's not true of course, just because you're paranoid it doesn't mean they're not out to get you, etc, etc.)
Still no evidence links to research.
Or even:
Still no links to research evidence.
It's too late for thinking!
Petra. As the last doctor standing in this titanic battle I shall leave after this brief sojourn. It seems that we disagree on several things, but mainly on the issue of trust of professionals. I trust my colleagues to make the right decision at the right time most of the time; you don't and seem to think that by being informed of statistics (which I rarely quote in my personal practice as even if a procedure has a 1% mortality rate, you're still dead if that is you) you are 'empowered' to make the right decision. I don't think you are; I think you are being given the illusion that you are. And I don't think your midwife said the right thing as, to me, that statement stinks of defensive medicine which I abhor. I also try not to treat my patients as statistics or case-series or RCTs but (cliche ahead) as individuals. But it would seem that overall my attitude is more paternalistic than yours.
I work in a speciality with 10% mortality & meet with grieving families almost daily to discuss the 'right' thing to do. Not surprisingly, there are no 'right' answers & the process is stressful & ongoing.
Consent is usually not an issue as my patients are mostly unconscious & few people have Power of Attorney orders to represent their interests, so it falls to us, the medical & nursing staff to arrive at the 'right' decision in conjunction with the family. Perhaps I am incorrectly applying my beliefs to the situation that you describe.
On a lighter note I can certainly relate to you wishing to avoid Barnet General. I did my anaesthetic training there many years ago & it was one of the reasons I left the country!
Richie:
Agreed - we'll have to agree to disagree. But just a few points before I let it go....
I do accept that as an epidemiologist, I find being quoted stats and risks very empowering but that I'm probably unusual in that.
I also accept that, at times, it may be preferable for a doctor to act in a paternalistic manner. At least that means you care!
I don't distrust doctors or medical professions. But I do expect to make the final decision. As you said, there is often no 'right' answer but a choice between various paths. Having had a very sick child (thankfully fully recovered), I remember well the dilemmas that we faced - but WE had to make the decisions.
I also think that medical professionals should be more aware of the various influences on their clinical decision making. I'm not referring to some kind of conspiracy theory or even explicit decision-making. Medics don't operate (literally and figuratively) in a vacuum and are products of their environment. But a lot of doctors don't admit to that and insist that their clinical decisions are always completely objective without a critical analysis of their thought process.
Finally, I had my last child in the US. Very likely the midwife was practicing defensive medicine (I don't blame them, given the litigous culture). But she was right and I felt supported when I did make my decision.
OK, enough! Thank you Richie for providing such diversion from the tedium of dissertation writing!!
Richie says
"they will only intervene with a procedure that contains risk when the risk is deemed greater if they don't.
THIS IS THE BASIS OF ALL MEDICAL INTERVENTION. I fail to understand how non-medics continually rally against this basic principle of common sense (including Primum Nocere"
If only things were that simple! I'm not talking specifically about home births, but just the general principle you espouse. There have always been, and will always continue to be medical interventions that are thought to be more benefacial than the perceived risk at the time; taht later turn out to have greater risks than initially perceived.
For example HRT widely prescribed both for menopausal women to deal with unpleasant symptoms, and for supposed other benefits to health. On a personal level, an operation to remove extra bone that led to lots of nerve damage - a risk never even mentioned by the Consultant. The risk of leaving the bone was a deformity of appearance of the leg I would happily have lived with if I had been told the risks.
Now I don't believe Dr's are 'gods'. Of course there will be medical interventions that appear to be a 'good thing' at the time when risk is weighed up, that are later shown to have high unanticipated risks. Or Consultants who do not explain the risks to patients. But lets not pretend that all medical interventions correctly identify the risks of doing nothing versus the risks of the intervention.
Anonymous:
"But lets not pretend that all medical interventions correctly identify the risks of doing nothing versus the risks of the intervention."
We don't have to pretend. We have scientific evidence. If you expect anyone with scientific training to accept your claim that obstetrical interventions have more risks than benefits, you need to demonstrate it with scientific EVIDENCE. Do you have any scientific evidence?
Petra,
What interested me about your post is your statement that "you" would bear the consequences of your decisions.
Actually in homebirth & in your own teaching example, the person bearing the consequences much more than you is "your child".
Interesting.
Anyway.
You may have some knowledge of an interesting aspect of the literature in your narrow field, but you can't individualise it to your own or anyone else's medical situation unfortunately.
Now, you can argue all you like about whether professionals should be trusted, but you know what? You're NEVER going to make a better decision on a certain subject than an appropriately trained professional who has the advantage of experience, objectivity and much deeper knowledge than even the talented amateur can bring to bear.
