September 14, 2009

Midwifery on Trial on Today

Last week, the Today Show aired a segment initially titled “The Perils of Midwifery,” which despite the title was not about occupational hazards for midwives (ha), or even about midwifery in general, but about home birth specifically. Although it has since been recaptioned “The Perils of Home Birth” on the NBC website, the original titling as aired to many viewers can still be seen on various websites, including Hulu.

The piece itself tends to gloss over the variety of personal reasons women choose home birth, treating it as a simple lifestyle matter or consumer trend, with one interviewee quoting an unnamed doctor as saying that “home birth had become almost the equivalent of a spa treatment for women.” A montage of photos of celebrities who have had home birth is also provided. The story calls the tragedy experienced by the featured couple “the dark side of an increasingly popular trend.”

The 7-minute piece focuses around the story of a couple whose baby did not survive after what is reported as four days of laboring at home. The couple had CNM Cara Mulhahn as their midwife, who has gained recognition after being featured in the film The Business of Being Born. Mulhahn was profiled by Andrew Goldman (interviewed for the segment) for a recent New York Magazine piece. In that piece, she is framed as a risk-taker, with BOBB director Abby Epstein saying, “She’ll put herself on the line way more than most people, like taking on a birth that’s a little more high risk that most midwives wouldn’t take… She puts her ass on the line in a huge way every time she kind of steps out of bounds to help somebody. That’s just who she is.”

Given this assessment, it’s unfair to hold Mulhahn and her approach and outcomes up as representative of all home births and/or midwifery. Rather than providing women with information on the various types of midwives, their education and credentialing, or questions to ask to determine whether the woman and provider might be of different minds with regards to safety thresholds and approach, the piece simply includes a recommendation from Goldman to ask about malpractice insurance and back-up physicians. No representative of a professional midwifery organization or midwifery educational body was included in the segment, who might have addressed some of these concerns and factors.

The Today Show did feature an ACOG representative, who spoke about unpredictable emergencies and the organization’s position against home birth. The piece also cites unnamed doctors as claiming that it is “impossible” to compare home and hospital birth because of the higher risk cases hospitals tend to see, but this is simply not true. Although a randomized, controlled clinical trial will never be possible, there are good data, especially the recent British Columbia study (.pdf), that compare low risk, uncomplicated pregnancies among women choosing a hospital birth or a home birth. There are many areas in medicine where good data, although imperfect, can guide policy setting, and ACOG fails to appreciate that this is one such example.

Conveying this information, however, requires more detail and nuance than typically provided in a morning news show. As the ACNM concludes: “Women and health care professionals need to be making decisions that are informed by evidence-based medicine—not reactionary interventions and unbalanced investigative journalism. Women deserve better.”


36 Responses to “Midwifery on Trial on Today”

  1. Judith Lienhard Says:

    I find it interesting that it never seems that any deaths from hospitals get featured, “the perils of hospital births”, right?! When you are a celebrity, it is ok by ACOG to choose a trendy elective Cesarean, just not a water birth or home birth!

  2. Amy Tuteur, MD Says:

    Homebirth kills babies. Indeed, it is the most dangerous form of planned birth in the US.

    CDC statistics show that planned homebirth with a homebirth midwife (CPM, LM, DEM) has almost triple the neonatal mortality rate of low risk hospital birth. The recent Canadian and Dutch studies of homebirth reveal that homebirth with an American homebirth midwife has more than triple the death rate of homebirth with a Canadian or Dutch midwife.

    American homebirth midwives are grossly undereducated and undertrained. The CPM designation (certified professional midwife) is a post high school certificate program, not a college degree. Most courses are not eligible for transfer college credit because they are foolish: homeopathy, flower essences, gem energy, etc. There is no training in managing complications because there is no hospital training. Clinical training is nothing more than an apprenticeship to an older midwife. A CPM does not meet the standards for midwifery in Canada, the Netherlands, Australia or any first world country. In contrast, certified nurse midwives (CNMs) with far more training and experience meet the standards for all countries.

    Homebirth with an American homebirth midwife can never be safe unless the midwives are held to a higher standard. Their level of education and training must be brought up to the same level as midwives in every other first world country. Homebirth must be subjected to the same eligibility requirements as in other first world countries. Unless standards are raised, babies will continue to die unnecessarily at births attended by American homebirth midwives.

  3. liberality Says:

    I think the MD above is grossly oversimplifying the issue here. All of the midwives that I know of do have rigorous training and qualifications.

  4. Researcher Says:

    Amy above is well known for her rants against homebirth all over the internet, but they are not truthful.

    I am a Certified Professional Midwife (CPM) and I am well trained in normal pregnancy, birth and postpartum and emergencies. I went to midwifery school here in the US and had Canadian students in my class (who used their US training to become a Canadian midwife). The school I went to is a Midwifery Education Accreditation Council (MEAC) accredited, a Department of Education credentialing body. My midwifery partner did an apprentiship, a midwifery course and clinicals, she too has excellent normal pregnancy, birth and postpartum and emergency birth skills. The certification process to become a CPM is rigorous for both MEAC midwifery school students or apprentice trained midwives. The CPM credential earned by a midwife is run by the North American Registry of Midwives and it is accredited by the National Commission for Certifying Agencies, the same agency that accredits the certifications for Nurse Midwives and Pediatricians among many other professionals.

    It seems to me that Amy would like you to think that we just do voo doo and pray by the bedside but in reality we are true professionals with the statistics to back it up, if you care to do the research.

