Monday, May 23, 2011

Home vs. Hospital Birth

When a woman I know in real life or online tells me they are interested in giving birth at home, I am never entirely sure how to react.

While I am a physician, I'm not an obstetrician or pediatrician or someone who works regularly with childbearing age women. When it comes to the statistics and research about home vs. hospital birth, I know very little. All I can really offer to an expecting mother is anecdotes from my brief experience on L&D. I can share a story about a severe postpartum hemorrhage that might not have made it to the hospital from home, or the newborn with unexpected heart problems whose life was saved only by immediate medical care. Based on that experience, I would never consider giving birth at home or advising anyone else to do it. But anecdotes don't equal evidence-based recommendations.

In contrast, a lot of women having home births have done tons of research on the topic. Something I recently discovered is that some women who are pro-homebirth not only feel that it's safer to give birth at home, but that this is an undisputed fact supported by solid medical evidence.

There are probably women who read and write on this blog who know the evidence back and forth, but I'm not one of those women.... which is why I'm writing this post. I am not entirely sure what to make of women who proclaim that they're giving birth at home because it's safer, then try to convince others to do the same. Yet I feel like as a physician, I have to speak out on behalf of my profession.

The readers of this blog are generally medical professionals of one kind of another, or at least people who likely respect physicians. So I ask this specific community for the sake of my own (and the readers') curiosity and knowledge: what are your thoughts on home vs. hospital births?

128 comments:

  1. The 'safer' claim sounds pretty iffy to me. The most comprehensive meta-analysis that I know of was the 2010 article showing a 3x increased infant death rate in home births. (I easily could've missed something more recent or better structured, though.)

    http://www.ajog.org/article/S0002-9378(10)00671-X/abstract

    Now, I understand the difference between relative and absolute risk - and that's why I continue to be pretty sympathetic to the home birth movement - but "not THAT much more dangerous" doesn't equal safer.

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  2. Hospital. For the baby. (And yourself though I know less about the obstetrical data). Might not be needed, but if you need a life saved (for me I chose the hospital with residents, pediatricians, neonatologists available and a strong NICU and was thinking about the babies if they were to need intervention) you/I want to be in that hospital with a pediatrician there.

    As a pediatrician or as a friend/relative of someone entertaining the idea of home birth, I would try to support someone in their decision, but I would do my best to counsel them, help them to understand the (big) risks and the many possibilities in which they might need a doc there. Stat.

    I practice in an area and with a population for whom choosing a home birth is extremely rare (if ever). Actually, it only happens by accident with my patients.

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  3. Home, if the birth were low-risk, though I'd certainly consider transfer if there were problems. There's risk in every pregnancy and every birth; it's not possible to entirely eliminate risk by being in a hospital. It is possible to minimize intervention by staying out of hospitals, though.

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  4. One thing that may weigh on some people's decisions is the risk of unnecessary intervention. It does seem that homebirths are somewhat more dangerous, in the sense that there is an increased rate of infant mortality. But the rate is still very low.

    So do you base your decision based on something that is quite unlikely? Or on the more likely scenario, wherein home birth can help you avoid interventions that you would quite probably face in the hospital (depending on your particular hospital).

    Not saying that's right or wrong...just that it may be a factor.

    For me? Probably birthing center, if I had access to one. If I didn't have access to a birthing center, I'd have to evaluate my local hospital - if it was baby and mother friendly, then sure. If not, I'd have to really think about my decision. It'd be a difficult one.

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  5. When I hear of people wanting a home birth, I encourage them to (1) at least visit an OB/Gyn, a few times to ensure that their pregnancy is low risk enough, and so that they have someone they know if they need to transfer to a hospital. (2) Do their homework on their particular midwife, the midwife can make or break that situation. One of the issues with home births is that midwifes aren't as tightly regulated as physicians, so some can be terrible and not recognize a dangerous situation (of course some are fantastic too. And (3) I'd really discourage it for a first time mother who really doesn't know what to expect. All the reading in the world can't prepare you for that situation.

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  6. I had a breezy, intervention-free birth with #1, and briefly considered home-birthing my second. Glad I didn't, because #2 was delivered emergently with a cord pH of 7.03. She came out crying, but I shudder to think what could have happened without an OB or a fully-equipped hospital with a NICU team at the ready.

    Obviously anecdotal evidence, but needless to say, I thank God for my little girl and the people who guided her safely into this world every day!

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  7. I had 2 planned home births - my first was successful and uncomplicated and my second one also resulted in a successful, uncomplicated, unmedicated vaginal delivery but involved an ultimately unnecessary last minute transfer to the hospital. Both of my pregnancies were textbook and low risk. I live in a state (WA) where home birth midwives are fairly well integrated into the medical system and both times I lived within minutes of a hospital.

    For me the decision came down to - what risks did I feel more comfortable taking. Given that I want up to 6 children avoiding a c-section is a high priority both for my future health and the health of my future children. My experience transferring to a hospital convinced me that it is not the place I want to be giving birth as long as the risks of home birth for me are still relatively low. I don't believe that the studies of risk of home birth compared to hospital birth take into account the compounded risks to future pregnancies and babies for women planning to have many more children.

    I think it is also hard to tell which of the scary situations doctors think of are solely or partially Iatrogenic - often from non-evidence based practice and overuse of Pitocin/Induction/Epidurals/Immobilization during labor and also which of those situations would have been risked out of a home birth or transferred to the hospital before it got to that stage. It may sound selfish but for me - my safety and experience of birth is more important than the potential (but not proven in my mind) reduction of risk to the baby.

    I seem to recall that there were also significant methodological problems with the study cited.

    I hope to never have to give birth in a hospital again - home is just a better fit for me.

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  8. First to establish my street cred, I'm a masters prepared RN who did my practicum on labor and delivery and worked for several years in clinical research from designing databases to project management.

    I chose a CNM-attended home birth. In methodologically sound studies planned home birth and hospital birth for pre-screened, low-risk women are equivalently safe. For every bad outcome averted in the hospital another is caused. And this only considers select short-term outcomes (not rates of exclusive breastfeeding, PPD, PTSD, etc.) without adding in the additional risks to mothers and babies in subsequent pregnancies (placental issues, higher morbidity in repeat c-sections, etc.) Based on the research and what I had seen myself of how labors are managed in the hospital, my personal and family characteristics made me even more likely to be done a disservice by hospital management (family hx of LGA/macrosomia without GD, primip, BMI > 30 though only a 9 pound weight gain). My 9 lbs 13 oz daughter with a nuchal arm was born after a 16 hour first stage and 4 hour second stage. Labor was hard and I could not have withstood pressure to have pitocin, an epidural and ultimately a C-section. I would have been unlikely to find the upright position that finally allowed me to birth my daughter if I had been attached to continuous EFM. After the birth, no one attempted to take the baby away for admissions procedures, bathe her immediately to avoid having to wear gloves, or interrupt our skin to skin contact and breastfeeding to get us up and transferred to postpartum within two hours. Our strong breastfeeding start helped us get through a fairly significant bout of newborn jaundice without resorting to formula supplementation.

    As for the Wax meta-analysis, a pretty thorough critique (one might say debunking) is available here: http://www.medscape.com/viewarticle/739987. Joseph Wax belongs next to Andrew Wakefield in the research hall of shame.

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  9. Three words: Confounding by Indication.

    People who want to give birth at home because they think it's safer have no concept of how to read the medical literature. Many of them are afraid of losing control during the birth process and feel that giving birth at home will somehow prevent this. Part of this is likely brought on by tales of bad bedside manner and actual bad experience at the dr.

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  10. When I did my L&D rotation, we had hospital rooms that were reserved for patients being delivered by midwives and doctors were NOT allowed in this room. Why isn't this a better option than homebirth? You're able to remain doctor-free, but if there's an emergent situation like a hemorrhage or sick baby that needs immediate care, you're already in a hospital.

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  11. The common thread in the comments advocating a home birth seems to be the conviction that a hospital birth means induction and/or C-section.

    While C-section rates have been rising in the past 30 years (though the largest factor contributing to this has been defensive medicine and to a lesser extent "lifestyle"-motivated demand from patients, this is a discussion for another day), hundreds of thousands of women deliver their babies vaginally in hospitals across the country each year.

    Creating a false dichotomy whereby hospital means induction and C-section, while home birth is the only way to ensure vaginal birth is disingenuous to say the least. It may help some women feel more confident in their personal choice by couching it in this sort of "justification", but it is less than admirable to try to paint it as absolute truth.

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  12. Two words: commission bias

    Patients who choose to give birth at home frequently have heard of, or had, unpleasant experiences with physicians who believe they must intervene. This is a mentality which seems to be rampant amongst certain (though not all) of the OB/GYN population. Patients who elect homebirth are willing to accept higher levels of risk to themselves and their baby in order to avoid these interactions. I agree physician-free birthing suites are an excellent alternative.

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  13. I had a homebirth because pregnancy is not an illness and the standard of care is just that - standard. No woman births the same and because so many women are uneducated to birth in general, they have forced a vicious cycle of CYA. The docs have to manage birth for fear of being sued if they just sit back and let birth happen. This is the ignorance of woman's fault. Too many time I hear of a woman who forces labor to begin, which makes the contractions very strong and then she gets an epidural. Now she can't feel anything, but the strong contractions are still affecting the baby and all the sudden, the baby is in distress and results in a C-section. Hooray, the baby was saved! But if the woman was educated to let labor begin when is was intended and trusted in her body, the snowball effect would most likely not have happened.

    I wouldn't say any place is more safe than the other. My midwife is also a certified EMT and has been for years. He can have a baby on oxygen and intibated within minutes while awaiting the ambulance. There are some who are not as qualified - which can be more risky.