That professional might well be wrong, but they're wrong less than you could ever be.
It's no coincidence that women who are relaxed and trust their doctors and midwives to decision make have a much lower incidence of intervention than those who don't in the UK (eg. Leeds study - forceps delivery rate increased fourfold when there's a restrictive birth plan).
You wouldn't buy or sell your home without a solicitor/conveyencer (or if you do then you're a fool), so the same should apply in medicine. Thankfully, 98% of people have this same sensible view.
Amy,
"We don't have to pretend. We have scientific evidence. If you expect anyone with scientific training to accept your claim that obstetrical interventions have more risks than benefits, you need to demonstrate it with scientific EVIDENCE. Do you have any scientific evidence?"
You claim to have evidence, but consistently refuse to provide it. It's no point giving you evidence because you dismiss it.
I still can't understand how you can dismiss Odent. I notice nobody here has commented on his practice to say why I should ignore it. His public hospital had a 1000 births a year, including high and low risk mothers. Many of the common interventions used in most hospitals were not used at all, others were nearly a quarter of the rate. These are facts. I agree, it's not a peer reviewed study but the figures have been published for years without being challenged by colleagues so I think it's safe to assume they are accurate. There are so many people like you out there who are vehemently against natural birth, so I find it difficult to believe that the figures wouldn't have been debunked it it were possible.
Unless you think he falsified the figures or have another conspiracy theory? If that were the case I find it difficult to believe that none of the hundreds of women who would have had these procedures or the staff that carried them out would have read the published figures and challenged them. If he was planning to falsify the figures he would have been safer to reduce the rates to say 1%. If he refused high risk mothers I think the surrounding hospitals would have noticed that lots of extra high risk mothers were travelling from the Pithiviers Hospital area to their hospital and would have challenged his assertion that all levels or risk are included in his figures.
If it is possible that using his methods would cause say c-section rates to be safely lowered to 6.6% from 20+% we will avoid the many risks of c-section over vaginal birth for those mothers and babies. The RCOG lists these risks as:
Increased with CS
Abdominal pain
Bladder injury
Ureteric injury
Need for further surgery
Hysterectomy
ITU/ HDU admission
Thromboembolic disease
Length of hospital stay
Readmission to hospital
Placenta praevia
Uterine rupture
Maternal death
Antepartum stillbirth in future pregnancies
Not having more children
Neonatal respiratory morbidity
BTW, Odent has stated that reducing caesarean section rates should not be the primary objective and that the most dangerous guidelines would be those recommending a limit to the rise in caesarean section. What needs to change is the fundamental approach to birth. If hospitals implemented his methods, the c-section rate would fall whilst still applying current indications for c-sections. Unless of course he had some unknown skills that will be unavailable to normal obstetricians. Maybe he methods will only work for him? A trial of his methods would be a good idea. I suppose it's possible that his methods will only work if carried out by someone who wholeheartedly believes in them, a bit like the placebo effect. There are examples in education where charismatic teachers have achieved great results that other teachers have been unable to replicate.
"We don't have to pretend. We have scientific evidence. If you expect anyone with scientific training to accept your claim that obstetrical interventions have more risks than benefits, you need to demonstrate it with scientific EVIDENCE. Do you have any scientific evidence?"
Hi Amy
If you had read my post properly you would see that I was not commenting specifically on home versus hospital births, but on the idea that you expressed that all medical interventions are carried out on the basis of accurately analysing the risk of the intervention versus no action.
My argument was that for a number of reasons this is not always the case, although it is the ideal. I also gave an example and could give many more. Please read the post properly before criticising it.
"If you had read my post properly you would see that I was not commenting specifically on home versus hospital births, but on the idea that you expressed that all medical interventions are carried out on the basis of accurately analysing the risk of the intervention versus no action."
It's not even as if Amy believes this happens in practice herself. She has said elsewhere:
"Finally, (and most depressingly for me as a doctor), many doctors are simply not paying attention the way they should. They don’t order the right tests, they don’t look at all the results and they don’t listen to what the patient is telling them."
If doctors don't order the right tests, don't look at the results and don't listen to patients, all of the scientific evidence in the world won't make any difference. And Amy expects us to trust doctors like this and take their word on the best treatments in their individual situation? Amy has just confirmed my desire to research my own and my children's medical conditions for myself!
Unless, of course, there's another Amy Tuteur MD out there, in which case I apologise.
http://treatmewithrespect.blogspot.com/#114659784995445628
Jane_T - do you know anything of Odent, other than the studies you've quoted here?
It's very easy to see why mortality was low in his practice, very easy if you actually know Odent and his work and are not just wildly googling for backup.