    In the United Kingdom their National Midwifery organization and National OB/GYN organization work together on Maternity policy; they encourage, for healthy women, and pay for homebirth under their nation health system. They have better maternal and neonatal outcomes than we have in the US. Politically, we do not have this kind of relationship between midwives and ob’s in the US and the above poster as well as the Today Show segment are good examples of the kind of ignorance and unkindness that is common in our maternity system towards well trained midwives and their well informed clients. This energy is all spent trying to eradicate independent midwives, a safe and healthy option, at the expense of our mothers and babies. Instead we should be looking at how we can improve our failed maternity system.

  5. Amy Says:

    Amy, M.D., I think that was the least inflammatory remark of yours I’ve read on the internet. I was actually impressed by what you said. Instead of saying no to midwifery and homebirth, you are saying the standards need to be set higher. That gives me hope!

    You were kind to CNMs in your response. Thank you. I find it interesting that the midwife featured on the Today show for the homebirth baby death *was* a CNM.

    I think midwifery becomes only better when it’s standards are high and global experience is sought. That’s why I really appreciated my (lay) midwife who had had extensive training through both midwifery schools at home and training abroad. Most of the midwives I’ve known have travelled out of country to gain experience. Why? Because other countries are a lot more accepting of them, and allow them to be part of numerous births in hospitals, clinics and homes. Perhaps the U.S. should consider this. Welcome midwives and allow them a wider range of experience here.

  6. Amy Tuteur, MD Says:

    “I find it interesting that the midwife featured on the Today show for the homebirth baby death *was* a CNM.”

    Cara Muhlhahn is a CNM who does not observe rigorous standards for homebirth. The death of the baby in the Today Show piece is at least the second neonatal death resulting from her refusal to transfer patients. Most doctors will never have an intrapartum death in 40 years of practice. Cara Muhlhahn has already had two.

    Most hospitals in NYC have CNMs on staff; some even have CNMs who attend homebirth on staff. Muhlhahn, however, as detailed in a recent NY Magazine profile, has been refused hospital privileges because doctors think she is reckless and dangerous.

    Homebirth in Canada, Europe, and Australia is heavily regulated because childbirth is inherently dangerous. Criteria for midwifery training are rigorous, and criteria for homebirth eligibility are even more rigorous. You don’t get to have a homebirth simply because you want to.

    In contrast, American homebirth midwifery operates on the delusion that childbirth is inherently safe. If that’s what you believe, extensive training makes no sense and rigorous eligibility requirements are pointless. Hence homebirth with a homebirth midwife is the most dangerous form of planned birth in the US.

    What I find distressing about homebirth advocacy is the deliberate attempt to mislead and withhold information:

    American homebirth advocates attempt to blur the distinction between CNMs and CPMs. Indeed, the recent name change from direct entry midwife (DEM) to certified professional midwife (CPM) appears to be a deliberate attempt to confuse women.

    American homebirth advocates are not honest about what the national statistics show (homebirth with an American homebirth midwife has nearly triple the mortality rate of low risk hospital birth).

    Perhaps most disturbing, the Midwives Alliance of North America (MANA), the trade union for homebirth midwives, has collected statistics on homebirth safety since 2001. The results can be obtained by those who can prove they will use them for the “advancement” of midwifery, but they are hidden from the public. It does not take a rocket scientist to suspect that MANA’s own data shows homebirth with a CPM to increase the risk of neonatal death.

    Unless and until homebirth midwives accede to more education and training, more rigorous eligibility requirements for homebirth, and transparency in their safety data, American babies will continue to die at homebirth.

  7. Death by Tuteur Says:

    Amy Tuteur kills babies! In her own words…

    Death by epidural:

    Most maternal deaths are due to serious complications of pregnancy, or serious underlying medical problems, such as heart disease, that are exacerbated by pregnancy. Like any obstetrician, I’ve been involved with several maternal deaths, though never as the primary physician. Each one has been a searing experience, but in retrospect, an unavoidable event.

    All but one, that is.

    The patient died because of a series of unfortunate anesthetic complications, compounded by inadequate medical response. I cannot tell you when, where or how, since the case is so unusual that any details might lead to identification and compromise of privacy.

    Amy didn’t perform a necessary c-section and the mother returns in labor with a dead baby in utero:

    The patient returned two days later in labor, and the baby was head down … and dead.

    After the delivery, we could easily determine the cause. There had been a true knot in the umbilical cord. While the baby moved of its own accord into the head down position, the knot had tightened, depriving the baby of blood flow and oxygen, leading inexorably to the baby’s death. Telling her that the baby had died was one of the hardest things I’ve ever done. Knowing that her baby was dead, she still had to go through labor.

    It often seems that when disaster strikes, it is inevitably followed by more disaster. It’s hard to imagine how this situation could have gotten worse, but it did. The baby was big, and during the delivery, the mother experienced a very unusual complication. She ruptured her symphysis, the piece of cartilage that holds the two halves of the pelvis together in the front at the pubic bone. Much to our horror, the nurse and I literally heard it pop. The patient could not walk for months thereafter.

    The patient also developed a raging infection that required a week-long hospitalization for IV antibiotics. She ultimately went home to a long course of oral antibiotics, a walker, and months of physical therapy to help her as her ruptured symphysis healed. I must have apologized to her a thousands times, but, of course, I couldn’t change what happened.

    What did I learn from this dreadful experience? I learned that if I was going to have to take responsibility for bad outcomes, I ought to be sure that it was my decision and not someone else’s. I had felt at the time of the failed version that the C-section was the right thing to do, but I allowed myself to be talked out of it. It’s true that the senior obstetrician had more experience than me, but I had been looking for a way to avoid responsibility for performing a C-section on a woman who had had two previous vaginal deliveries.

