I’ve been lurking at the Skeptical OB for a while and enjoying Amy Tuteur’s very effective criticism of some of the extremes of the homebirth movement. I had noticed that among some advocates of homebirth that were proposing risky behavior for pregnant mom’s that conflict with the literature that it appears to be a movement rife with denialists who promote the valorization of ignorance in Dr. Tuteur’s words. Mostly their problems seem to be with accepting there is a real, measureable increase in risk with homebirth, and rejecting the very real health benefits that medical physicans offer in preventing fetal and maternal mortality. She summarizes the argument for homebirth-advocacy-as-denialism here and my heart was warmed that she used our 5 criteria for identifying denialist argumentation.

I’ll also point out she has some really compelling posts I’ve read in the last few weeks that are worth a look for anyone who is considering homebirth using a CPM rather than an OB/Gyn. See:

Humbled by Birth
Latest in homebirth deaths plus a near miss
Homebirth midwife requirements “tightened” to include high school diploma
Yes it is your fault that your baby died at homebirth
and
even more homebirth deaths- in particular I was jumping up and down angry when I read about people describing their childrens deaths from group B strep! What the hell! This is imminently preventable, treatable, and such an example of an obvious preventable death I nearly fell out of my chair.

Dr. Tuteur does an excellent job of providing compelling data, experience, and examples of why this movement is bad for mothers and bad for babies. Denialism can kill. There are very real advantages to appropriate prenatal screening and testing offered by OB’s, and very real problems that can occur even with “low risk” births that may result in the death of an infant or the mother. People can argue about homebirth and rejecting medicine as a choice, but you can’t argue that this is risky behavior that is resulting in preventable deaths. The idea that a high-school dropout with a CPM certification (requiring passing a test and attending a handful of births) can offer the same level of experience and safety as an OB/GYN that has training in hundreds of deliveries, is a medical doctor, can perform prenatal risk assessment and screening, and has the ability to surgically rescue in an emergency is ludicrous. In my very limited OB experience as a medical student I’ve seen “low risk” go to “potential disaster” and the life of the baby and possibly the mother be saved by interventions as simple as fetal heart monitoring and ready access to an operating suite. These stories of people being in labor for 48 hours and delivering dead infants are very distressing because we can avoid this! It’s like choosing non-sterile surgery over anti-septic surgery because bacteria are natural. Why ignore decades of research, experience and the obvious improvement in perinatal and maternal mortality that obstetrics has provided over the last century?

Comments

  1. #1 JBC
    October 20, 2012

    I mostly agree, BUT I had my three babies at home (first one in hospital) with a nurse practitioner midwife who was part of an OB/Gyn practice–however she was out of the room for the delivery; she was “on call”.

    i had OB/Gyn pre natal care, all recommended testing, and was less than ten minutes from a large hospital. I have a history of precipitous delivery and likely would not make it to a hospital anyway–nor would I ever consider laboring at home for eight hours, let alone 48! I’m opposed to ignorance, but not to every home birth.

  2. #2 Mark
    October 20, 2012

    I think there’s a big difference between a CPM (certified professional midwife) which strikes me as a diploma-mill level of certification and an actual CNM (certified nurse midwife) because nurses are actually trained in and usually have experience with emergencies. Nurses know what to do when it hits the fan, they can start IVs, they can push drugs, they are trained to recognize and deal with emergencies. To the extent that Dr. Tuteur has demonstrated many CNM are pushing some risky and quacky ideas, I’m less enthralled with it, but it strikes me as a huge step up in safety from a CPM.

    I still would not recommend being outside a hospital for delivery but I’ve been chastened by medicine from having seen some really dramatic disasters – disasters averted by having a OR suite on the same floor as the L&D rooms. You have to give the OB’s credit, when they decide they need to operate, their “decision to incision” time is lightning fast and that can make the difference between life and death for the infant. When you have an witnessed loss of fetal heart signs from a sudden placental abruption for instance, that can be a life saver. It’s one thing for the homebirth advocates to say it’s a choice, it’s more comfortable, and it’s a better experience, but that has to include a frank discussion about the realities of the disadvantages of home birth including higher perinatal death. To the extent that there is significant denial of such risks, and a refusal to engage in some basic medical prevention like prenatal screening for GBS, I’ve got a big problem with some of the more extreme elements of this movement

  3. #3 Sandra
    Florida
    October 20, 2012

    Risk screens are part of our practice protocol in Florida. The State licenses the practice of Midwifery in our State. GBS is screened and cultured. Protocols states that we offer and provide the same treatment as I the labo were occurring in a hospital. While some providers ( I have yet to come across one) may choose to disregard the law , we are trained to