Anonymous:
"If you had read my post properly you would see that I was not commenting specifically on home versus hospital births, but on the idea that you expressed that all medical interventions are carried out on the basis of accurately analysing the risk of the intervention versus no action."
I read it and understood it. It is hardly a newsflash that doctors are not perfect. That tells us nothing about whether specific claims are true. Only scientific evidence will tell us if specific claims are true. Announcing the obvious fact that doctors are wrong sometimes does not absolve you of the responsibility for reading the SPECIFIC scientific evidence for the specific claims you are making.
As regards HRT, new data changed the recommendations. That's how science is supposed to work. We learn something and we act on it. We learn more and we modify our actions based on new learning. Why do you have a problem with that?
Amy - the reason she has a problem is because she had a miscarriage, and now has her own personal vendetta against doctors because her foetus died at what... 12 weeks was it Jane? As we all know, miscarriages are so terribly rare, but all foetuses are always 100% viable if the doc tries hard enough.
OH WAIT... that's not how it is at all!
Trying to talk to Jane through her cloud of Doc-Rage is like trying to breathe treacle.
I am a bit stunned at your posting amy. I have posted twice on this thread in response to the comment below.
Richie says
"they will only intervene with a procedure that contains risk when the risk is deemed greater if they don't.
THIS IS THE BASIS OF ALL MEDICAL INTERVENTION. I fail to understand how non-medics continually rally against this basic principle of common sense (including Primum Nocere"
My point was 1. yes Dr's are not perfect. I agree hardly a newsflash, but one that Richie didn't seem to take into account.
2. As more research takes place and new evidence gathered risks are better understood, and interventions that were once commonplace are now recognised as having unrecognised risks.
How this lead to your posting above baffles me and I wonder if you are getting my 2 postings mixed up with previous postings. You say
of the responsibility for reading the SPECIFIC scientific evidence for the specific claims you are making.
I have made no specific claims at all in this stream. So I haven't a clue what you are referring to. Indeed I specifically said that my posting DID NOT relate to home births versus hospital births.
You said
"As regards HRT, new data changed the recommendations. That's how science is supposed to work. We learn something and we act on it. We learn more and we modify our actions based on new learning. Why do you have a problem with that?"
I do not have a problem with that and never said I did.
But I'm not going to make any more postings in this strand as there doesn't seem much point when I get such a strong response that doesn't actually relate to my posting.
Just broke my promise to not make any postings when I saw in severe pain jane's posting above. Please read who has posted. I am NOT the same person as jane t who posted about her miscarriage.
I do find the level of vitroil from some of the posters disturbing though.
I believe in listening to expert advice from people who know more than I do about any given subject.
I also understand that it must be extremely frustrating for busy doctors to be assailed by ill-informed patients who have ‘Googled’ their illness and now think they know all about it and what treatment is best.
However, at the same time, the days when most people just did what the doctor tells them regardless are over. People take more interest in their health and their bodies and generally want more information than was the case with previous generations.
I make no comment on whether this is a good thing or a bad thing, but it is what it is and doctors will have to accept this to a certain degree. I’m sure the good ones do.
Odent's obstetric practice is as far removed from normal practice as you can get.
The CS rate that he quotes is unobtainable in normal practice.
If he confined his births to multips, then he could achieve his figures. There'll be some dodge he uses to get his rates down that low, believe me. Probably sends all his sections to a colleague! Or the colleague has all the primips!
Jane T,
For fuck's sake fuck off and troll someone elses's fucking blog.
Fucking get it!
in severe jane pain said:
"Jane_T - do you know anything of Odent, other than the studies you've quoted here?
Not a lot, I'd be interested to know more if you have some links. Do you dispute the facts I've quoted?
"Amy - the reason she has a problem is because she had a miscarriage, and now has her own personal vendetta against doctors because her foetus died at what... 12 weeks was it Jane? As we all know, miscarriages are so terribly rare, but all foetuses are always 100% viable if the doc tries hard enough."
If you can quote anything I've written that blames a doctor for my miscarriage I'll never write on this blog again. Ever.
I know the doctors had nothing to do with the miscarriage. I didn't go to the hospital during the miscarriage because I knew (from reading on the internet and a discussion with a midwife) that nothing can be done to stop a miscarriage. I also knew that the miscarriage rate for my age is 70% so I was almost expecting to miscarry. But most miscarriages (4/5 according to one report) happen before 12 weeks so I had begun to hope that it might be OK. But this is besides the point. It was the handling of the miscarriage that I objected to. The lack of information about what I should expect so that I would know if I needed to contact a midwife again if something was going wrong. It would also have made the process a lot less scary. I believe that complications are more likely after 10 weeks gestation too. The lack of sensitivity in the way the doctor handled my call afterwards also upset me. Maybe he's one of the posters here.