    Again, it is up to women to fully educate themselves and have empowered births in order for our society to get off this crazy CYA birth practices and get back to the way things have been for thousands of years.

    Home is not for everyone. But neither is hospital.

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  14. Val - that's a little harsh, isn't it? There are physician posters (OB's) on this board that I've read posts from repeatedly who don't seem to have that attitude. I've also not met a single person going into OB at my school or on faculty in OB (so far) that has that attitude. The practice who delivered me encouraged me to try natural if I wanted to - they said - who knows maybe I would want the experience. I was the one that pushed for an epidural. I just don't think physicians are quite out to get women like that. I really do think that is a stereotype that perhaps used to be true, but isn't anymore.

    Hoping our OB/GYN Mothers in Medicine posters chime in...

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  15. I'm a premed, so I have no experience on the physician side of a delivery, but I have had 2 kids of my own. Both babies were born without issue and I felt that the hospital and my OB provided appropriate support while I labored. I felt comfortable that more intense medical care was at my fingertips if necessary and glad that it wasn't ever needed. I delivered vaginally without an epidural. No one coerced me or pushed for a c-section or medications I didn't want.

    I would never consider a home birth for myself and it makes me nervous when others do. It may be a natural process, but it is also the most risky and physically traumatic event most healthy women go through, and there is no way to predict the course it will take from woman to woman, or even birth to birth for the same woman. In the end, the priority for me is to make sure both the mother and the baby come through the experience healthy and I feel that outcome is most likely in a hospital setting, in case of emergency.

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    Replies
    1. Remember....more births equal more money, more drugs used equals more money... lets get these babies sectioned out and save them from any risk whatsoever! surgeons get to practice and no threats of litigation. Win Win "Modern medicine saved my baby" "Next"

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  16. Honestly, I'm surprised there aren't more claws out on this one. I guess it speaks well of this forum!

    I'm just a pre-med. But I've got two kids, and two very different hospital births. The first was very traumatic and stressful. Induction, long labor, epidural, threats of c-section if I didn't deliver by a certain time, constant fear of baby heartbeat changing (oh, looks like the EFM slipped again), BP rising & OBs freaking out then the nurse was like um, I think she is just dehydrated (imagine that!), holding the legs, nurses screaming "push" at me-- awful!

    I really wanted a homebirth for the second, but insurance wouldn't cover it. So, I stayed out of the hospital as long as humanly possible. When I delivered my second I was 10 days past my "due" date, and stayed in labor at home for as long as I possibly could. I knew I was close when I got to the hospital, but they didn't believe me until they checked & I was at 9 cm. No IVs, no nothing-- I delivered an hour later, peacefully breathing out my baby. A beautiful, quiet, fully present birth. So healing! And none of those stressful drugs for my baby!

    I agree with that earlier poster who talked about the balance between unecessary hospital interventions that cause trouble, versus life-saving interventions. Its a self-fulfilling prophecy. Induce someone, create stress, whisk them to c-section--look we saved that baby! (who could have potentially been fine...). I think it comes down to OBs have a surgeon's skills-- let them do surgery! But I don't want them itching to do do surgery on my non--complicated birth--looking for a crisis where there is none. Leave the normal births to midwives, who can refer to OBs as required.

    There is not enough research on this. And how in the world could you eliminate all the bias? I'm not sure pregnant women would agree to a randomized trial--(you- a homebirth, you- a hospital birth)--it is such a deeply personalized experience.

    Personally, I'm done with having kids. But I'll be super-supportive of anyone who wants to stay out of the hospital for their birth. -Amber-

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  17. I think the other MiMs will probaby chime in when they get home from work :) I'm fairly sure most of them don't endorse homebirth.

    I gave birth in a hospital, and I had to BEG for an epidural. They didn't want to give it to me at first because I wasn't dilated enough (I came in b/c my water broke).

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  18. Was your post inspired by the New York Times article today about the 20 percent increase in home births? (Still a whopping 1 percent of all births in the U.S.) There is an accompanying discussion at http://well.blogs.nytimes.com/2011/05/23/having-baby-at-home-share-your-story/?ref=health
    It's mostly women recounting the good, the bad and the ugly (more of the good than anything else.)

    There are also some scathing and not too well informed opinions in there. Whether in a hospital or at home, these women are doing something legal and at least relatively safe - it's certainly the norm in countries with better health outcomes than ours has. I don't have an opinion myself on home versus hospital, except that it's just another women's health decision I am glad I get to make FOR MYSELF! It wasn't always that way.

    I too look forward to hearing from the OB/GYNs on MiM.

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  19. While I agree that pregnancy/birth is probably overmedicalized in this country, I resent the attitude (prevalent in the home-birth movement) that doctors somehow "messed up" birth. Childbirth was the number one killer of women until the middle of the twentieth century in the developed world, and still is in many parts of the developing world. I would never choose to deliver outside of a hospital, but I chose my hospital carefully.

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  20. Fizzy's suggestion of hospital rooms just for midwife deliveries is what makes perfect sense. Best of both worlds.
    If we take the attitude that childbirth is just a natural function, let's look at the mortality rates in developing countries. Believe Afghanistan ranks 1st.
    I'm Int.Med, but did rotations in developing areas, so have seen lots of "delivery gone bad" situations. No way I would choose home birth. Because when stuff goes bad, it goes bad fast.
    It's also important that the mother get a certified mid-wife. We have an episode in my area now where "lay midwife" is probably going to do jail time for dead baby. Elderly (over age 40) primip with breech postion. Local certified midwives turned down the "opportunity" for home birth. Patient found an out of state midwife who advertised on the Internet that she could do such high risk deliveries at home. Baby's head got stuck, baby died before hospital transfer. Midwife recently indicted.

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  21. Fizzy - that does sound like a good option. Unfortunately as I'm sure you know, many women do not have access to birthing suites like that. There are in many places great options for women who want intervention free births that also provide access to medical care. But in many places, there are not. Access, as usual, is such a problem.

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  22. I'm in agreement with the "home away from home" laboring rooms in a hospital with a midwife in attendance. You can never predict what might happen, even in the best of circumstances, and it seems like this is a nice form of insurance to have available.

    I think we might be a skewed bunch with our war stories, but I do agree that hospital births are the way to go. If you have good communication with your physician and a birth plan in order, there's no reason that you can't have a (relatively) intervention-free birth.
    A

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  23. Anon: I posted this last night, so maybe the NYT was inspired by ME :)

    Theresa: You're right, although I think the mortality rate for births has dropped in general due to better prenatal care, plus hopefully all women who are higher risk delivering in a hospital. Although I wouldn't do it myself, I can understand why some women opt for a home birth in low risk situations. But I recently heard from a woman who was attempting a VBAC at home. That's a bit scary.

    Dr. Nana: What a terrible story! See, I don't get why a woman would risk a homebirth in an obviously high risk situation like that. At the point that no reputable midwife is willing to touch you, wouldn't you realize going to a hospital is better? If the midwife is getting indicted, shouldn't the mother-to-be get indicted too? In fact, she's MORE responsible, because if that midwife hasn't agreed to help, she would have surely found someone else or just gone it alone.

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  24. I am an anesthesiology resident (1 month from graduation) and have spent a significant amount of time on the L&D ward throughout my training. I have to say, L&D is unlike any other place in the hospital in terms of emergencies; emergencies that happen here are true emergencies in every sense of the word, and there are often 2 lives at risk--unique to OB. People who haven't been in the situation of an OB/GYN or an anesthesiologist really don't understand how quickly things can go really, really wrong. I have multiple times in my short career seen patients who no doubt would have died (or their babies) if they had attempted to give birth at home. I have also seen pts transferred in from giving birth at home who are literally on death's doorstep from post partum hemorrhage (which, by the way, can happen in an otherwise totally uncomplicated pregnancy, even for 1st babies). I understand that CNM's have significant training and that most of the time things go "just fine" for home births of low-risk pregnancies, but despite the statistics, I would not want to be that fraction of 1% where things don't go well. For these reasons, there is NO WAY I could ever support giving birth at home. Also, from a patient perspective (I have a daughter, delivered in hospital, vaginally with epidural), my hospital was great in terms of letting labor happen on its own and not pushing unnecessary interventions.

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  25. There was a recent article in CMAJ on home birth vs hospital birth. I will look up the link and post later.

    I am a family doctor in an urban city and have had several of my patients have home births. I do not endorse home births as part of my practice and personally think it's irresponsible as a physician to do so. My patients have done their research, I'm sure, but few actually ask my opinion on the matter.
    -Dr. T

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  26. I agree with most posters here that while most home births go quite well, it is a risk to have your child away from immediate medical care.

    A lot of women defend home birth by saying that it's what women have been doing for centuries and it's still what women in many countries do. BUT--look at those maternal mortality statistics. Lots and lots of women died in childbirth in the past and lots still do.

    While I would never insult or coerce a friend or a patient who chose a home birth, I would also never encourage one either.

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  27. I'm currently a 3rd year medical student planning on going into Ob/Gyn. Just in the short 6 weeks of my Ob rotation, I witnessed so many birth complications in low-risk, healthy pregnancies, that there is NO WAY I would ever consider a home birth. And these were not complications because of inductions or interventions - these were happy, healthy, look-at-my-awesome-bump pregnancies.

    It seems to me that home birth has become popular simply because we are putting SO much emphasis on "the birth experience" rather than on having a happy ending - a healthy mom and a healthy baby. Yes, it is true that a lot of Ob physicians have gotten a bad reputation because of pushing for C-sections and inductions, but this is changing and definitely NOT the case everywhere. You need to find an Ob or group practice that feels comfortable and agrees with your desire regarding your birth, as well as a hospital that is equipped with all the bells and whistles, in case something does occur.