    The recommendation from the senior obstetrician allowed me to push off the decision, and I had naively thought that no harm could come from pushing it off. Either she would show up in labor with the baby head down, or she would show up in labor with the baby in the transverse position and we could do the C-section then. I had never considered the possibility, albeit rare, that she could show up with a dead baby.

    Amy kills adults, too:

    But I cannot help but think that I colluded in a theft. We stole Mr. Rivera’s dream of a peaceful death and replaced it with vomiting, fever and pain. We had no right to do what we did; we were guilty of a terrible crime, not a legal crime, but a crime all the same.

    Amy Tuteur is dangerous! Indeed, she was the most dangerous form of planned birth in the US when she still had a license.

    [See how stupid that sounds? Stop the spam. You post the same sheisse over and over.]

  8. Elke Saunders Says:

    If homebirth is so dangerous, why doesn’t the research show that? The above MD’s claims are ignoring the most respected and recently published studies in the Canadian Journal of Medicine and the British Journal of Medicine which report homebirth as being equally safe for baby and less interventions for mother. (less cuts, punctures, procedures, hemorrages, etc.)

    Besides, this is all about choice. Informed women are chosing to stay at home because in the hospital they are given very little choice and autonomy about what is “done” to their bodies.

  9. Amy Tuteur, MD Says:

    “The above MD’s claims are ignoring the most respected and recently published studies in the Canadian Journal of Medicine and the British Journal of Medicine which report homebirth as being equally safe for baby and less interventions for mother.”

    American homebirth advocates continue to celebrate the recent publication of homebirth studies from Canada and the Netherlands. Evidently, they have failed to grasp the central lesson of both studies: homebirth can only be safe when practiced by highly educated, highly trained midwives under rigorously controlled conditions. Since this is in direct opposition to the philosophy of American homebirth, it is not clear what advocates are celebrating.

    Reading the Canadian and Dutch studies makes it clear that Canadian and Dutch midwives don’t “trust birth.” There is none of the prattle traditionally associated with American homebirth. No babbling about how birth “is not a disease”; that women’s bodies are “designed” for birth; that babies are “not library books,” due on a certain day.

    In fact, the fundamental premise is exactly opposite: birth is inherently dangerous and great care must be taken to prevent, diagnose and manage complications. Practitioners must adhere to the tenets of modern obstetrics. Consistent with that premise, both countries mandate rigorous education and training of midwives. Midwifery is a university degree; midwives are trained for both hospital and home; and significant education and training is devoted to handling complications. No one pretends that homebirth midwives are “experts in normal birth,” as if such a thing were even possible. There is no such thing as a homebirth midwife. All midwives attend births in the hospital and at home.

    So although homebirth might be safe in Canada or the Netherlands, it is certainly not safe in the US. Homebirth with an American homebirth midwife has TRIPLE the neonatal death rate of homebirth in the Canadian and Dutch studies.

  10. Amy Says:

    Dr. Amy,

    I hear what you’re saying.

    As researchers with a cause, it’s important to have good studies available and be able to read them correctly.

    Could you please direct me to the place where I can view the studies/statistics that show that Homebirth with an American Homebirth midwife has triple the neonatal death rate.

  11. Georgina Says:

    “Most doctors will never have an intrapartum death in 40 years of practice”

    Dr. Amy, Dr. Amy..I think she’s asleep Dr. Amy—– snap out of it. Will someone please put away the shiny pendulum in front of her face so she’ll come out of the ridiculous spell she is under. I also would like to kindly and respectfully ask that you retreat to your hideous web page and leave the our body ourselves website altogether. You are no friend to woman’s health. Also- perhaps you might benefit from a freshman college level research methods course so you can find unbiased research to help get you out of your fantasy about what women reallly want in maternity care today.

  12. Kelly Says:

    I am planning a homebirth and can say with utmost certainty this is the most calm and confident I have felt in all of my 3 pregnancies. After the near death of my first born- due to the fault of the hospital/OB and the fact that evidence based materinty care does not happen in our country. I educated myself immensely and had a successful hospital VBAC that still caused issues (thankfully minor) for my baby due to hospital intervention.

    Dr. Amy- ever hear of Ina May Gaskin? Her statistics are astounding- first hospital transfer and c-section at the 187 and then something like 337th birth. Birth is not a condition, it is a natural event! A woman’s body knows how to give birth if given the support, encouragement, and respect it deserves. I love how you put it Georgina and agree 200%! I personally would never let an OB touch me again and am so thankful for my wonderful, highly trained, and experienced midwife!!

  13. Amy Tuteur, MD Says:

    “Her statistics are astounding- first hospital transfer and c-section at the 187 and then something like 337th birth.”

    Her statistics are terrible. The only paper published on the subject (Durand, 1992) showed that The Farm had a neonatal death rate of 10/1000. That is more than ten times higher than the neonatal death rates in the Canadian and Dutch studies.

    Ina May Gaskin epitomizes the worst in homebirth midwifery. She is “self-trained,” her own baby died at a homebirth, and she has absolutely no standards for homebirth.

    Why do you think that the only people who claim homebirth is safe is homebirth advocates themselves? They are the only people who don’t understand what the scientific papers and national statistics actually show.

  14. the real Amy Says:

    Does this “Amy Tutuer” actually have a license to practice medicine or is she simply an internet troll?

  15. Amy Says:

    I’m still waiting on those studies you got your homebirth statistics from….

  16. the real Amy Says:

    Seriously, does this woman actually have a medical practice somewhere or does she just sit next to the computer all day and periodically google anything related to homebirth to she can post her questionable statistics? It’s rather akin to being an internet troll, is it not?