I know that in the scheme of things a miscarriage at 12 1/2 weeks is nothing. Losing a baby at term, cancer, chronic diseases like diabetes, etc are all much, much worse. But knowing that others are worse off doesn't really help much when you are going through it.
anonymous said 6.02pm:
"If he confined his births to multips, then he could achieve his figures. There'll be some dodge he uses to get his rates down that low, believe me. Probably sends all his sections to a colleague! Or the colleague has all the primips!
The figures were for the whole hospital, 1000 births per year, a public hospital with high and low risk pregnancies. If he did fix the figures I'm sure someone here will be able to find evidence. It would be impossible for him to fix the figures when there are so many people like you around who appear to hate even the possibility that it could be true.
People... you're not giving up?
Two hundred posts is in sight if we can keep the argument going a bit longer...
"Increased with CS
Abdominal pain
Bladder injury
Ureteric injury
Need for further surgery
Hysterectomy
ITU/ HDU admission
Thromboembolic disease
Length of hospital stay
Readmission to hospital
Placenta praevia
Uterine rupture
Maternal death
Antepartum stillbirth in future pregnancies
Not having more children
Neonatal respiratory morbidity"
Jane, um, you do realise that the reason complications, morbidity etc are higher with C-sections is that they are done on higher risk patients, yeah? You don't cut a baby out of a woman unless you kinda need to to prevent hell breaking loose. Of course complications are going to be higher, these ops are often carried out in diabetic mothers with huge babies, in women with cardiac problems for whom labour would place excessive strain on the heart, in cases of obstructed labour (hence increased risk of uterine rupture), in women who have placenta praevia etc etc etc. Hence you are already dealing with a cohort who will have drastically increased risk of complications. Therefore, common sense would tell you that it is not C sections and only Csections causing complications in this otherwise perfectly healthy set of mothers and babies!
I sympathise that you had a miscarriage, however, don't let your bad experience lead you into following an ideology that may harm your future babies. I am a bit appalled at the above remarks on the subject from other posters, but it is born out of a deep frustration that people cannot understand things that seem to be so obvious to us. Like smokers who say that it absolutely doesn't cause cancer.
Dr Jane Doe,
"Jane, um, you do realise that the reason complications, morbidity etc are higher with C-sections is that they are done on higher risk patients, yeah?"
Yes, of course, but how do you explain Odent's low c-section rates on a large, mixed risk group of mothers? Odent does not suggest that c-sections should be avoided at all costs. He is on record as saying that it would be dangerous for guidelines to limit c-section rates and that c-sections must be carried out when the usual indications appear. He believes that changes to practice from the beginning of labour can make it less likely that these indications will appear and it seemed to work for him.
One example of the type of change that could be made that's already recognised by the RCOG is one-to-one care. The RCOG state that one-to-one care throughout labour and birth reduces the likelihood of c-section.
"I sympathise that you had a miscarriage, however, don't let your bad experience lead you into following an ideology that may harm your future babies.
Thank you for your concern but there won't be any future babies. Incidentally, I had recognised that I was a high-risk mother this time around and had requested a hospital birth and had been booked for shared consultant/midwife care. I doubt it will be an issue for my daughter either as she will also be in a high-risk category, though for different reasons.
"I am a bit appalled at the above remarks on the subject from other posters,"
I'm frankly stunned at the level of vitriol raised by requests for evidence and clarification to back up statements made by posters. It's as though they are shocked at the idea of a peasant daring to question the god like medical profession.
"but it is born out of a deep frustration that people cannot understand things that seem to be so obvious to us. Like smokers who say that it absolutely doesn't cause cancer.
I have been asking for evidence to persuade me that home birth/natural birth for low-risk mothers is dangerous. What is so difficult and challenging about that? I have stated before that I am on the fence on this issue. Smokers have had given plenty of evidence that smoking causes cancer. They haven't been expected to take the establishments word for it.
I've had too many experiences of the medical profession getting it wrong to just take their word for it. For example, I've been told by doctors and consultants that carbohydrate counting is unnecessary for the treatment of type 1 diabetes, coeliac disease has no connection to type one diabetes, children sometimes grow out of type 1 diabetes, low blood glucose readings only indicate hypoglycaemia if there are symptoms, etc.
Dr. Amy Tuteur MD, an obstetrician-gynecologist who received her undergraduate degree from Harvard College and her medical degree from Boston University School of Medicine and a former clinical instructor at Harvard Medical School said (unless someone else is using her name on blogs):
"Finally, (and most depressingly for me as a doctor), many doctors are simply not paying attention the way they should. They don’t order the right tests, they don’t look at all the results and they don’t listen to what the patient is telling them."