    Believe me, Ob's are not out to get more C-sections under their belts (definitely not all the ones I know - they care very much for their pregnant patients and the health of the unborn child). So, it comes down to finding a physician that you trust! At the end of the day, if your Ob tells you that you may need a C-section, then you probably should listen to them, especially if you know them well and know that they wouldn't be suggesting one otherwise.

    There is a documentary that has recently been released on the OWN channel called "No Woman, No Cry" (you can learn more about it at www.everymothercounts.org). It was filmed by Christy Turlington Burns, a very famous supermodel. It is such a heart-wrenching film - so many women, all over the world, die from complications of childbirth. So, although pregnancy IS a natural process, please do not say that "our bodies know what to do and how to take care of themselves during birth" because, if that were the case, then no woman would ever die from childbirth. Instead, we should be thankful that we do have the resources to treat any situation that may arise during the birthing process.

    I do agree that there has to be a happy medium - and having mommy-friendly birthing centers WITHIN hospitals, with full access to Ob care if needed, is an excellent way to go.

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  28. Anon@3:35PM: I really hate when homebirthers look at OBs as Evil people who just want to do C-sections to make money or go home earlier. In fact, I know lots of women who delivered in hospitals but still seem to feel that way. If you talk to women in support of home birth, they will pull out stats about high C-section rates when there are financial incentives or shift changes.

    Honestly, I don't know why C-section rates are so high in this country. Maybe it's because lawsuits are so much more prevalent here, and while a woman might say she wants to avoid a C-section, that same woman will turn around and sue her OB if they don't do the C-section soon enough and something happens to the baby. So really, it's our fault that the C-section rate is so high. And the evil lawyers.

    Personally, when I started to get afraid of my impending labor and told my OB I was wondering about a planned C-section, she didn't support that decision at all.

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  29. I have a theory why c-section rate is so high. Women really like to be induced. No - seriously, they do. I've watched my friends from many spectrums talk about going in to be induced on Facebook even. It is a casual thing these days. And often times they aren't concerned if they don't have a "favorable" cervix, station etc.

    I think a lot of blame goes to the OB's when instead we should be looking at how many women want to be induced ...Why is this never talked about either? Why is the OB always the one that wants to section?

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  30. Here's what I don't understand: why do so many people (including some commenters here) make the claim that to avoid interventions, one must avoid hospitals? Honestly, I gave birth in a large university-affiliated hospital in Philadelphia, PA. The first time, I requested an epidural, which they provided, and I had the associated interventions of IV catheter and various monitors. The second time, and the third time, I requested that they leave me alone unless i wanted something. They did. Yes, they periodically came in and checked the fetal heart rate, and during my third labor they checked my cervix at one point when I asked them to. Otherwise, I was left alone until the baby started coming out and then they caught the baby after I pushed it out. I don't understand why so many women talk about having interventions pushed on them or forced on them. No one forced anything on me and I don't think I'm such a special snowflake that I got any kind of exceptional care that is different from that which they'd have provided to anyone else! certainly if something had been going wrong, they'd have intervened, but then - wouldn't it be better to be in the hospital in that case?

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  31. Inductions are probably more common due to policies about maternity leave in this country. If you know you're going to have to work till your due date, and if you go late, that will mean wasted time spent at home without the baby, those are reasons women are more eager to deliver early or at least on time. I got so little time off for maternity leave, I was really freaked out by the idea of being late. It would have severely limited the time I got to spend with my baby. Even 12 weeks is not all that long, but I know a lot of women in medicine who got only FOUR WEEKS for their maternity leave.

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  32. Fizzy - I agree, but at the same time - these are the same voices that are critizing America's OB's for sectioning too much when it is our women who want to be induced causing them to NEED a section (more likely)!

    See my point? It's like OB's are %^&& if they do, ^&**^ if they don't.

    Not blaming our American women here, but if you want to be induced - be prepared to fully understand you are potentially part of the reason your OB's practice has a 20% c-section rate.

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  33. Yeah, I agree, Anon. I think a variety of factors are conspiring toward having a high C-section rate, but I don't think greedy, lazy OBs are one of those major factors.

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  34. The link to the CMAJ article: http://www.cmaj.ca/cgi/content/abstract/181/6-7/377?maxtoshow=&hits=10&RESULTFORMAT=&fulltext=%22planned+home+birth%22&searchid=1&FIRSTINDEX=0&sortspec=date&resourcetype=HWCIT

    -Dr.T

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  35. I don't think my comment is harsh. I have read it stated just like that on OB friendly sites.

    I know that some moms and babies die at home (the 1% quoted to not go well), but no one seems to talk about the moms and babies that die in a hospital. I know it happens because I personally know of a couple people it has.

    I am not saying one is better than the other, but I find it sad that a lot of people are 100% No Home Births. It can be, and is, a great options for a lot of women.

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  36. To expand on my decision making process from above, the other factors I took into consideration when choosing home birth were cost (is the 10,0000 extra a hospital birth costs the system worth it), my ability to resist getting an epidural or any other intervention being pushed if the option was available - at home there was no possibility and therefore no temptation. I don't think that greedy OBs are out to C-section everyone - but they do have every incentive to do a C-section on the margin and not look too hard for evidence against doing a c-section and their judgement about risks and benefits does not take into account all of the relevent information about my life and preferences. The very fact that a doctor that I have no relationship with feels entitled to judge my medical choices is exactly why I prefer to avoid them. I see the claim that people who choose home birth are prioritizing the experience over a healthy mom + baby - and even if that is the case - so what? That is a reasonable choice for someone to make that the much higher likelihood of a good experience is worth the increased risk (which again is not proven for low risk situations). I am not out to convince other people to have a home birth if they don't want one - but I will give them information about my experience and perspective so that they at least know they have the option.

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  37. What is that saying? "There are lies, d*mn lies, and statistics." You could feasibly find any study to support that for which you wish to find support, on either side of the equation.

    That being said, you can shove 200 papers under my nose, but it won't replace my personal clinical experiences which have taught me that when things go bad, they can go bad quickly and irrevocably, no matter how many babies you've had, how healthy you are, or how few "interventions" happen in the process. I've seen babies come out floppy and blue who looked absolutely perfect throughout the entire labor. I've seen abruptions and hemorrhages that would make your hair curl, and I've also seen really tough dystocias which may have been impossible to deliver without a skilled team of professionals working together. Too risky for the *baby* for certain.

    I've also had a few messes to clean up from attempted home births, luckily none so tragic as the baby with the head entrapment, but did have a lay midwife who labored a woman at home who didn't realize the baby was breech until the butt crowned. She then packed them up and drove an hour with the butt on the perineum to the hospital. Baby's bottom was blue. One of my first vaginal breech births (back down, of course, higher risk of head entrapment) as a resident. It all ended up ok, baby was acidotic at delivery (Apgars 2 and 8), but did recover well. The mother was just ticked off that her home birth got "ruined" by having to go to the hospital. (You're welcome, for saving your baby.)

    I would not ever have a home birth, nor would I consent to be a "back-up" physician for one, but I'll defend to the death your right to choose whether or not *you* want to have one (and pray I'm not the one on call if it all goes to h*ll and I have to pick up the pieces). Informed consent is the most important thing, in both places, home and hospital.

    I see several problems with today's society driving this issue, intense focus on the "birth experience," desire for immediate gratification, reluctance to lose some perceived "control" over an uncontrollable process, and ever increasing entitlementiasis, liability, and the attitude that when there is a bad outcome it is *someone's* fault.

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  38. cont.
    Cesarean rates are rising for a number of reasons, most of which have already been touched upon above; first and always foremost - *litigation* thank the lawyers for this and I mean it sincerely, failed elective induction, increasing rates of high risk pregnancies as our population becomes more and more obese (thus increasing rates of pre-ecclampsia, ecclampsia, and gestational diabetes), and higher rates of multiple gestations due to very successful ART, and increasing requests (*gasp*) for elective primary cesarean sections.

    In my practice, we do no elective inductions (i.e. patient requests!) prior to 39 weeks gestation, Bishop score > 8. With medical inductions, we do what we can to ripen the cervix, but circumstances are not always ideal. As a busy practice with plenty of unscheduled labors, I can assure you the inductions are not done for our convenience, but for that of our patients, the driving force behind elective inductions (need specific times off from work, planning around family schedules, arranging child care, etc.)

    As for the person above who said something akin to "don't send a surgeon in to deliver a baby," I find that personally insulting. Ob/Gyns are a heck of a lot more than "surgeons." The last thing I am doing is sitting around, sharpening my knives just looking for an excuse to cut someone open. Give me a break. Truth be told, I'd be much happier if I never had to do any C-sections (but I'm glad that I can do them, quickly, safely, and efficiently). Vaginal deliveries are faster, easier, and more fun, and I don't particularly enjoy doing C-sections for the surgical aspect alone. There are far more interesting surgeries out there to do.

    So, yeah, that's how I feel about that. What was the question again?

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  39. The thing is, ancedotal data is just that. For every horror story of a mother/baby diad that would have died without hospital intervention, there are horror stories about mother/baby pairs who were *harmed* by their hospital birth. I am military and I remember a few years back at Tripler AFB in Hawaii when a baby was accidentally given CO2 instead of O2 after birth. By the time they figured out why this poor baby was deteriorating, he was essentially brain dead and did in fact end up dying. I would hardly call that situation a "norm" of hospital births.

    The fact is that even in the ajog study referred to above (which I have serious issues with methodology), *not a single woman died* in the hospital birth or the home birth category. So this idea that women are take this tremendous risk to their lives by birthing at home away from the life-saving equipment that only a hospital can provide is not borne out in evidence comparing low-risk mothers who hospital birth vs. home birth, and risks of higher death for babies is skimpy at best. So, statements like "I've seen too many cases where a woman/baby would have died unless she was in the hospital" speaks nothing to the safety hospital birth versus home birth.