  17. the real Amy Says:

    I found her (Amy Tuteur) website. Before she spouts off again about statistics, perhaps she should fix the glaring spelling errors on her own page. It really does speak volumes about her “fact-checking”….

  18. Joy Says:

    Wow! I have never heard of “Amy Tuteur” until I happened onto this blogsite. I guess I may be naive, but I find it rather appalling that an OB would be posting things personally attacking another person (Ina May Gaskin). To me, that is the pinnacle of unprofessional behavior and it really reduces or just plain obliterates credibility when someone makes it their personal mission to attack someone or something.

  19. Brooke Hosey Says:

    I just veiwed “The Perils of Midwifery”. I also just gave birth to my 9 pound daughter in a pool in my bedroom 9 days ago with no medical intervention. I am a respiratory therapist who has worked in several different hospitals and has been called to more than one unexpected tragedy in the hospital delivery room. Yes sometimes babies die. This case on The Today Show was a true tragedy. Don’t think for a second that birthing in a large hospital with a specialized NICU is going to prevent tragedy like this. It doesn’t. If the education of CPM’s is so poor, but there is a clear rise in the desire for homebirth and more birth choices in this counrty than why not accept this already and try to improve the situation?

  20. Georgina Says:

    Here’s a little background on Dr Amy. Teuter, MD (mentally deranged)
    Amy Teuter “chooses” apparently to stay unlicensed. She is a certifiable lunatic as evidenced by most of her writings- everywhere on the internet- she is the “hate speaker” of home birth and relies on creating outrage and frothy emotional appeal by only discussing poor outcomes from home birth.
    I sometimes like to picture her sitting behind the keyboard writing her crazy talk- it’s like she never set foot inside a post high school classroom or something. Maybe she gets all her facts from pamphlets. I bet you she laughs the whole time because she knows it is almost comedy/fiction.
    Apparently, Dr. Amy has no room in her truth chest to put poor outcomes in birth from the hospital or obstetricians.
    There is a fine line to walk with her- she is like black mold, If you allow her to sit in the dark (and write and conjure up her crazy talk) she will become an out of control problem. I can’t stand to see her (like black mold) but if she stays hidden than who knows if she will become a true epidemic of crazy talk. She is a true shill, for what I am not fully certain as I highly doubt any certifying body of medical professionals would want to be associated with her.
    I write this for all the people who are like– what the? Yeah, here she is- when is she leaving is my question. Maybe if we all be real quiet she’ll get the hint and leave.
    Oh yeah before I forget- Dr. Amy I have some more RESEARCH- made by DOCTORS (pronounced ree-serch and dokk-tors) on the Gaskin Maneuver which is a viable tool for doctors who hope to avoid a poor outcome in the hospital when shoulder dystocia presents.

    http://www.obgynnews.com/article/S0029-7437(02)70996-8/fulltext

    LAKE TAHOE, NEV. — Because there’s no sure way of predicting shoulder dystocia, physicians would do better to shift their focus from trying to avoid it to learning the best strategies to deal with it, Dr. Thomas Benedetti said at an obstetrics and gynecology conference sponsored by the University of California, Davis.
    Physicians probably have more time than they think to work on getting the baby out safely. “We used to think that after 2-3 minutes from the time of the shoulder dystocia you were getting into trouble if the baby wasn’t delivered. But now there’s some suggestion that up to 5 minutes may not increase the risk of injury, and some data even suggest that the critical time may stretch to 7 or 8 minutes if the fetal heart rate is normal,” said Dr. Benedetti, professor and director of perinatal medicine at the University of Washington, Seattle.
    Physicians should start a stopwatch or get a colleague to time them when they start tackling the dystocia, because “it’s hard to keep track of the time, and often when we are under that kind of stress we mistakenly think much more time has passed than is actually the case,” he said.
    The common maneuvers that are used to release a shoulder dystocia all have roughly the same rate of brachial plexus injury, 13%-21%. But Dr. Benedetti said that one less common maneuver, the all-fours maneuver, may have some advantages over the others.
    “This maneuver is relatively new to obstetricians but [is] very commonly used among midwives, and one study showed it had an 80% success rate,” he said.
    The study reported that out of 82 cases of shoulder dystocia, 68 were resolved using the all-fours maneuver, also known as the Gaskin maneuver. Only three complications were reported: one postpartum hemorrhage, one newborn injury (a fractured humerus), and one low 5-minute Apgar score (J. Reprod. Med. 43[5]:439-43, 1998).
    In the all-fours maneuver, the woman moves from the dorsal lithotomy position into a hands-and-knees position. The physician then attempts delivery of the baby’s posterior shoulder by gently guiding the baby’s head down toward the floor.
    “The position can be a problem for the mother who has had a heavy epidural, but it’s something to consider before putting the baby’s head back in the vagina and going to a cesarean section,” he said.
    In the McRoberts maneuver the woman pulls her knees up to her abdomen, which flattens out the symphysis pubis, giving 30%-40% more force to each maternal push.

  21. Rachel Says:

    Hey, everybody, I appreciate the lively discussion, but I personally prefer if we keep name-calling and insults out of it (on both sides). Thanks!

  22. Amy Says:

    I understand the strong feelings, but I really do not see how being nasty is going to help the two sides of the situation come together. We need doctors and midwives to have a working relationship. How can we do this? How can midwives gain the support of OBs? Certainly not with this type of bashing.
    If you’ve followed Dr. Amy for a while, you would see that she is slowly coming around! I see hope in that! Please reconsider your tactics in proving your point on homebirth and midwifery. It may be doing more harm than good. Name-calling and flame-throwing is just stooping to her level. Rise above it and use concrete evidence to support your position. It tends to work better.