Why do you think I should take their word for it? It's mine and my children's health at stake, not theirs.
I'm sure everyone will be happy to hear that this is my last post on the subject (though I'd still welcome and follow any links to evidence or relevant articles people post). It's just going round in circles and it appears that either my writing skills are very poor or reading comprehension levels are low here (probably the first option judging by the number of people who appear to have misunderstood my points). This started out as a distraction from stress but has ended up causing more. Maybe I'll just go study an OU course to help me understand the study reports. It'll be easier.
Jane t - good for you that you have risen against the totally unnecessary unpleasantness from some commenters. Equally, fair play to those experts who put their points patiently and without recourse to personal comment. This has been an interesting debate for a layperson to observe.
Personally I think all homebirth advocates are nutters who place having a pleasant ‘birth experience’ above the safety of their children, aided by a group of people with their own socio-political agenda for encouraging ‘choice’.
Does it really matter how your child arrives in this world? It what happens after they’ve got here that counts.
That said, like Jane T I have yet to meet a GP who has more than the most rudimentary understanding of the working of Type I diabetes, so maybe she is right not to just take their word for anything…
Look, private midwifery is a gold mine. 4 years ago, ambitious, well spoken young nurses were jumping into midwifery quick smart to get on the gravy train.
They are in business and they are raking it in. Show me a pure business model of healthcare that doesn't put profits ahead of 'old fashioned and outdated' clinical priorities.
Start thinking for yourselves people. Stop asking others to fill in for your lack of common sense.
If anyone non-medical is still reading here, there is RCOG (Royal College of Obs and Gyne)consensus statement about homebirth on their website here, and one about intervention rates (warning - large PDF) here
The statement on home births is interesting (at least to my non medical eyes, having read this thread) for what it leaves out as much as what it includes. One phrase that did stand out was the following:
"Careful selection of low-risk maternities is important to minimise complications. Ideally, this should be by senior midwifery and obstetric staff."
Very interesting links, phd scientist, thanks. Thanks also to scribbler, rob clark and also to others who have offered information.
To be honest, I don't read a lot of studies regarding Obs and Gynae-I work in med for the elderly so not really an issue :)
But having done it in final year med, and having spent a 6 week rotation in a labour ward, I would personally be SHITLESS at the thought of having to give birth anywhere but in a hospital. Jesus, when stuff goes wrong it happens so fast there's almost not time to deal with it in a hospital setting sometimes, nevermind someone's HOUSE! I will never ever forget the 22 year old girl, low-risk pregnancy, no complications, in labour when she suddenly developed flash pulmonary oedema and became unconscious. As she was in a labour ward attached to a tertiary hospital, a consultant cardiologist was there in minutes. She had to be transferred to CCU, baby C-sectioned, and the shocked and bewildered young husband told that neither of them might make it. It was one of the saddest things I've ever seen. Fortunately they did eventually pull through, she had this condition I'd never even heard of called peripartum cardiomyopathy-apparently had had no symptoms and so no-one would have thought to do an ECHO on her or anything. But if they had been in a lovely cosy bathtub at home, that young man would have buried his young wife and baby.
I guess what I'm trying to say, is, for certain situations you don't need huge amounts of cohort studies etc. If you are going to be in an anticipated situation where there may potentially be large amounts of blood loss, high pain levels, perineal and vaginal injuries, placental problems, obstructed labour, exhaustion and a newborn infant coming into the world that may be damaged from complications, why would you WANT to be anywhere but a hospital? I would be terrified to give birth outside of a GOOD hospital near a tertiary centre, and most female docs I know feel the same. It's not that rare for things to happen in labour. It's just we don't usually see them so much thanks to modern medical interventions. But why do people defend homebirth so much? It's obviously not a particularly sensible thing to do, all research aside. I wouldn't have a dental extraction at home, nevermind a baby. I might have a reaction to the local. I might have a coagulation disorder I didn't know about and bleed a shitload. Why would this be something ANYONE wants? Is it just they haven't seen the consequences like I have? Is it just because they don't like feeling they are told what to do and would rather risk their baby and themselves and exercise their RIGHT TO CHOOSE? I am honestly mystified by this.
http://women.timesonline.co.uk/tol/life_and_style/women/families/article3887554.ece
Ther're back!
I love this open honest and unbiased article.
The Times has now stopped employing writters and just asked anyone with a vested interest to submit a few hundred words.
What drivel, the obs and gynae dept at out hospital is nothing like the hole they describe, and i also like how they take the opinion of one mum
"They would only do a Caesarean. I was “high-risk”, it was explained. It seemed ridiculous when I'd had a trouble-free pregnancy and was carrying a good-sized baby".