    However, the statistics are *crystal* clear that women who birth at home are dramatically less likely to end up with a c-section, pitocin augmented labor, AROM, and episiotomies, not to mention the lower risk of unnecessary intervention for babies.

    When hospitals are walking around with c-section rates between 30-45%, then something is systemically wrong with how L&D care is being provided in that hospital. There is no earthly justification from an evidence-based-medicine standpoint for those kind of numbers....none.
    My first child was born in a hospital because he had IUGR. There was never a question he needed a hospital birth. What I heard from the OB pracitce at Walter Reed made it clear to me to never give birth at a hospital without clear reason.

    I believe until OB/GYNs and ACOG start having a less adversarial approach to homebirth and instead encourage a continuum of care model with communication between all lines of care providers (High risk OBs-OB-GYNs-CNMs-CPMs) then care for mothers and babies is compromised. There needs to be far more respect in the OB/GYN community for the safety and benefits of homebirth for low-risk women, and an understanding of the fact that a giant deciding factor in the choice to homebirth is the overall lack of EBM within labor and delivery wards. We are now in Colorado and the c-section rates of my local hospitals are truly jawdropping. I will never in a million years step into a hospital with where 1/3-1/2 of women are having c-sections and 98% are being put on pitocin at some point in their labor, and where nurses come in and tell me what I may and may not do according to hospital policy (like *eat*, and *move*) I do not feel safe birthing in that kind of environment without a clearly indicated need.

    Until the general OB/GYN community can truly understand what this subset of women finds so horrifying about these statistics, then they won't be able to respect why we make the choice to birth at home.

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  40. I don't think I made my point clear. I think women should have the right to choose how they want to deliver, no one should be mandated (but they need to be informed and willing to accept the risks, benefits, and consequences of their choices without holding others liable), but the question was if I would have or if I would support a home birth. Personally and professionally, based on my experiences, I would not. Regardless of any paper, good, bad, well done, or poorly done. It won't be my (theoretical) baby taking that statistical bullet. Are hospitals perfect? Of course not. Are they preferable to house/no hospital. Definitely.

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  41. Some people prefer to have heart attacks at home too. I don't recommend it.

    Joking aside women are passionate about home births. Doctors try to advise against it. Hard to be passionate in discouraging without alienating your patient.

    My advice, beware of extreme points of view. If birthing at home the last thing you want is a midwife with a chip on their shoulder reluctant to get you help if you need it.

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  42. i agree with the poster who pointed out that we should remain grateful for the resources that we have, which have no doubt reduced infant mortality. As internist with a normal pregnancy and delivery whose full-term child needed to be intubated within a half hour of birth for severe, not expected respiratory distress, I'm really happy I was in a hospital and that he received oxygen, and intubation, within seconds - not minutes or hours - of needing them. There's a picture of my son at age 4 on a wall of donated tiles in the NICU at the hospital where he was born - he's beaming, and surrounded by pictures of other babies and children who spent time there and their grateful families. I'll be forever grateful to the doctors and nurses who were there to take care of him immediately.

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  43. I'm the poster who had the IUGR baby and subsequent two homebirths. I have five children total (two via adoption) and four with significant medical needs. I have a daughter with complex congenital heart disease who has had two surgeries with more in her future, in addition to a medically fragile son with CP/CLD/RAD and g-tube fed due to liquid aspiration. My point is not to doctor bash or hospital bash, nor am I ungrateful for the medical care my children are blessed to receive.

    I fail to see however, why any of us should be "grateful" for unneeded, unnecessary medical care that is driven not by need but by fear of litigation.

    Dr. Whoo said that "it won't be my baby taking that statistical bullet." I fully respect your judgment for your family and your right to choose to where you want to birth. However, birthing in a hospital comes with plenty of far more plausible statistical bullets. For me, the bottom line is I wasn't willing to risk my body or my babies to completely unnecessary intervention or medical procedures. I was not willing to take a 1 in 3 or 1 in 2 chance of ending up with major abdominal surgery. Four of my kids have had surgery...some of them several surgeries. To me, decisions for *any* medical intervention should be made with utmost respect for the medical need for such intervention. In many fields of medicine, this is the approach adopted by medical providers. For some reason, OB care seems to be the giant exception.

    The bottom line is that statistically home birth is safe for low-risk mothers and babies. Where one feels comfortable birthing or not birthing is a completely personal decision, but in terms of data and statistics, home birth can be a safe, rational, sound choice for low risk women who desire to lower their risk of unnecessary intervention and surgery for themselves and unnecessary intervention for their babies. --RJH

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  44. Hospital. No question. I used to care about my "birth experience" and was very upset to have had a c-section, but a dear friend of mine just delivered her son at 27 weeks and obviously this would have been impossible outside of a hospital. More importantly, it gave me the perspective that your birth experience should be irrelevant; obstetrics, rightfully so, is very results oriented. This whole obsession with the way women give birth is just so bizarre to me because there is simply no evidence based medicine that supports claims that natural childbirth is any safer than "medicated" birth. I truly understand that people don't like hospitals and mistrust doctors -- because I sometimes do too. One of the things I liked least about being in the hospital is that I went from being under the care of an OB I LOVED to residents and attendings who were total strangers to me. It's very hard to trust someone you don't know with the birth of your child. But, as someone who is married to a doctor and with a majority of my friends being doctors, I know that the claims about the knife-wielding OBs just dying to intervene and do sections are totally wrong and misplaced. Of course there are crappy doctors out there (I'd count the one on call the night I had my c-section among those ranks), but OBs are not out to get women or undermine and control how a woman wants to give birth. You never know when the shit is going to hit the fan, and I'd certainly want a doc there if it did.

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  45. Dr. Whoo, one reason women may choose home birth is that they feel their ob/gyn's don't have compassion for their desire to have a pleasant or even non-traumatic birth. Of course you realize that for some women, especially those who have traumatic histories, negative birthing experiences can be very triggering or traumatic in their own right? Your attitude that the woman you describe was simply ungrateful and petty is really dismissive. I'm sure the woman was happy that she and her baby were alive and well. Isn't she also allowed to grieve that she didn't have the experience that she wanted, or perhaps grieve that she DID have an experience that she experienced as traumatic?

    One reason I am inclined to consider birthing with a midwife is simply that - I want someone who is compassionate to my desire to have a positive experience. Birthing is described as many women as the most profound experience they will have. Why is it wrong to want and work to have a profoundly positive experience? Of COURSE women value the safety of their babies. But they are not simply ungrateful if they feel disappointed that the experience didn't end up the way they wanted.

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  46. Jess,

    I feel like your comment begs the question, "is it more important to give birth vaginally at home, or is it more important to have living, healthy baby?" In the end, I'd be far more traumatized by losing my child than I would be of a losing my ideal birth experience. But, you are absolutely right -- an OB could certainly be dismissive of a woman's birth experience because (and I'm a lawyer, not an OB so I can't say this definitively), the OB's main concerns will be a living mother and living baby. I don't disagree with them for placing that as their paramount interest.

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  47. I second everything Dr. Whoo said.

    The latest edition of AAP NRP states that 1% of babies need extensive resuscitation at birth.
    I don't care if you are an EMT or a neonatologist, you do not have the equipment and resources to properly resuscitate an infant in a living room.

    Would I recommend a home birth? No.

    I to have seen many 'low risk' deliveries go to h*ll way quicker than you can transfer someone to the hospital.

    Sadly, I also been the one to deliver a failed home birth with a cord prolapse and a dead baby.

    At the end of the day, yes some doctors are jerks, but if you choose a bad doctor then you might end up with a c-section. If you choose a bad home birth midwife, you could find yourself mourning a dead baby.

    Home birth is about choosing the experience over the safety of your baby. Several of you have said that you are OK with that, I am not.

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  48. The way I think about it is if I had a C-section or a bad tear that could have been avoided, I wouldn't be happy. But I'd get over it.

    If I lost my baby due to a decision to homebirth, that is something I don't think I would ever get over for my entire life. So even if that risk is small (and it's not clear how big the risk is), I wouldn't want to take it. Even if the baby still would have died in a hospital setting, I'd still always wonder and probably never forgive myself. Obviously, it would still be really horrible to lose a baby after a hospital birth, but at least I wouldn't blame myself.

    There is actually a blog called Harmed By Homebirth where women post stories of homebirth gone wrong. I'm not even going to link to it though, because it's very very sad to hear about women losing their babies. I couldn't even read it.

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  49. Jen, I don't disagree.

    What I do disagree with is the disdain that Dr. Whoo shows towards the woman who was upset that her experience didn't go as planned. It's possible to tolerate the ambiguity of caring about both - the experience and the ultimate outcome, and it's ok for a woman to grieve a negative experience. I think that the attitude that it is not ok is incredibly prevalent, and incredibly harmful to women and to birthing as an institution. It shuts down dialog and possibilities, AND is non-compassionate.

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  50. Okay...not a doctor here at all, just a mom. But I think if you have a good relationship with your OB which lets face it, hopefully you do then I think you should be comfortable that there won't be unnecessary interference from them unless necessary. I would just want to be in a hospital where if something happened the baby or myself could be quickly attended to. Not wasting precious seconds on the ride to the hospital.

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  51. I try to be as compassionate and as accommodating of my patient's birth pans as possible. I discourage inductions and have a relatively low C rate.

    But in the end what is MOST important is a healthy baby and a healthy mom. If that means that they don't 'LIKE' me because I recommended interventions that weren't in their plan, then I can live with that.