  4. #4 Sandra
    Florida
    October 20, 2012

    Risk screens are part of our practice protocol in Florida. The State licenses the practice of Midwifery in our State. GBS is screened and cultured. Protocols states that we offer and provide the same treatment as I the labo were occurring in a hospital. While some providers ( I have yet to come across one) may choose to disregard the law , we are trained to provide , interpret and refer the same way an OB would. The reason midwives are able to , in many cases, provide superior care to the avg low risk mom, is the time and attention given during the prenatal period. Affording our moms on avg. one hour per appt. assures them th individualized care and attention to detail that is lost in the avg, OB practice. We review a clients diet, looking not for minimal dietary intake but optimal nutrition, this happens at every visit. Vitals are scrutinized and any deviations are discussed inside that appt. if a B/P has risen we ask why? Is it stress? Is it dietary? Is it something else? And we follow it thru. Rechecking to make sure this is either determined to be normal or cause for referral. The reason that so many women are choosing this kind if care is because they see the difference In the care they receive. They know as do we that O.B.s are highly specialized surgeons. And when needed they are the best at what they do. Being with woman is not their specialty. Nurturing a relationship with your client isn’t it either. Sitting and getting to to the cause of a urine specimen that falls slightly off range isn’t it either. That is the realm of the midwife. The reason that midwifery care is esteemed worldwide and more and more O.B. practices across the US are bringing midwives into their practices is because women are better educated an more assertive about the level of care they want. That care for the most part is safe, effective and in higher and higher demand. Lets face it, if you assume that the women choosing to have their births attended by a CPM, LM or CNM are just uneducated, leftover hippies from the 60s, then you have made an obvious error in judgement. And therefore if these highly educated, women from all walks of life ha e made the choice to forgo the “safety” of the hospital. Then a better discussion would be “Why are women forgoing safety of hospitals”. The answer lies in the dehumanization of birth that has occurred in the last century. As long as you discount the spiritual and sacredness that is the birth of a family and baby then you will continue to see women leave your Obstetrical floors and OB practices in exchange for the care and compassion they are finding with their midwives. ~ Blessings

  5. #5 Mum
    Houston
    October 21, 2012

    I definitely agree that there should be a frank discussion of pros/cons of homebirth – but also of hospital birth so parents can make informed decisions. It seems like midwifery training in the US needs to be looked and national guidelines developed for the training.

    GBS is not routinely screened for in most European hospitals and the most recent cochrane review shows routine antibiotics brings with it another set of problems.

    A sudden placental abruption can happen anywhere without warning – same as a heart attack… but nobody is suggesting we live close to a hospital or book in for a few weeks at a time just in case?

    Have you had a look at the UK Birth Place study published late last year – it makes for interesting reading (but take into account UK midwives have Degree level – 3 years of training)

    https://www.npeu.ox.ac.uk/birthplace/results

  6. #6 jane
    October 21, 2012

    You mention neonatal strep B death as something so preventable that the mother is blameworthy if she didn’t submit to IV antibiotics for the sake of avoiding the very small absolute risk that her baby would be a victim. However, there was at least one clinical trial of this practice that found no net benefit, because the already-low infant morbidity and mortality from strep B indeed were greatly reduced, but were replaced by a comparable number of infections from other types of bacteria, such as E. coli. It is not news that using antibiotics that wipe out one type of bacteria can render you more susceptible to other types. When many laboring women who carry or might carry strep B, and their fetuses, must be subjected to an intervention to save one baby from dying of that particular cause, unless the intervention has been proven to be harmless it’s necessary to ask hard questions about its risk-benefit ratio as defined by all-cause mortality rather than cause-specific mortality. (The delivery of this intervention could also lead indirectly to more unnecessary C-sections, which Dr. Tuteur thinks are great but which are increasingly recognized by others to carry real health risks for children as well as – oh yeah – women, to say nothing of the dollar cost to families.)

  7. #7 Mark
    October 21, 2012

    As long as you discount the spiritual and sacredness that is the birth of a family and baby then you will continue to see women leave your Obstetrical floors and OB practices in exchange for the care and compassion they are finding with their midwives.

    Sorry, I’m an atheist, and it applies to naturalistic fallacies about childbirth as well. I realize that people that are members of this naturalistic religion have different beliefs and desires, and that’s fine. I’m not arguing with people’s right to make medical decisions for themselves or their freedom of religion. I’m merely saying that when it comes to the data, homebirth is not as safe, and attempts by homebirthers to assert that their safety is equivalent are falsifiable. Homebirth in the US is 2-3 times more likely to result in death of the infant. That’s the difference between the US and Mexico, or Honduras in neonatal mortality. It’s a substantial downgrade in safety for a better “experience”. If that’s what you want, fine. I’m not saying you don’t have the right to put your unborn baby at risk. You do. I only object to the denial of data that demonstrates it is not as safe, and is instead about 2-3 times riskier for the infant.