Yeah how stupid to doa c-section for a high rish breech baby.
Idiots like this should really be advised not to breed.
dr janedoe
I think it is partly that "if you haven't seen it it isn't real" - see also MMR-scare, people have never seen a measles encephalopathy, ergo they believe measles is a trivial childhood illness.
It is also partly about distrusting experts, a modern trend if ever there was one. The paradox being that the "alternative" views are usually dispensed far more paternalistically, but under a kind of cloak of empowerment.
I have written about this from my medical spouseperson's viewpoint over on my blog here.
PS Among all the female doctors with kids Mrs Dr Aust and I know, we can't think of a single one in any specialty who opted for a home birth. Like you I find it difficult to believe they have all been "brainwashed" by the obstetric establishment.
If anyone is unaware of it, there is an excellent blog/discussion forum called Homebirth Debate, led by Dr. Amy Tuteur, at
http://homebirthdebate.blogspot.com/
[Jane T.] We will have to live with any consequences of unnecessary interventions on a day to day basis, possibly for the rest of our lives.
~~~You will also have to live with the consequences of refusing NECESSARY interventions which you don't have the necessary education or expertise to understand. Your doctor, and your professional midwife [NOT "madwife"] know so, so much more than you do. Listen to them, and take their advice. Who are you to decide what is a "necessary" or an "unnecessary" intervention in labor?
Next time you get into a plane, try telling the pilot what to do--after all, as a passenger you do have that right, yes? No you don't, the pilot's the expert, not you, no matter how many times you've flown, or seen movies about flying.
John, well done for exposing these dangerous cranks. As for the Times - what a sorry excuse for a serious newspaper.
[Jane T] still can't understand how you can dismiss Odent. I notice nobody here has commented on his practice to say why I should ignore it. His public hospital had a 1000 births a year, including high and low risk mothers.
~~~First, the man is a charlatan and an idiot. He isn't even an OB, but trained as a general surgeon. His "statistics" are highly suspect. His "ideas" as you call them are universally disparaged by every reputable specialist in the field.
Second, a hospital doing 1000 births a year is a cottage hospital. The average mid-sized teaching hospital with full facilities, including an NICU, has that number of deliveries in between 1 and three months.
Did you know that Odent also thinks that husbands and male partners should not be in the room with the laboring woman? [apparently it's all right for him to be there]
Antigonos I don't think people wanting to understand why a medic is recommending a certain course of action is similar to telling a pilot how to fly a plane.
In some medical instances there is an obvious course of action. However in many cases the decisions are not so straightforward and different medics would take slightly different actions. In these cases of course as patients we want to know why a medic is recommending a particular course of action.
I personally in the past have tended to trust Dr's and do what they recommend. After many instances where this hasn't worked out I now feel foolish for not questioning recommendations in the past. Every member of my immediate family has had great medical care, as well as instances where the medics have clearly got it wrong.
For example, my elderly mother in considerable pain being told by her GP she had indegestion. This led to her gall bladder bursting that night and an emergency admittance to hospital. My partner has a rare bone disease and the consultant recommended some of this being removed from the leg as it was unsightly. The only risks ever mentioned was a risk of infection. As a result of the operation my partner has been left with nerve damage and burning pain and says quite clearly that if they had known this was a risk they would never have went ahead with the operation. The 4 members of my immediate family have had similar experiences with 4 different Dr's. As well as some excellent health treatment.
If we go back to your flying a plane example for a moment. I fly frequently as do my parents. If all 4 of my family had been in different planes flown by different pilots where there was an accident, then I suspect we would now be ringing the airline before a flight to check the credentials of a pilot. But this doesn't happen because most of the time when flying a plane there are clear right and wrong things that a pilot does. This isn't the case with medics. Often the decisions are much more complicated and much more open to interpretation. This is why people ask questions of medics when they don't ask them of pilots.
Dr. janedoe says
"I work in med for the elderly"
gotcha, enough said ;-)
A Hard Truth to Swallow
The Indypendent
Things weren’t going quite right. I noticed I was tired enough to put off going on errands that demanded a long walk. And I was weaker than I had ever been. My balance was a bit — no, a lot — off, and I was dizzy from time to time. At 75, I dismissed all this as “just getting old,” although I did complain mildly to my phalanx of doctors about general fatigue. I griped to my primary care doctor about the armload of prescription medications I was taking. Her response was, “Well, you have a lot of things wrong with you!” And she was right. I live with a medical textbook’s worth of pathologies, including severe vision impairment, atrial fibrillation (heart disease) and kidney issues.