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  52. In response to Jen, you're right that results *should* have something to do with it. It has been proven in several studies that an increase in C-section rate has not led to a corresponding increase in improved outcomes for babies or mothers. Translation: our nation's continuous steady rise in c-section is unjustified from a result perspective.

    So, the dramatic rise in c-sections doesn't result in better outcomes for women or for babies, but it now places you at risk for every complication that comes from surgery--- including infection, internal scarring, injury to your bladder and other internal organs, and dramatically lengthens your recovery time.

    Surgery should be highly respected and should *ALWAYS* be necessary. Granted, some surgeries carry a far more serious set of risks than others. A Norwood procedure on a days old newborn to construct a heart able to give a baby born with only half a heart a chance to live is far more inherently dangerous than a T&A on a four year old, but at some point surgery is surgery. I'm not volunteering to let someone take out my appendix when I'm perfectly fine, nor do I feel any desire to place in myself in a scenario where I make a set of choices that dramatically increase a sudden *need* to take out my appendix either.

    It's not all about "experience", it is about systems, evidence based medicine, and treating medical intervention with the utmost respect and reverence. My heart baby is on multiple medications with all kinds of possible side effects. I am 100% at peace with that because I know it is necessary. I would be 100% NOT fine with a toddler of mine being placed on ACE inhibitors with absolutely no medical justification.

    Any provider that has a c-section rate on par with the "average" in the US is performing unnecessary c-sections, period. I absolutely agree the reasons are complex. I don't believe in the myth of the "knife happy" OB, at all. I don't believe in the myth of the lazy OB, at all. It still doesn't change the fact that I am not willing to be the potential next-in-line for an un-needed surgery. I have only met two OBs that have c-section rates that I would consider acceptable, but the hospital policies where they practice were byzantine and unnecessary themselves.

    My children have spent more cumulative time in a hospital than 99.5% of the population. I'll deal with byzantine hospital policy and surgery and medication and all they entail when *needed*. Unfortunately, too much medical intervention is happening in OB care that flies in the face of definition of necessary.

    Since homebirth is equally safe for low risk mothers, has equally good results for low-risk mothers, and I know I am only going to end up with necessary medical interventions, that is why I homebirth. The fact that the entire experience of homebirth is exponentially superior to the atmosphere of the hospital is the icing on the cake, but not the make or break.

    Also--- in terms of informed consent, a woman choosing to homebirth is *highly* informed by default. She has to go against the societal norm and work very hard to seek out and arrange a homebirth. I have *never* met a homebirthing mother who wasn't very attune to the risks and benefits of a homebirth, and who wasn't crystal clear on why she was choosing a homebirth over a hospital. Since OB/hospital is the default option in the US, you are far more likely to find uninformed or underinformed OB patients than homebirth clients.

    Respectfully, RJH

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  53. I love my practice's policy. If the pregnancy isn't complicated/high risk, then the midwives are normally present for delivery, especially during the day. If the patient is high risk or sees an OB normally and asks for an OB to be present, they are. I wouldn't consider a home birth because of my family history of complicated births. And it turns out both of my births have been complicated, so I made the right decision. But, I think for a healthy mom with a certified midwife living close to a hospital a home birth can be just as safe.

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  54. Jess~ I think you are filling tone in to my post and reading disdain, where, really, there was jaw-dropping disbelief. This person had a vaginal breech delivery, a baby that had to be aggressively resuscitated, and as the NICU team is working on her baby to revive her, she is asking how soon she can leave (first birth experience, BTW, so no previous "birth trauma" to speak of). I'm sorry, but that absolutely blows my mind. Her baby was in danger because of her choices and her "provider's" actions, her baby was saved because of the big, bad doctors in the hospital, and she never even said so much as a thank you. It is she, and the homebirth community, that view *our* profession with disdain, not the other way around.

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  55. I wasn't talking only about birth trauma, for what it's worth. It doesn't have to be that identical to be triggering. (I'm not sure why you put quotation marks around birth trauma though? You see why I might read dismissive.) And of course, any birth requiring a NICU team has the capacity to be traumatic in itself.

    People react to that in all kinds of ways. Perhaps she wanted to go home to curl up and feel safe, and try to calm down. Perhaps she was having trouble processing how serious the situation was - that would also be a normal response. There's nothing wrong with either of those options. A thank you would be nice, but in the end (and I say this as a person who is also a helping professional) whether or not she has it in her to be polite to you is really not the issue. I'm not sure why you even brought her up, except to comment on her lack of a thank you and her "jaw-dropping response." I'm sure you don't do what you do for the thank yous. And I'm sure you realize that one anecdote is not data. So why bring up this woman, who didn't even bother to say thank you, except to malign her and other mothers who care about their birthing experience?

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  56. Dr. Whoo--- there is most definitely disdain and mistrust that goes in both directions. ACOG's highly aggressive stance against home birth I would consider pretty close to disdain. I find it interesting that Britian's version of ACOG takes the exact opposite approach and is openly supportive of homebirth as a safe option for low-risk mothers. One would presume the women of Britain are not so drastically different from the women of America that one college of trained OBs finds homebirth completely reckless and dangerous while the other openly supports it as a safe alternative to a hospital birth, but it is what it is. The tone ACOG sets in its opinions on homebirth are openly hostile, and the fact that ACOG actively works on a local/state and federal level to restrict women's right to birth at home also further works to degrade the relationship between various players in the birthing community.

    I think it benefits birthing women and their babies when all those invested in providing quality care to the pregnant and laboring mother and her child are able to communicate respectfully with each other. Unfortunately, this is not typically the case. OBs in this country need to start respecting what OBs in other developed nations have realized for a long time now: that homebirth is an equally safe, viable option for low-risk women, and that they are unable to provide the type of pregnancy and labor care that some women consider acceptable. Likewise, the homebirth community needs to respect the fact that there is a need for OBs and hospitals, and that both daily save lives.

    In my experience, the homebirthers I know (and myself) do not reject the need for OBs or the need for the care they provide. They question the frequency and necessity of intervention, surgery, and hospital policy that works against the goal of healthy mothers and babies.

    RJH

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  57. As a pediatric resident in the busiest MTF in the country with 350+ births a month. I have seen too many bad things happen during "routine" deliveries to be comfortable with the idea of home birth. Although most will be fine there is still the small chance something could go badly, really badly. My idea of a birth plan is "get the baby out safely."

    Of course a hospital will have more interventions than you would have at home but those interventions are made to protect the mother and child. I am tired of the opinion that Drs are somehow out to "do things" to people or that the decisions we make are not in the best interest of the patient. Certainly as a pediatrician in the Navy I am not in this for the money and other than trying to provide the best possible care, what would my motives be?

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  58. Are all c sections unnecessary? Just want to be sure lay mothers out there do not get the idea that the c section rate equals unnecessary intervention rate.

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  59. As a pediatric neurologist, I have seen enough of that "statistically useless anecdotal evidence" to know that homebirth is not for me. Off the top of my head, I can think of three neurologically devastated children that I've taken care of who had severe hypoxic ischemic brain injuries due to home birth. One with unrecoginized abruption, one who was laboring at home with a prolapsed cord, and one with poorly treated perinatal respiratory depression who was then having unrecognized seizures for several days before being brought to medical attention. These children can't walk, can't talk, and all have intractable epilepsy.

    For all of these, I feel that the blame goes to inept midwives. Maybe it is just as easy to encounter inept OBs, but at least in the hospital there is monitoring to let you know that things are going wrong, and back-up if more help is needed. I don't want to put all of my trust into one person.

    Also, based on my own small personal sample, the homebirth seems to greatly increase the risk of brain injury. As I said, I have 3 patients injured following homebirth. If you use the 1% statistic for the current rate of homebirths, I would have to have several hundred patients brain injured following hospital births to feel that the risk is equal. I have not. More like 30 or 40. So, that is the math going on in my head, and it does not look good for homebirth. Obviously, as I said above, this is anecdotal, but it is enough to firmly place me in the hospital birth camp.

    Personally, my son was born in a hospital. I had rupture of membranes but never went into labor. I was eventually induced and had an epidural. I think the epidural was WAY too strong, and it made it really hard for me to push. After 19 hours of labor, I then pushed for four hours (past the point that many OBs might have recommended c-section). I was never pressured. My OB asked at the three hour mark if I felt I could keep on going. I said yes. We kept on going and my son was born without complications or any additional interventions. I never felt pressured. The epidural was my choice. Continuing to push was my choice. The OB supported me, and was actually a brilliant labor coach (I actually felt guilty, beause I basically made her stay in the room - I could only make progress when she was encouraging me).

    Anyway, I'll end by agreeing with Fizzy above. I might not be sure, based on the literature, that homebirth is more dangerous for the baby, but I suspect it is. I would never me able to forgive myself if something went wrong at home -- even if it might have gone just as badly in the hospital -- I would second guess myself forever; it would destroy me. An unnecessary c-section is much lower on my list of concerns, and I think, unlikely, if you have a good relationship with your OB.

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  60. I'd rather be hacked into and put out under general anesthesia with zero memory of the entire birth experience if it means I delivered a healthy baby. Period. End of story. And yes, I am a mom, so I've had a child. Even giving birth according to my birthplan (gasp) in a hospital (double gasp) with an OB who did not perform an episiotomy but let me tear, and who didn't start pitocin even after hours of pure labor because my birth plan stated I only wanted it if necessary (I let him start it)....

    I would forego all of that experience, be hacked into with a machete, under general anesthesia with zero memory of anything. I repeat. Just to have my beautiful baby delivered healthy.

    I'd let pretty much anything happen to me if it meant my baby was safe.