    A sudden placental abruption can happen anywhere without warning – same as a heart attack… but nobody is suggesting we live close to a hospital or book in for a few weeks at a time just in case?

    No, in that instance the mother was at known risk for abruption and was being monitored carefully during labor. I was using it as an example of how ready access can be lifesaving. I doubt even a homebirth advocate, unless they were totally insane, would have recommended that particular patient be anywhere but a hospital, as she was not “low risk” by any stretch. I just recall it as a dramatic example of the OB’s I trained with being fast as lightning when trouble popped up. I was impressed.

    Have you had a look at the UK Birth Place study published late last year – it makes for interesting reading (but take into account UK midwives have Degree level – 3 years of training)

    You might have noticed in what I wrote, I am critical of this CPM degree in particular, as it appears to require virtually no education beyond high school, and is does not demonstrate the rigor that should be involved with any kind of patient care. And they certainly should not be involved in a process that has potential deadly complications for the infant and the mother. Worse, as Dr. Tuteur demonstrates, there are a great number of examples of obvious failure to rescue by these “practitioners”, and a great deal of repetitive poor judgements leading to deaths of not one, but multiple infants. These examples are anecdotal of course, but they appear to provide an explanation for the data that home births have 2-3 times the risk of mortality in the US.

    You mention neonatal strep B death as something so preventable that the mother is blameworthy if she didn’t submit to IV antibiotics for the sake of avoiding the very small absolute risk that her baby would be a victim.

    In several of the examples Tuteur cites, it’s not even the failure to administer the antibiotics as the “failure to rescue” by CPMs who did not recognize the infants altered breathing as being abnormal. If you miss stridor, it’s no longer about risk benefit ratios as much as incompetence.

  8. #8 Composer99
    http://composer99.blogspot.ca
    October 22, 2012

    jane claims:

    However, there was at least one clinical trial of this practice that found no net benefit, because the already-low infant morbidity and mortality from strep B indeed were greatly reduced, but were replaced by a comparable number of infections from other types of bacteria, such as E. coli.

    jane; I’m sure you can provide a cite.

  9. #9 JBC
    October 22, 2012

    I’d be interested in the reasons for the higher mortality–much could be attributed to uninformed idiots who have had non-medical or no prenatal care and were never good candidates for home birth. But you make it sound as though this statistic stands alone as evidence against any home birth.

    My midwife was a Certified Nurse Practitioner Midwife–I think that’s the correct title, but as I said, she did not actually participate in the birth that she attended. My first home birth was unattended (and I confess some ignorance in my views at the time), but again, mine are so quick from onset of labor to delivery, that the average OB would still be washing up or putting on gloves while I delivered (this is, in fact, what happened at my one hospital delivery.

    Finally, I am an atheist as well and abhor all talk of “spiritual” things, but I do treasure my home birthing “experiences” or whatever you want to call them. My first grandchild was born in supposedly “family-friendly” birthing center at a hospital and I found that there was extensive interference, most of which, according to the OB, was defensive medicine aimed at preventing lawsuits.

    Birthing is just the one place where I park my rationality, I guess. Just to be clear, if at any point during pre-natal care had my OB stated a valid medical reason to deliver at the hospital, I would certainly have taken that advice.

    I appreciate your thoughtful responses to these comments, I just think that they place too much emphasis on the lunatic fringe at the expense of those who thoughtfully made a decision in conjunction with good medical advice.

    • #10 Mark
      October 22, 2012

      I’d be interested in the reasons for the higher mortality–much could be attributed to uninformed idiots who have had non-medical or no prenatal care and were never good candidates for home birth. But you make it sound as though this statistic stands alone as evidence against any home birth.

      With the CPM certification I think this is quite possible, the MANA has been acquiring death statistics from its providers, but as Tuteur points out, they’ve been sitting on this data for about 3 years, likely because it’s not positive. Anecdotal reports are showing evidence of some major errors in judgment, but you are correct, the data don’t tell the complete story. We need to have evidence from cohorts who have chosen this pathway to compare to the historical or OB standard. I would not suggest a RCT with randomization simply because I think it would be unethical given the preponderance of evidence suggests inexpert providers should not be doing this.

      My midwife was a Certified Nurse Practitioner Midwife–I think that’s the correct title, but as I said, she did not actually participate in the birth that she attended. My first home birth was unattended (and I confess some ignorance in my views at the time), but again, mine are so quick from onset of labor to delivery, that the average OB would still be washing up or putting on gloves while I delivered (this is, in fact, what happened at my one hospital delivery.

      I think attendance by a nurse is excellent. Nurses are trained in resuscitation, recognizing emergencies, interventions, and are often the coolest heads in a catastrophe. Dr. Tuteur’s critique of the CPM, however, is spot on as the educational requirements are virtually nill, certification is based on a single standardized test, and the experience required is minimal.