  23. Georgina Parker Says:

    Okay, I apologize to the readers of this blog, but absolutely not to Amy Teuter, MD. I stand by my remarks about her being better out in the open here with people who believe in the safety of home birth and the effectiveness of the midwifery model of care. If you care to- please see her old website homebirthsafety blog spot- THEN come back- we can then discuss what you think of trying to bring people together.

    Her rhetoric because she has a credential after her name is used in articles and such in the mainstream culture that seeks to undermine the validity of home birth.

    “Homebirth kills babies. Indeed, it is the most dangerous form of planned birth in the US.” Amy Teuter, MD, (on this blog see previous post for details)

    It is becoming a known fact and statistic that the United States has one of the highest infant and neonatal mortality rates in the “modern” world. The underlying argument is about the fact that little is being done to improve the standard of care provided to mothers whether they have a baby with an OBGYN, a midwife in the hospital setting, or a midwife at home. The most important thing is to identify why it is we have this deplorable track record with all birth.
    Additionally, since home birth parents comprise such a small portion of the actual “birthing” population, than why are we at odds to protect them? It is everyone’s responsibility and everyone’s fault that this is happening.
    I thought of another detail last night as I am even more disheartened to see that now some articles are quoting Amy Teuter, MD and Erin Tracy MD, ACOG delegate, together. Any non discriminating viewer or reader will be more inclined to take them at their word because they are doctors. (see the show “Doctors” for details we love doctors in this country)
    The CNM featured in the Today show piece was a CNM who under NY State law is supposed to be practicing with a physician’s agreement. Suffice it to say, she is not.
    Why are doctors PERMITTED to agree to not cooperate, but this midwife will likely be sanctioned for not having an agreement. If it is a requirement, than both professionals should be required to participate. I think of course for the record that she should lose her license to practice if she is found at fault for not using a physician’s agreement and if/or she if found to be negligent in the care of the mother and baby who were featured in the today show piece. I do not excuse poor health care providers for any reason.
    I think it is very simple that doctors should be required to be available for consult with home birth midwives across the nation whether they support and condone it or not.
    Here is another for instance, there is a CPM in my community who routinely goes to the nursing supervisor of one of the hospitals in her practice area to have them keep the chart of her home birth client on the floor should an emergency arise and a transport become necessary. This would of course be good sense and be critical if information is needed in a true emergency-(blood type, drug allergies, pre-existing conditions, vitals, pattern of contractions, FHTs etc.) The nursing supervisor does the same thing every time- she consults with the “legal” dept. of the hospital and then refuses to accept the chart. This same thing happened to me-
    I offered my entire medical record to the OBGYN whom I maintained concurrent care with during my pregnancy and he would not accept it. He said “I cannot back up your midwife.” This is not what I was asking him to do. I was hoping that if he looked at my chart as a board certified physician he would make a reasonable diagnosis if a home birth would be safe or out of the question based on the nine months of data plus my former record to see if any red flags were raised. I was hoping too he would suggest if even further diagnostic tests were needed. (He did put my current chart at the hospital, but did no tests.)
    The other piece to this is that although birth is mostly a safe process, emergencies do arise. A pregnancy where a women is at risk for a medical problem or evaluated where one is found needs to be managed by a medical team. A low risk routine pregnancy is not cause immediately for a hospital birth. Birth does go one very routinely, in fact in hospitals, (with or without- augmentation, with or without intervention) and in birth centers and homes. I have attended births in hospitals as a doula and found that for the most part we were left alone (the mother and I) for long stretches of time between EFM. I believe from my experiences that medical staff know that birth is inherently safe or they would be with the mother in labor for every minute. I am grateful that I have never had a situation suddenly develop where a mother lost a baby in a sudden cord accident or anything similar when there were no nurses or doctors present. I contend although I know I will face a lashing from any anti-home person that an out of hospital provider: a CPM, CNM, or CM, or highly qualified DEM will monitor mother and baby and know when to transport before an emergency arises. I also read a post from a CNM who thought that the track record of CNMs (on the whole) was being questioned from the Today show piece. That was disheartening to me when so many OBs have them in their practice and appear to embrace it as another complimentary form of maternal and infant health care. CNMs help to bring us forward-it is in some circumstances the best of both worlds. OBs too are highly trained to help when a birth emergency arises, they are trained to do c-sections for a reason- it is the unnecessary augmentation and intervention in birth that causes problems not birth itself. (BTW, think about the time from when a C-section decision is made in a hospital and the actual surgery is done- anything can happen to the baby- that wait is very dangerous in some ways. I know many women whose babies died while waiting for their c-section. This is a modern tragedy.)
    I also thought of this recently- we hear all the time of women who have babies on the way to the hospital because of one reason or another- and we never turn and say: “Wow that lady was hedonistic, indulgent, reckless and dangerous (said of home birthers) she should have known to get to a hospital sooner!” Women as a result of a lack of insurance sometimes wait until they are thirty-two weeks pregnant to seek health care, and we do not condemn them. They have very little choice. I had to wait until I was 20 weeks pregnant to be seen because I did not have health insurance- The doctor whom I usually use a great OBGYN would not even see me as a walk in at the ER because I was completely uninsured at the time. I realize now I should have gone in and said I had a stomach ache. I was only asking for a routine pregnancy test, blood work to make sure everything was okay and an early routine pelvic exam. I had to fight with the commonwealth connector in Massachusetts because we were a half a percent over the poverty level and were required to pay a 7,000 deductible before we would be allowed to get insurance. We were Thousandaires!!!!
    We also as a culture do not even begin to investigate why it is that a mother will lose a baby at 41 weeks in a stillbirth only to find out afterwards that she had a treatable blood clotting disorder that could have been managed throughout her pregnancy.
    These are to me where the real problems are- it is not as polarized as Dr. Teuter would like to make it. I personally am tired of hearing rhetoric from doctors about how dangerous home birth is. Yes, there are problems, but these are maternal and infant health problems- not home birth problems.