    I do not understand this experience this. The birth was a beautiful experience for me, because it resulted in a baby. Well, that and I was finally not 40 weeks pregnant anymore. (My swollen feet were also thankful for the birth "experience.")

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  61. no, not all c-sections are unnecessary, and I certainly don't mean to imply that. WHO studies have tentatively placed the "ideal" c-section rate at 15% (without dividing into low-risk or high-risk categories). Average rates below 15% are linked with a significantly higher risk of maternal and fetal mortality. However, rates above 15% show no corresponding improvement in morbidity or mortality outcomes for mothers or babies.

    It is interesting how much of this conversation has gravitated to gut feelings and personal experience. It is a perfectly normal and human way to react in forming a personal risk-assessment, but it still doesn't negate the fact that there have been no definitive studies that demonstrate home birth as unsafe for carefully screened women. Several Western European countries openly embrace homebirth as part of the continuum of OB services, and in all of their studies, in a place where homebirth is integrated into the system of healthcare and women have access to a continuity of care, studies show no difference in morbidity and mortality but a significant difference in interventions.

    Considering that pitocin can cause fetal distress that leads to the need for an emergency c-section, and the fact that c-sections themselves are associated with a whole host of higher risks (including technically, the risk for death itself), I hardly place a c-section "low" on *my* list of priorities. Considering the liberal use of pitocin and the current c-section rate, the probabilities of adverse outcomes relating to just these two interventions alone are far more likely than any possibility of fetal death or maternal death or morbidity from a low-risk homebirth.

    I used BirthCare in VA for my first homebirth a CNM practice that has a professional relationship with the local OB community. They deliver 1 to 2 babies per day. When I was sitting in my "birth month meeting" for all those due in my month, they had assisted in thousands of births and had never had a single true maternal emergency,nor a true neonatal emergency when defining emergency to mean the life of mother or baby was in imminent danger of death or permanent injury. They were highly trained CNMs who risked women out of pregnancy care when appropriate, and transferred in labor when they assessed that it was necessary or a woman requested it. And as a result of assisting truly low-risk women, transferring care when needed, and providing a kind of care that didn't include drugs of any kind, Continuous fetal monitoring, or restricting a woman's movements or eating, and including constant observation of the laboring woman, they have never had an adverse outcome for mothers or babies. Those were the statistics I relied on.

    Respectfully, RJH

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  62. Oh, and as for "hacked into with a machete to have a healthy baby"--- that is a completely false dichotomy in this discussion. The choice being presented here has nothing to do with having a c-section *or* having your baby die. If that was the only choice, then we'd have a c-section rate of 100%.

    No one is arguing against a necessary c-section. No one is stating they'd rather have their baby die than undergo a surgical delivery. It is in fact, quite simple to make a decision for a c-section when you know it is necessary for your baby's health and survival. The problem is that at least half of all c-sections are *NOT* originally necessary. Some are a direct result of attempting to induce a woman who is not yet ready for labor. Statistics are showing that half of all women are induced. 50%!!!!! You can't tell me that 1/2 the pregnant population *needs* an induction, which then leads to a higher rate of c-section, any more than anyone can say a c-section rate of 35% is *necessary*. However, I've yet to meet an OB with a 35% c-section rate who is willing to state 1/2 their c-sections and most of their inductions are un-needed.

    I had an unequivocally needed induction with an IUGR baby in a hospital. I ended up on pitocin, with AROM, and I fully knew I dramatically increasing the need for a c-section as a result, as well as because of my son's fragile condition. I have complete peace about it because everything I went through in his birth was necessary for his health.

    My other births did not require this type of care, and this is the type of care that hospitals provide, and this is borne out not by some crazy need of mine to villify doctors and hospitals, but by the facts.


    RJH

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  63. RJH,

    First, you are totally contradicting yourself in the last paragraph of your last comment.

    Second, you are thinking about induction completely the wrong way. As previously stated already, most inductions occur because of mother's preference, or because of truly being past a woman's due date. Very few Ob's push for inductions on a regular day to day basis, as has already been stated by Ob physicians on this blog.

    Third, you really should talk to moms that have had sudden complications from pregnancy. The previously mentioned movie No Woman, No Cry is a perfect example. Maybe then you will have a better understanding of why not being in a hospital while birthing is a poor choice.

    Ultimately, a happy medium needs to be found. If that means having more birthing centers within hospitals, run my midwives, with Ob's on staff in case of complications, so be it (I think this would be an excellent choice). However, having only a homebirth or only hospital birth and nothing in between does not work for the health of babies AND mothers. A lot of the data that you are referring to relies on heavy bias. Just read Hurt by Homebirth and you will see why so many of us disagree with homebirth - because we have seen, with our very own eyes, the damage it can cause. Can these things happen at hospitals? Yes; will there be a chance that you don't get to have "the birth of your dreams"? Yes. But at least you'll have all the necessary interventions at your fingertips to try to solve the problem.

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  64. I'm a med student, and I mentioned the word "induction" as a back-up, because of school circumstances, and my OB gave me a mini (but appropriate) lecture on Bishop scores, favorable vs. unfavorable and why he would not induce me if I was unfavorable unless I was past-due and amniotic fluid measurements required it etc. etc. He was not a fan of me just up and wanting to be induced.

    For what that is worth....

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  65. RJH, I am just so curious, and you absolutely do NOT have to share if you don't want to, but

    what was it like to home-birth a baby with CP and a baby with a complex congenital heart disease (or were these the adopted kiddos)? How was the transition from the home birth to the inevitable medical interventions your kid(s) received?

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  66. As a lay person, I would never feel comfortable giving birth at home. If I give birth at home, it better be an accident! I'd prefer a birthing center with OBs present and on call with the option of having a midwife. I've heard peers chant "trust birth" and "our bodies know what to do" and use that to support their reasoning behind a home birth. Quite frankly, I don't trust birth. If it was so safe, then why did so many women die during or after giving birth? Yes, my body knows how to give birth but I don't want to find myself in a situation where I need emergency care and can't receive it quickly enough. Just like I know how to drive a car safely and have done it many times but I'm still going to put my seat belt on every time I get into the car.

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  67. >>the statistics are *crystal* clear that women who birth at home are dramatically less likely to end up with a c-section, pitocin augmented labor, AROM, and episiotomies>>

    This. Most pregnant women are basically healthy people. They don't think of themselves as patients and though most are agreeable because they want healthy babies, they don't enjoy being subjected to procedures. No normal, healthy person does. Even minor issues like IV access, repeated exams, hospital gowns, and being confined to bed for fetal monitoring can be intrusive, though this usually isn't considered a big deal by those who see it daily, professionally.

    I still think a physician-free zone staffed by midwives in a hospital is the best of both worlds.

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  68. I'm interested to hear from the OB's commenting about their relationship with the hospital systems regarding birth. It seems to me that many hospitals are set up to discourage variation in birth, preferring instead a "standard" approach codified by hospital policies: CEFM, all moms NPO, all babies to the hospital nursery, etc. If I were an OB practicing in such a hospital, I would find these sort of policies frustrating to say the least. How much choice do OBs have in their place of practice? How do unfriendly hospital policies contribute to the overall desire to avoid hospitals?

    FWIW, I'm an internist, mother to a son born in a hospital, with OB, induced for PIH, epidural, CEFM, and he went to the hospital nursery for hours every morning because how else would the pediatrician be able to see him? My daughter was born in a more progressive hospital with a CNM, spontaneous labor and precipitous birth (born an hour after arriving at the hospital). I am grateful beyond measure for both of my children who are healthy and the joys of my life; however, the second birth experience was infinitely better.

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  69. Scrubmama--- I don't mind answering at all. My son with CP/CLD/RAD is adopted. He was a drug-exposed micropreemie and spent 3 months in a NICU before he came home as a foster. My other adopted child was a 24 weeker who spent 10 months in a NICU and is blind with significant developmental delays.

    My biological children were my IUGR baby (born in a hospital), my daughter with heart defects, and a perfectly healthy baby boy.

    My daughter with heart defects was born at home at 2 am, seemingly perfectly healthy. My CNM practice (and I agreed) had a policy of wanting all babies evaluated by their pediatrician in the first day of life. I brought her in at a day old, they heart her murmur, we were immediately sent to the pediatric cardiologist in town where she received an Echo and EKG and then she was transferred to the hospital.

    As for how I dealt with it: I was fine until she was in the hospital bed being poked and prodded. I cried. A lot. I was newly postpartum and recognizing the pain and struggle my daughter would have to endure made me very sad for her. I grieved the loss of the healthy baby I expected, while over time learning to accept the reality in front of us. It was a very emotional time, and it still is emotional when I think of her future.

    The actual transition of care was very easy. When the PP says "But at least you'll have all the necessary interventions at your fingertips to try to solve the problem." that is actually not true. Many hospitals *do not* have NICU staff, or attending pediatrics 24/7. Only the largest children's hospitals with CICUs have attending pediatric cardiologists 24/7. The reality is that unless you are giving birth at a tertiary center with a level IIIb NICU, you in fact *do not* have all the care you need for your baby at their fingertips.

    The pediatric cardiologist told me outright that she wouldn't have received care any earlier if she had been born in the local hospital. We still would have waited for her pediatrician to come in the morning to evaluate her, and we would have waited for the same cardiologist to be called to the hospital. Instead, we went to them.

    Ironically, in the world of CHD, we know numerous families whose babies with serious heart defects were sent home from the hospital. My good friend's baby had a heart murmur and required oxygen. The hospital insisted the murmur was innocent and just sent her home on O2. Mom saw the pediatrician every 2 day. Finally at 9 days old, the ped. noticed there were no pulses she could feel in her legs. Sent her to the Ped. Card. Had an echocardiogram and she had an interrupted aortic arch, VSD, and unicommiseral aortic valve. Her PDA was closing and the cardiologist had to say "It will be faster for you to run across the street to the ER than it will be for us call an ambulance." She was life-flighted to the Children's hospital and in surgery hours later. Hers is not the only story like this I know either. There are no guarantees in a hospital or a home birth in individual circumstances, which is why statistics are so important.