      More disturbing to me, and I’m really not super comfortable attacking this as a male, is the overall tendency in the movement disparage pain control during pregnancy. It strikes me as a bit sadistic to say because pain is “natural” as part of pregnancy that means it shouldn’t be treated, managed, minimized etc with technology we have available. There is no surgical procedure that I would perform on someone that would create equivalent pain that I would suggest should be performed without significant analgesia if not general anesthetic. Pain sucks, and if it’s unnecessary, or preventable, why does it seem like the home birthers are attacking women for personal weakness if they need or want pain control? Pain avoidance seems pretty normal to me. If it were predominantly men in this movement highlighting the importance of pain, I think we’d call this misogyny.

  10. #11 auntbea
    October 23, 2012

    Just running the numbers from the CDC WONDER database, I am finding that while a CNM is substantially less risky than a non-CNM midwife, neonatal death is 2-3 times more likely at homebirth with a CNM than a hospital delivery with a CNM. So, yes, the training matters, but the place also matters. Home is simply not as safe.

    Raw data for babies of normal gestational weight, singletons only, with no fetal or maternal risk factors.

    CNM in hospital: 103 deaths out of 291,706 (0.35 per 1000)
    Other midwife in hospital: 15 out of 16,376 (0.92 per 1000)
    CNM at home: 11 out of 10764 (1.02 per 1000)
    Other midwife at home: 36 out of 14493 (2.48 out 1000)

  11. #12 Composer99
    http://composer99.blogspot.ca
    October 23, 2012

    Incidentally, the comments in the Skeptical OB post which notes the flaws in homebirth advocacy (any advocacy which downplays or ignores the small, but real, increase in risk of morbidity & mortality to mothers & infants) in terms of the characteristics of denialism have several cases where homebirth advocates package specific forms of denialism with other medical denialisms (anti-vaccine denialism, in particular).

    Crank magnetism lives.

  12. #13 JBC
    October 24, 2012

    I am not denying the risk of home birth, I simply think that the risk in the presence of quality pre-natal care and attended by a highly trained health professional (whatever the designation) is acceptable for informed people and it is the one area (the only one) where I would call health freedom (a term I reluctantly use as I am decidedly not in company with the cranks that typically use it).

    As to pain, that too is an individual call. While I found it miserable but short-lived I would never dream of enduring a lengthy labor of the type one sees in films. I found the after effects of the spinal (pre epidural days) that I had with my first much worse than the combined discomfort of my subsequent three drug-free births.

  13. #14 Kisha
    New Orleans
    October 27, 2012

    Have you actually seen what the training and schooling is like for a CPM? I am guessing not since you think that CPM’s have no knowledge of I.V. placement and carry no drugs for emergencies. Yes CPMs try to be as hands off as possible and let birth happen naturally but trust me when I tell you a GOOD CPM knows when something is wrong and knows what to do when shit hits the fan. Go to page 38 here http://narm.org/wp-content/uploads/2012/06/CIB0612.pdf and you can see what kind of skills and knowledge CPMs have to have to become certified. And honestly most CPMs have another carer background such as nursing or EMT I even know a few with PhDs.

    • #15 Mark
      October 30, 2012

      It’s sad that you think those requirements are strict or substantive. And while CPM may also have other certification such as nursing degrees it is not a requirement. In fact no college or graduate education seems to be required unlike for nursing. Beyond that you take a multiple choice test and attend a handful of births. I’ve probably attended twice as many births and easily performed as many newborn exams, and let me say, I would never presume that gives me enough experience to attend births as a career. I’d be better than nothing but not by much. If anything my experience has chastened me, as Ive seen just how serious and dangerous birth has potential to be, and the years of training and expertise that goes into preparing Ob’s for anything.

  14. #16 Calli Arcale
    October 30, 2012

    Just one quick comment: there is often a dichotomy suggested between the OB-attended birth and the midwife-attended birth. Yet this ignores a middle option: the family practice doctor. Family practice doctors who attend births will be present for more of the birth than an OB is, you are much more likely to be attended by the actual doctor that you saw for your prenatal visits, and the doctor is also qualified to serve as the baby’s pediatrician as well. They can perform episiotomies and instrument-assisted births, but generally must defer to an OB if things go badly south and a c-section is needed. Most hospitals have an OB on staff at all times who will step in at this point.

    For both of my pregnancies, I selected a family practice doc. She is now the doctor for both of my children. Both times, she came to the hospital as quickly as possible after learning that I had been admitted, and remained long enough to perform the baby’s first exam. Both times, things went south and we needed to do a c-section; she assisted the OB on call both times, because she likes to be there for you throughout. Obviously not all family practice docs are like this, but many are. It does sometimes cause issues for scheduling; a few times, my daughters’ well-child visits have been rescheduled because a patient went into labor. ;-)

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