  24. Amy Says:

    Georgina, I agree with a lot of what you wrote.

    One thing that I jotted down in my notebook when I first read Dr. Amy’s response was on being “extreme, dangerous and risk-takers”. These terms are used often when discussing midwives, and out of hospital births. But I’d like to bring the other side into the looking glass. What about all of those OBs who have high intervention rates. Who induce for no real medical reason, use procedures that are not scientifically proven as safe or effective (NPO, continuous EFM, restricting a mother to the bed, etc.), and have high cesarean rates. How is this a safe alternative to Cara’s “extreme” way of practice?
    We need to investigate doctors with high rates. Why are their rates so high? Not because all of their women are high risk. Why aren’t they helping to prevent these complications? Why aren’t they practicing evidence-based care? *They* should be disciplined. *They* are creating truama on a daily basis.
    Georgina, I know how passionately you feel. I am a childbirth educator, doula, birth network leader, and on the board of a grassroots organization which is trying to legalize CPM in our state. It’s hard to be up against the medical establishment when you feel that your beliefs should be respected. What I was trying to say in my last post, was that we will never have that support from OBs, get back up physicians or be well treated in transfers if midwifery supporters are being nasty to the medical establishment. This does not mean we should accept those who offer sub-standard care, or agree with them. But using non-violent communication tends to bring people to a better understanding of one another than language that puts the other side on the defensive.

  25. Amy Tuteur, MD Says:

    “It is becoming a known fact and statistic that the United States has one of the highest infant and neonatal mortality rates in the “modern” world.”

    No, that’s not a fact, but it is something that homebirth advocates like to tell each other, continually perpetuating misinformation.

    First, it is important to understand that there are 3 different kinds of mortality: infant mortality (birth to 1 year), neonatal mortality (birth to 28 days of life) and perinatal mortality (from 28 weeks of pregnancy to 28 days of life.

    The statistic you are referring to is infant mortality, which is a measure of pediatric care since it includes death up to 1 year. You are correct that it is not nearly as good as European infant mortality statistics.

    Neonatal mortality is a measure of obstetric care and perinatal mortality is the internationally recognized standard for measuring obstetric care. That’s because different countries have different ways of measuring neonatal mortality. For example, the Netherlands counts very premature babies as stillbirths even when they are born alive. That’s one of the reasons why the Dutch neonatal mortality rate is lower than the US. They simply eliminate premature babies while we count them.

    The World Health Organization recommends using perinatal mortality as the best measure of obstetric care because it includes late stillbirths, and deaths during labor as well as neonatal deaths. According to the 2006 WHO report, the US has one of the lowest neonatal mortality rates in the world, lower than England, Denmark and the Netherlands.

    The truth is that the US obstetric system is among the best in the world. That’s what the WHO says.

    This is yet another example of deceptive tactics on the part of homebirth advocates. I’m sure that you were not aware of the distinctions between infant, neonatal and perinatal mortality. Therefore, you never realized that professional homebirth advocates were deliberately quoting the wrong statistic. The correct statistic is perinatal mortality, and in the absence of that data, neonatal mortality is a reasonable second choice.

  26. Georgina Parker Says:

    Amy:
    I just wanted to let you know that I never even took into consideration whether non-violent communication is part of this issue. I personally believe after many years of dealing with all kinds of public, religious, and political groups that open, non-violent communication is only going to work if people are willing to find a common ground. There are staunch opponents who oppose home birth and they have no willingness to look at data and positive evidence to even examine the possibility that what they contend may not be entirely true. They cannot be swayed. They are trying to keep home birth unsafe and unregulated (in this state) and about 20 others. Dr. Teuter is hardly considered part of the medical establishment. She is unlicensed and an academic at best- she does not take patients and has no practice so I don’t even consider her part of the Massachusetts Medical Establishment.