    RJH

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  70. I'm finding this discussion fascinating. I'm 17 weeks pregnant with my first, and I'm an American living on the Netherlands. The differences that I am seeing here between my experience so far in NL and the predominantly (wholly?) American experiences is huge. In NL, the default is homebirth unless this is medically contraindicted. In fact, while most (if not all) insurance plans cover all prenatal care, mine specifically does not if I choose to have a hospital birth without it being recommended by my midwife (in that case I would have to cover the cost of renting a room/using the facilities). I have seen a midwife three times so far, and have no OB/GYN. I have no qualms at all about home birth, in part for two reasons. First, I am about 5 min. from a major hospital. Second, many of the stories here have had to do with midwife incompetence. Here, midwives must be certified ny the Royal College of Midwives. I have great faith in the college's ability to maintain high standards. If they couldn't, home births would not be the norm here.

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  71. As a pediatric resident, about to complete my training in a children's hospital with a level 4 NICU, I have seen too many tragedies result from the home birth situation.
    As a MIM who delivered a boy (now thankfully very healthy) in my intern year, I can epmathoze with women who want a home birth, but not agree. The OB covering my practice when I gave birth, did not go along with my birth plan at all, and started pitocin and gave me an epidural without discussing it with me at all- and I'm a physician! However, my son was also born (vaginally) apneic, so I thank G-d that there was a NICU attending right there to resuscitate him and take care of him right away, so that the result is a happy, healthy boy, with no resultant hypoxic injury (as might have happened with a home birth). I know most home birtyhs go allright, but how can a mother risk the injury to her baby and family?

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  72. Women don't necessarily want a home birth. They DON'T want a hospital birth with an OB who may behave as Anonymous 2:02PM's did (pitocin and epidural without discussion, despite her being a physician). Pregnant women see no happy medium, no alternative, and that's not right... is it?

    My experience with OB/GYNs has been that they're trigger-happy with interventions, even when watchful waiting might be prudent... and I've never given birth! Maybe I've been unlucky, but no one can deny these types are out there, and they're making life unpleasant for many patients and dangerous for others who are driven to avoid them entirely.

    1. Fix the attitude problem amongst the aggressive segment of the OB population

    2. Provide a safe alternative for women who prefer a low-intervention birth, like midwife-staffed centers within hospitals

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  73. RJH, can you clarify your comment that 50% of all women are induced? I can't find this statistic anywhere.

    The two countries that come to my mind when I think of Western countries that have integrated home births more fully into the spectrum of care are the Netherlands and the UK.

    The Netherlands actually has one of the highest perinatal mortality rate in Western Europe. There was a large study in the BMJ last year that found that the risk of perinatal mortality among low-risk women delivering with a midwife was double the rate of high-risk women delivering with an obstetrician in hospital. It wasn't a study designed to compare place of birth, but it does bring up the question of how easy/accurate it is to classify women as low-risk or high-risk antenatally because many of the emergencies that occur during labour and delivery are unpredictable.

    In the UK, a very preliminary study found that although the national intrapartum-related perinatal mortality rate (meaning asphyxia, anoxia or trauma) decreased over the study period, the IPPM rate for planned home births actually appear to have increased. Also although the IPPM rate for home births was low overall, if women required transfer to hospital, the IPPM rate skyrocketed. To me this makes sense. If there's a true fetal emergency, you really only have minutes to intervene, and I think it's obvious that there's a delay associated with transfer from home to hospital to OR that's not present when the patient is already in hospital.

    Also interesting to note that the C-section rate in the UK was 24% in 2008 (not too different from Canada, where we have very few home births currently), so it's overly simplistic to say that more home births will equal less C-sections.

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  74. The truth is, there are situations (unforeseeable situations) that in a hospital could cost the mother some comfort, but at home could cost the baby his life. I don't care how many studies told me that home births were "safe" and I don't care how small the risk is. To me, it is a completely unnecessary risk that I will not be taking with my child's life.
    And, for the record, I get the whole "experience" business. I memorized parts of Bradley's book, had dreams of a drug free, husband coached, baby-nursing-at-a-minute-old idealism. And I ended up with an induction, epidural, 22 hour labor, 2 hours of pushing, csection started after signs that my epidural had gone venous, a dose of ketamine that made me think I had died, then after still being able to feel them working, some general anesthesia. I've got a blank slate where the memories of my son's first few hours of life should be. And he got caput and a cephalohematoma to show for all our hard work. I get it. But looking at him now, a wonderfully (thank God) healthy toddler... who cares about my experience?
    I will never take the risk of delivering at home myself. And I can't see myself ever encouraging anyone else to either.

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  75. Thanks for sharing your story, RJH!

    I feel that most factors in a woman's birth experience have little to do with the OB/GYN herself. So many of the horrible hospital experiences mentioned could be at least partially attributable to hospital policies, nursing care, the legal climate ("standard of care"), residency training patterns, and the patient's own input.

    Why is the "happy medium" is the midwife-attended birth center? Why shouldn't/couldn't there be OB-attended hospital-associated birth centers? Aren't OBs capable of attending intervention-free births, too?

    OB/GYN was one of my top specialty choices, but I felt there were too many incongruities with how I would want to practice and how I would be pressured to practice. This is a serious issue, and I'm guessing that it drives more medical students away from the specialty than just me. Or maybe I'm wrong. I hope I'm wrong. ;)

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  76. Two major assumptions by many of the anti-hospital brigade:
    1. C-sections are in and of themselves bad: why? Prove to me that they are more dangerous than natural birth if you want to prove that we should worry about a caesarean section rate as an isolated percentage. There is no such thing as a "too high" or a "too low" C-section rate in isolation.
    2. The assumption that midwives speak for women and have women's interests at heart. From my experiences on labour ward, most midwives actually speak for their own ideology regarding birth, which certainly doesn't represent all women. In fact I have seen many, many, many more instances of midwives pushing their no drugs/no intervention line on women who didn't want it than I have of Ob/Gyns pushing a pro-intervention line. Many women just want a safe outcome for themselves and their baby, and couldn't give 2 s**ts about the "birth experience".

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  77. >>Aren't OBs capable of attending intervention-free births, too?>>

    Sure, and they can do that anywhere in the hospital, just not in the physician-free areas.

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  78. Physicians could also be allowed to work low-risk, low-intervention births in the midwife area if they agreed to accept lower, midwife rates of reimbursement. I don't think many OBs would agree to lower reimbursement, though, nor is it reasonable to expect them to do so.

    Physician-free zones for low-risk births are a change in philosophy, not just a change in geography.

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  79. Hospital, 100%.
    My first pregnancy was induced at 40 weeks due to polyhydroamnios. I had cervadil, pitocin, and epidural and progressed well. Pushed for 2 hours, with a nurse who was less than helpful and my husband who was a deer in headlights. The OB gave me a time limit and told me to get the baby out or c-section (no change in fetal HR or my vitals). After 2 hours of pushing, he demanded a section. I was tired and gave up. C-section it was, with no real explanation, just that he was too big for me (7 lbs 12 oz). Turns out the hospital had a 50% c-section rate.
    For my 2nd baby, I decided to go to a CNM, who delivered at a very different hospital with a NICU, to attempt a VBAC. i had a birth plan (no epi). I went 5 days overdue, water broke, labored naturally in varying positions (in the shower, jacuzzi, on the bed, walking, etc). No epidural, pushed for 2 hours in varying positions and gave birth to an 8 lb, 7 oz baby boy (head was 1 in bigger than 1st son). My support team (nurse, husband and midwife) were amazing.
    I would never birth at home. The risks are far too great for me. I think pregnant women need to do research into their provider (OB or CNM) and hospital before making a decision. They need a birth plan and lots of support. This is the only way to be satisfied with your birth experience.

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  80. C-sections are "worse" than natural birth (when they are unnecessary) for a number of reasons. I tend to think that common sense would indicate that giving birth vaginally (aka in a way your body was designed to birth and recover from) is preferable to having major abdominal surgery. Sometimes it seems that people forget - C-sections are invasive surgery. They are more difficult to recover from than vaginal births, which can interfere with early parenting. They are also, incidentally, more expensive. So if we're concerned about health care costs, unnecessary c-sections are a negative thing.

    They are also more dangerous health-wise: I don't know if I can make links here or not, so I'll just paste them below, but in about 30 seconds I found two studies indicating that c-section is riskier especially in terms of infection. The risk of maternal morbidity or mortality is increased with a c-section.

    (http://gateway.nlm.nih.gov/MeetingAbstracts/ma?f=102272723.html

    http://mcr.sagepub.com/content/61/2/203.short)

    Of course you'd want one if it was necessary for your baby...but there are good reasons to avoid c-section if possible (just like there are good reasons to avoid ANY major abdominal surgery, in the absence of need for it.)

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  81. Liana--- you are correct and I apologize for my poor wording. The induction rate for the hospitals in my local area are 50%. The national rate is 22-28%, a significant difference ( IMV still questionably high).

    I'd love for you to link to the two studies you are referencing, to be able to view the statistics. I'm not familiar with either one, and I would be interested in being able to read them; I can't comment intelligently on them until then :-)

    And Anon, the risks of unnecessary surgery, no matter what they are, are by definition unacceptable. It is hard for me to believe in a cavalier attitude towards un-needed surgery as "no big deal." You have higher rates of infection, higher costs, greater risks of complications, not to mention the that previous c-sections increase your risk for complications in future births. When large statistical surveys can prove that there is no corresponding improve in the health of mothers and babies with the rise in c-section rates, then it means many c-sections are done with no need. Even ACOG recognizes this.