If you would like to read more please visit the website:
www.indypendent.org
Has anyone else noticed the similarity between this debate and the pro-life/ pro-choice debate surrounding the issue of abortion? Both debates in their most extreme forms become polarised and hinge on a similar issue. The sovereignty of a woman’s body and her right to unilaterally choose what happens to it. Whether to have an abortion or not and where to give birth vs the right of Doctors/ politicians/ lawyers (the priestly class and mainly male?) to censure this right and advocate the “rights” of the unborn baby either not to be aborted or birthed in a safe environment.
I think it was Anonymous @ 12:53 06/05/08’s reply to Petra that made me think, this
“Petra,
What interested me about your post is your statement that "you" would bear the consequences of your decisions.
Actually in homebirth & in your own teaching example, the person bearing the consequences much more than you is "your child".”
I know in the maternity debate Doctors/ hospital midwives
1. are not all male
2. are not seeking to over ride a woman’s right to choose a home birth
they are however seeking to dissuade women from a course of action they see as inadvisable and riskysvfbvb but I suspect that the independent midwives of Kent possibly see the debate in these terms which might explain their antithesis to the medical profession which they view as a male dominated priestly class bent on restricting a woman’s right to choose.
I wonder if the same people are on the same side of the debate i.e. is Nadine Dorries in favour of home deliveries and independent midwives?
I think this may have been better placed on the Dorries comments as this will disappear from the first page soon.
Limiting abortion appears to fit better with limiting home birth as both have the effect of controlling and limiting women.
e:
"I think it was Anonymous @ 12:53 06/05/08’s reply to Petra that made me think, this
“Petra,
What interested me about your post is your statement that "you" would bear the consequences of your decisions.
Actually in homebirth & in your own teaching example, the person bearing the consequences much more than you is "your child".”"
I didn't bother to reply to anon because I thought that s/he had purposely 'misunderstood' my comment in order to 'score a point'.
My basic premise in my comment is that a parent is concerned with the welfare and wellbeing of their child and places it as a top priority. It may not always happen, true, but that is my point of departure. My point was that if MY child is hurt, then I am the one who is personally invested. If my child dies, it is us who have to deal with the grief of losing a child. It goes without saying that the child is going to bear the consequences - I am the one making the decision in the best interests of my child.
In any case, you may find the following book interesting:
Armstrong, E. "Bearing Risk, Conceiving Responsibility"
It talks a lot about foetal alcohol syndrome and ties it in to issues of control of women's bodies.
See Google books for a preview of Conceiving Risk, Bearing Responsibility by Elizabeth M. Armstrong.
http://books.google.co.uk/books?id=SwTEAGD5eiAC&printsec=frontcover&dq=Bearing+Risk,+Conceiving+Responsibility&sig=rZ0FtKUzqDz13zj-xNjQcDoP_8I#PPA4,M1
What do you mean by that, e? the fact that I now work in med for the elderly isn't really here nor there is it? All the other docs on here are not obstetricians and gynaecologists as far as I know...
i am a 19 year old woman and hope to have children some day. Though after reading this blog i was disgusted in the way you "health professionals", (did i spell it right or are you going to pull me up on my spelling?) are so petty and immature. It felt as if i was at school again having an argument in a play ground. Do i really want people like you delivering my children? And by the way i would much prefer having a "madwife" deliver my babies than arrogant Dr Crippen
Anon 4.54
I am not a doctor - though I am married to one - but a couple of points:
(1) Dr Crippen, as an urban / suburban GP, presumably doesn't do deliveries except in v. rare emergencies. Specialist obstetrics & gyne doctors do the deliveries.
(2) A "therapist's" being sympathetic, and empathic, and so forth, does not prevent them being useless, or indeed sometimes an utter charlatan selling you complete rubbish. See any homeopath.
Picking a therapy professional of any kind is a bit of a balancing act, basically. If you are lucky you get excellent communication and loads of expertise in the "nuts and bolts" (e.g. the obstetrics) all in one package, whether that is in your obstetrician or your midwife. Often you get more of one and OK levels of the other. But if you can't find the two together, I'll take expertise over tea and sympathy every time. If the doctor is C-sectioning my wife I want him/her to be a hotshot surgeon, not someone who is good at "feeling my pain".
Re. the name calling, two things. First, blogs are not doctors' consulting rooms, so you get the views "unvarnished". Second, everybody - including doctors - finally gets exasperated by people who keep demanding detailed explanations, but (i) cannot comprehend them when they are given and (ii) also cannot accept that the problem might be that they don't have enough background knowledge to understand the explanation they keep loudly insisting on.