    As I have looked back at posts on here by Dr. Amy Teuter, MD and then some of her posts on the internet last night (feel free to surf around yourself). The one she penned on circumcision I found is priceless.
    I have lost interest in what she has to say because I honestly feel very little of it is constructive dialogue about anything that champions the cause of better maternal and infant health.
    I was just made aware that she was posting here on this blog recently and a friend of mine had noted the irony of it. It is such an insult that anyone who so opposes supporting women’s choices in childbirth would be here posting on the Our Bodies Ourselves blog. If Dr. Teuter wanted to really be a part of women’s health and women’s health care reform she would try to peddle a soft sell on her rehtoric. She never does. She doesn’t even stop for a second to think about how her words are taken by people who may have chosen home birth for all the RIGHT reasons and had successful home births– that is evidence- anecdotal but evidence nonetheless. (all successful home birth Moms can’t be wrong right?) She is hoping that her parade of horror stories and accusations will someday win us over. I had to personally draw the line somewhere- and meet her at her own level especially after the Ina May Gaskin remark. (Remember: she railed against Ina May Gaskin as a bereaved mother about her stillbirth- that was a low blow- I hope you and I can agree on that)
    The Gaskin Manuever is accepted second to the McRoberts Maneuver in helping to stop shoulder dystocia by doctors. Whether or not a doctor condones or dislikes home birth they are going to try what works to save their patients- that’s why I included the article.
    I am interested in listening to people who are currently in the practice of obstetrics who are doing positive things. I will no longer go after docs and their profession in terms of well- this is what docs do– here is all the needless interventions etc. etc. because it is a training of a whole different sort. Being trained to be a midwife of any kind and being trained to be an OBGYN are completely different- at the end you receive an entirely different skill set. Additionally, I think many birth professionals who have not witnessed first hand through a client the “near death” of a baby who was saved by a real intervention or sadly helped a client through the death of a baby after a routine, trouble free pregnancy usually like to criticize docs all day long. I have met so many women who have lost babies and have the most profound respect for doctors, and the work they do. Since I have met these mothers I no longer even feel remotely inclined to trash them I see both sides of docs and the work they do. Every profession imaginable has its charlatans and imposters. I don’t defend the shennanigans that are part of modern obstetrics. I now have a new appreciation and profound respect for the times when docs or midwives intervene and it saves a life, or when they do all they can for a family when a baby is lost. It is a huge catch 22 for me- I see their glaring deficiencies, but I also see their gifts. I also think maybe the malpractice insurance and HMO industry is more to blame.
    You could certainly find out about doctors by going to the office of vital statistics in Dorchester- and seeing how many IUFD happens at a given hospital, or contact CIMS to see if they can help you. I know too Jill the unnecesaerean has stats. we’re not doing so good here in MA.
    I know of many many stories where docs were compassionate, did everything they could, provided very little “intervention” so I’m not buying that anymore about the doc bashing. I also have seen docs stand up to patient’s wishes and patient’s stand up right back because they knew it was an unneceassry intervention during birth.
    Additionally, I am thinking you could contact the Board of Registration of Medicine if you wanted to know about certain docs. Anyone who has had a bad experience with a doc can file a complaint there- and if there is just cause then docs can be investigated and disciplined. Midwives cause birth trauma all the time- I know mine certainly did- and there is no board to go to with valid complaints as they are not licensed through the state of Massachusetts currently. As I like to say, currently in this state of non regulation of midiwves in Massachusetts there is no formal complaint process for OOH midwives if you have a bad experience with an OOH midwife in Massachusetts then you can exercise the- better luck next time clause. even if a midwife is sanctioned through NARM its sanctions are meaningless unless the state is involved. Has anyone else noticed that the ACNM is opposed to including the CPMs in state by state legislation but now wants to be part of the dialogue about what happened when one of their midwives was portrayed as a risky baby harmer on the today show- see the acnm webiste for details.
    So Amy, I just wanted to clarify after you posted some things. I hope that you have continued success in the work you do with mothers.

  27. Amy Tuteur, MD Says:

    In other words, you didn’t realize that you were quoting the wrong mortality statistics.

  28. Georgina Parker Says:

    Dr. Amy:
    As I think I made abundantly clear twice over now- you are persona non grata to me. As my ninth grade gym teacher said either you are part of the problem or part of the solution.

  29. Georgina Parker Says:

    Dr. Amy Teuter:
    I found where you crafted your post from:

    http://en.wikipedia.org/wiki/Infant_mortality

    Awesome.

  30. Amy Says:

    Georgina, Thank you for your response.
    I agree with you that Dr. Amy is not someone I consider an expert on this issue. She definately has a strongly biased agenda and will do whatever she can to make her stance known. I discovered this two years ago when I stumbled upon her blog. I naively made what I thought was an insightful comment, unaware of the pit of snakes I was jumping into. After the ridiculous and nasty comebacks, I decided this was someone I would not be able to have any type of dialogue with. I just want to make sure that we, as supporters of women having a choice in their birth options, and advocates of legalizing the practice of safe midwifery, do not follow in kind with attacks of strong opinions.
    If you notice, I did not engage in debate with Dr. Amy, and it’s for good reason. Though, I think she represents the opinion of a lot of the doctors I know, so I take her words into consideration, as they are good practice with how to discuss, and have good solid discussions with, the anti-homebirth side of this issue. I have asked Dr. Amy repeatedly for something, anything, to support her claims of the dangers of midwifery. So far, we have only received her words, and nothing to back them up, so I will assume they have no real support.
    As someone who works with pregnant women, I like to have all the data available on safe options. I tell my clients to never take my word, their doctor’s word, or their midwives’ word on something, but to make sure they look at the evidence themselves.
    One thing I found interesting was Dr. Amy’s insight that Canadian midwives are much safer practitioners than American midwives. I don’t know how true this is, but I find it interesting that when I became a midwives’ assistant, I was required to attain a certification in neonatal resuscitation. We were given the hospital version, with all it’s various forms of resuscitation devices, and we were also given the homebirth version, which expanded the hospital’s version with perfecting knowledge in mouth-to-mouth neonatal resuscitation. At our training, we had a handful of midwives from Canada come to the training. They said that they wanted to know how to give mouth-to-mouth because they would never be able to receive that training in their country. They wanted to be able to know what to do in case a woman gave birth in the elevator at the hospital and the baby needed help with starting. Or, if they went to a homebirth and didn’t have time to get their supplies. This made me feel good about my midwives’ and their expanded knowledge on all ways of resuscitating a newborn. The midwives were also taught intubation and issuing medication in cases of babies needing extra help.
    I know that not all midwives are cut from the same cloth, but I very much trust my midwives. I knew that signing on with a midwife, I was taking responsibility in the outcome of the birth. All parents need to know that no matter who they have attend their birth, there is no guaranteed outcome. Just because they choose a great hospital and a great doctor does not mean that they no longer have responsibility for their choices and what happens in their birth. Same with birth centers, homebirths and midwives.

  31. Lauren Says:

    Research on the reasons women chose to birth at home shows time and time again that homebirth is chosen because women believe it to be SAFE. SAFER than hospital birth. I did not chose homebirth because it was trendy or cool, and my birth certainly didn’t approach my luxurious spa experiences. It was hard, sweaty, and kind of gooey. It was peaceful, safe, and intervention free. My husband and I agree that homebirth was the best choice we have made as a family and look forward to our second homebirth in January.

    The Today Show segment was extraordinarily poor journalism, pure and simple. It’s the worst kind of shoddy, sensationalistic “news.” I say we ignore it — and Dr. Amy’s familiar and faulty ranting — and focus on working towards licensing all midwives to practice and integrating them into our healthcare system.

  32. Hildy Says:

    If home birth is so safe, why can home birth midwives in Australia not obtain malpractice insurance?

    For many years doctors insured each other through their medical defence organisations. Midwives could insure themselves through the same mechanism but they don’t have the same belief in their product (or in each other) to be willing to risk their houses, and are trying to insist that the public step in to protect them.

  33. Gayla Says:

    Amy Tuteur recounts one of her “mistakes”: the pregnant woman who

    “ruptured her symphysis, the piece of cartilage that holds the two halves of the pelvis together in the front at the pubic bone… The patient also developed a raging infection that required a week-long hospitalization for IV antibiotics…”

    I’m willing to bet that the laboring woman was flat on her back hooked up to machines, instead of standing or crouching or getting on all fours or taking whatever position her natural instincts tell her will help get that big baby out of her. And she was probably drugged to make her natural instincts get out of the doctors’ way.

    And as for picking up an infection, that’s because she was in the hospital.

    I had my first baby in the hospital, and my next two at home. There was no comparison in quality. I hate looking at my firstborn’s hospital portrait, him lying there in his tiny bed with all his limbs tensed up , with a look on his face like he was miserable and hated the world. My mother said the nurses put him under the cold water faucet to clean him up. After a labor spent uncomfortably flat on my back with a pitocin drip to make contractions extra-hard and a heart monitor, for no good reasons whatsoever.

    My second child was born after a short labor I spent naked at home, hanging onto a towel bar. That was EXACTLY how I needed to be and I enjoyed the birth mightily. My third child was born exactly at midnight at home after a short labor; I spent a lot of time in the shower, or finding a comfortable way to be on, my own bed in my own home.

    I try to avoid doctors generally, in order to stay healthy, and when it comes to inflicting on the birth process male-dominated greed-driven institutions filled with poorly-educated-doctors, I say no thanks; I’ll stay home, like a smart animal in its den, instead of checking into a profit-driven institution full of sick and dying people. Ina May Gaskin is completely right. Have your babies at home.

  34. Sean Says:

    Dr. Amy,

    I would like to state my appreciation for the information you are trying to spread.

    My wife’s brother and his girlfriend attempted to have a baby at their house with a midwife. To make a long story short, her water broke Friday night – she didn’t have the baby until late Sunday. The baby was very large, not breathing, and no pulse. The baby might live with brain damage, if she is lucky. Both mother and baby are at the hospital for longer than if the would have planned to go there, and they both are on many drugs.

    I am not trying to use a case study to prove my point, but I would not recommend a risky home birth – unless you want a brain dead or totally dead baby.

    You are correct that some or most US midwives are not qualified to assess medical situations. I am sure for a problem-free childbirth, they can manage, but they certainly don’t have the means to deal with an emergency.

    Take your baby to the hospital where they belong… This isn’t the 18th century.

  35. Aleisha B. Says:

    Dr. Amy,
    I personally attempted to have a home-birth with a midwife and I have to say it is the stupidest thing I have ever done in my life. It was a risk that I didn’t need to take with the life of my child and I will never do anything like that again. I put my life and the life of my child in the hands of a person without the education or even the wherewithal to support me when things went wrong.
    I was lead to believe that I was making a “healthy” choice for me and my son because I read a bunch of midwifery/home-birth/water-birth propaganda. I think there is too much pressure on women to do it “naturally” when the focus should be on safety and support.
    To make a long story short, when my labor took a turn for the worse the midwife I hired abandoned me because she didn’t want to face the music at the hospital for her botched job. My son and I are alive and healthy. Thank-God! However it is of no thanks to her. My son and I are alive today because there was a trained and talented OB-GYN in the emergency room when we made it to the hospital. I thank my lucky stars every single day. He was literally a life-saver. There are a lot of stories similar to mine. Everyone I talk to seems to have had a terrible experience with a midwife/home-birth situation. Next time I will have my baby in a birth center in the hospital where if things go wrong Ill have the care I need when I need it.
    Ladies, don’t feel pressured to have a “natural” birth, do what is safest for you and your baby. Always. Sometimes you need Western medicine. Please realize that midwives and doulas are also business people driven by money who spread the propaganda that hospitals and doctors are bad, sadistic and anti-women. This is not true. Believe me.

  36. Maria Says:

    Just going back to something Amy said about the UK having very strict criteria for homebirth and not just getting one because you want it… This is not strictly true, it is a womens right to birth in her home and the NHS are obliged to provide competent, supportive midwives. You will meet with resistance but if you write to the head of mid wifery they are obliged to support you, obviously they are are exceptions but increasingly women are having NHS midwives attend home birth VBAC’s

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