In fact, there is a special class of Internet troll who use this "nagging" tactic - sometimes called baiting - specifically to get more expert people to lose their rag, with the intent of casting themselves as the victims of "authoritarian paternalism and intolerance" and thereby conning casual observers that they really have a point. The anti-MMR-vaccine campaigners are famous examples of this.
jane_t
read the above, you're being talked about.
http://www.timesonline.co.uk/tol/news/uk/health/article3934513.ece
you may be interested to read this.
All obstetricians and most midwives recognise that they deal with horrible emergencies in low-risk women on a regular basis that takes all their training and a large amount of help to safeguard women & babies. All recognise that at home, these would be difficult or impossible to manage, even if the midwife were good.
flashlights rc helicopter video games
I have just read a few random accounts from the birth stories of the Kent Independent Midwives and it occurs to me that in the same way many midwives worry that senior obstetricians only experience the most unusual and dangerous circumstances of labour and delivery and suffer from shifted perception of the process as a whole, so independent midwifery is unlikely to appeal to women other than those in extreme rejection of the NHS for some reason. Could this account for a possibly cavalier avoidance of NHS procedures on the part of an independent midwife?
Married, as I am to an independent midwife I have been alerted to this vitriolic attack on Kent Midwifery Practise and feel obliged to add my two penneth worth
In the first instance, it astounds me that Dr Crippen (John) can presume to hide behind an anonymity and yet still be taken to be such an authority (on just about everything it would seem)
Whilst married to an Independent Midwife I would like to believe I can look at something with an unbiased eye
The posting of the original *reflective* story on the Kent Midwifery Practice website, may well have been an error in hindsight.....
There may or may-not have been practices during that birth which could be considered potentially dangerous....
However, Independent Midwives *are* subject to the same internal procedures and processes of their NHS Colleagues and are governed by the NMC and allocated a NHS Supervisor
The key, fundamental and blindingly obvious of this entire non-story is that *IF* there had been any concerns about the birthing of this woman during the homebirth stage or indeed when she was eventually presented at the hospital, then it would have resulted in a NHS review. Clearly there there no concerns which warranted such a review
Now, the only real people in this whole non-story are Sharon and her partner, the baby, Kent Midwifery Practise and the Hospital NHS Staff where Sharon was presented
Given that Dr Crippen was NOT involved at any point with the birth and given that she was presented into the NHS Maternal System, and given that NO actions were deemed necessary suggests that the esteemed colleagues within the NHS felt that there was no case to be investigated
Further down the line, it is suggested that Helen O'Dell had been informed of the standard of care/mal-care provided and that an investigation was to be held....
...An investigation was indeed conducted but Dr Crippen would prefer not to report its findings..Now, why *WOULD* that be?
Having tried to follow the majority of threads thus far posted, I have to say that I am impressed by many of the arguments presented by Dr Crippen however his arguments pale into insignificance given his reluctance to provide details of his identity, professional accreditation, etc, etc
I would be more inclined to care about what he (or anyone) has to say if they were to keep it rational, clinical and non-hysterical
The varied references to Madwives, MadWitches, Lunatics, etc whilst mildly amusing does lead me to suspect that Dr Crippen is indeed a teenager
Why else would they choose the name of one of the most infamous doctors of modern times behind which to hide?...Why Crippen?...Why Not Dr Harold Shipman?...Dr Josef Mengele?...
In conclusion, it is generally accepted that making mistakes is a frailty of human nature and that from mistakes, lessons are learned
A fatality is a tragedy wheresoever it should happen and nobody would want that...though I suspect Dr Crippen would actually welcome this in certain cases, such that he might continue with his rant?
Have we always birthed in hospitals?...Did not the Black Report move us OUT of the home into Hospitals?
How did mankind ever emerge from the caves without the reliance upon a NHS Hospital system?
There are choices which birthing women need to be given, thats a fundamental human right
Steve
The midwife involved has, it seems, now published further details of the case. It seems that most of the risks suggested had in fact been investigated beforehand, but the midwife wrote this story as a simplistic version for a lay audience. The full details are at
http://kentmidwiferypractice.blogspot.com/2008/11/sharons-story-normal-birth-of-12lb-baby.html
I notice also that on 15th November 2008 Dr Crippen published an email from the Nursing and Midwifery Council stating that the case has been looked at and they are not taking matters any further. It would have been professional to have noted that here, also.
Furthermore, in the midwife's account she states that local supervising officers reviewed her notes and all details of the case and not only found no cause for complaint, but commended her practice.
I think this just goes to show the dangers of commenting on a case based on a superficial report.
Dr Crippen, did you know that the Kent Madwifery Practice have posted a "blog" defending their actions in Sharon's case on the website? It's good reading, especially when they are defending their management of the PPH.
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