    I hear the idea that the experience means nothing, it's only the healthy baby in the end, and it confuses me. There is no inverse relationship between "experience" and "healthy baby". My gratitude for the lives of my children is not diminished by my evaluation of the quality of care they (and I as their parent and birthing mother) receive. No matter how healthy my child, if I found out she was needlessly given interventions, surgery and treatments that were without basis,I would be upset about it; it would introduce risk and harm that by definition was *not medically necessary*, whether we had the good fortune to escape them or not. Surgery comes with risk. Surgery should be treated with respect for its purpose and needs.

    And this may be where we philosophically diverge. I don't need to read horror stories of home-birth gone wrong, nor do I need to read an equal number of hospital-birth gone wrong. I find it interesting that our fall back presumption is that every death that happens in a hospital is somehow inevitable while those that happen in a home situation were automatically preventable, as this is a complete presumption. There are preventable" deaths that happen in the hospital all the time, so I do not share that view.

    People often make decisions for themselves based on their own experience, and this is no less true for birth decisions. Someone who has decided they have seen too many lives saved by a hospital birth with have that as their truth. Women who have felt violated and harmed by a hospital experience will have that as their truth.

    In the end, people make decisions based far more on their own determination of acceptable risk and their own truth. If you are willing to accept a risk-point of zero at home while simultaneously accepting the risk of death for you or your baby at a hospital because you feel any risks at home are preventable and all the risks of a hospital are instead inevitable then I would expect you would choose nothing but a hospital birth.

    If you flip this analysis on its head, then you're going to be someone who views homebirth as far less dangerous to you, your body, and your baby than a hospital birth.

    No birth is ever risk free. You won't find a zero-point risk set anywhere in medicine or in life. We all make decisions on what risks are acceptable to us or not acceptable to us.

    When it comes to the question of whether it is *reasonable* or *rational* for a low-risk woman to choose home birth over hospital birth, every statistical analysis proves the point that it is both reasonable and rational to choose a home birth. Women are making a choice to home birth based on evidence of its safety and its ability to mitigate risks of unneeded interventions and their subsequent complications.

    RJH

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  82. http://www.huffingtonpost.com/2011/05/26/malpractice-record_n_867439.html

    Of course, there is always this, as well. Yikes.

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  83. The two studies are:

    Perinatal mortality and severe morbidity in low and high risk term pregnancies in the Netherlands
    http://www.bmj.com/content/341/bmj.c5639.full

    An estimation of intrapartum-related perinatal mortality rates for booked home births in England and Wales between 1994 and 2003.
    http://www.ncbi.nlm.nih.gov/pubmed/18333936

    The second study as I said is very preliminary, and there are a number of deficiencies which will hopefully be clarified by the Birthplace Study (results available ???)

    I disagree that every statistical analysis provides evidence of the safety of home birth. Every single study I can think of bears a huge flaw which OMDG has already pointed out: selection bias. Most people think it would be unethical to do a randomized controlled trial of home birth vs hospital birth, so we're stuck with trying to make sense of imperfect studies. Many other studies are underpowered, retrospective analyses, or have inappropriate comparison groups.

    Since I'm Canadian, the Janssen study gets quoted most frequently in my setting. Women in different groups were not similar in terms of baseline characteristics which would almost certainly have some impact on delivery outcome (women delivering in hospital were shorter, older, had higher BMIs, were more likely to be nulliparous, were more likely to have had a previous CS). In addition, with only 1500 births, the study was underpowered to detect many adverse events. Even so, it's worth noting that there were 3 perinatal deaths and a further 5 babies requiring ventilation in the home birth group, compared with 1 perinatal death and no babies requiring ventilation in hospital. 3.6% of women required emergency transport to hospital and the average transfer time was 37 minutes (range 15-93 minutes).

    Reading the above statistics does not make me conclude that home birth is definitely as safe or safer than hospital birth.

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  84. >>Reading the above statistics does not make me conclude that home birth is definitely as safe or safer than hospital birth.>>

    That's not the standard many women who choose home birth are using. They're accepting higher risk, and the overall risk is low... unless it happens to you, of course ("you" being either patient or OB).

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  85. This is Anne from above.

    Christina - I can't believe your OB forced you to c-section after an arbitrary 2 hour limit... Like I said above, my OB coached me through 4 hours of pushing (possibly the hardnest 4 hours of my life) to a successful vaginal delivery. If the world had more OBs like mine, I think the bad reputation of hospital birth would really decrease... (now someone just tell me how to make sure she is on call again the night I deliver my second!)

    And, someone above mentioned that most hospitals do not have NICU attendings / cardiologists, etc. available 24/7. I guess I am just spoiled where I am. The hospital I delivered at had a level IIIb NICU and was physically attached to Children's Hospital with a level IIIc NICU. If my son had needed urgent cardiac intervention that night, he would have had it. If he had a hypoxic brain injury and needed theraputic hypothermia, he would have been cooled in less than an hour. If he was seizing, he would have gotten appropriate meds in minutes, and would have been on continuous EEG soon thereafter.

    Anyway, I can really appreciate how the risk / benefit ratio would change a lot if my choice had been between delivering at a podunk community hospital (with no NICU and a OB that would push for c-section after two hours) VS at delivering at home. That math is very different. So, maybe in is not fair to lump all "hospital births" into one huge group. Depending on each mother's options, the risks and benefits might vary widely...

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  86. Huh, I wonder if my doctor was so quick to call a c-section because I'm attorney!

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  87. Jess did you even read the articles that you cited in your 30 second literature review? Having glanced at the first one, I note that it found a significantly higher rate of VTEs and major puerperal infection post-c section, but a signficantly higher rate of obstetric trauma and PPH following vaginal birth. Certainly not what I would call convincing evidence of the danger of c-sections over vaginal births.

    If you actually go beyond the level of individual trials and look on Cochrane, you'll see that the one systematic review which attempted to compare c-sections for no medical reason with vaginal deliveries failed, because they could not find one single trial that met the eligibility criteria - probably a good reflection of the fact that many of the trials that do compare c-section complications vs vaginal births are inevitably comparing apples with oranges, given that c-sections are inevitably performed with medical intervention hence involve huge rates of confounders.

    As for the old "ZOMG IT"S MAJOR ABDOMINAL SURGERY ARGUMENT", which is constantly trotted out as though it somehow proves anything whatsoever. Yes, it is abdominal surgery. So what? Again, you are simply begging the question and falling back upon some essentialist assumption that because birth is a "natural" process, it is inherently better. Actually, vaginal birth is a pretty poorly designed process - a reflection of the mismatch between a species with a large brain (and therefore head size) and a small pelvis to enable us to walk upright.

    I have seen many vaginal births and caesarean sections, and have no doubt about which I think is the better designed process. Many (probably most) women will disagree, and I get that, and think that women should be supported as to their choice. But let's not make the assumption that caesareans are inherently worse, or that all women desire the awesome experience of pushing a 2-3 (or more) kg object out of a very small orifice.

    I certainly agree with you about recovery time, but I think this is a decision which needs to be left up to the individual woman. I personally would rather take the longer recovery against the risk of a 3rd or 4th degree tear, or the > 50% risk of pudendal nerve damage/levator ani avulsion in primips; and all the subsequent incontinence/prolapse sequelae. And I certainly would prefer an elective caesarean to a vaginal birth gone wrong, possibly followed by an emergency caesarean.

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  88. This post exposes the fraudulent underpinnings of claims about homebirth being safe.

    http://skepticalob.blogspot.com/2011/05/five-bald-faced-homebirth-lies.html

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  89. Kim: Great link. I showed it to someone i was talking to who was is pro-homebirth, saying that I was sorry I didn't know the evidence very well, but she might be interested to discuss it with this woman, who clearly does know the evidence.

    Her response was: "Sorry, but the fact that you even consider that guy to be someone who "knows the evidence very well" sort of sums that up for me."

    I hate that attitude, of refusing to even consider other people's arguments. Very closeminded.

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  90. Fizzy - it's actually super depressing sometimes for we, med students, who plan to apply in OB. I know that is what I'm meant to do, but at the same time - I'm walking into a profession where huge sectors of women think I'm out to section them for convenience's sake, ruin their birthplan, and all for the sake of getting home in time for dinner or something. Careless cutting. It's all over the place. I guess there are downsides to each specialty. This is a big one with OB that I've had to ask myself if I'm going to be comfortable walking into.

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  91. Re Tizzy and Kim's comment: actually, the Skeptical OB is a woman.

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  92. The Skeptical OB is a woman who has not practiced medicine in over ten years, BTW. She seems to spend much of her time on the internet. I'm surprised she hasn't shown up here. Yet.

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  93. I think most women like their OBs very much. There's always a small minority that's going to be haters.

    I don't know much about Skeptical OBs practice or lack thereof. The question is, is the information she presents accurate?

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  94. >>I think most women like their OBs very much.>>

    I don't see an OB/GYN at all. I utilize a FP instead. I'm not the only person I know who does so.

    >>is the information she presents accurate?>>

    As I haven't read every original paper she quotes, I don't know. Some probably is, but she presents only information that supports her arguments and redirects with ease to argue only those points she knows she can win (kinda like: "I think most women like their OBs very much"). Does she read articles that support her points critically? Nope, but neither do many home-birth advocates.

    IOW: she's not a scientist. She has a bone to pick.

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  95. "I think most women like their OBs very much" is an opinion, not an argument I'm attempting to win. Thus my use of "I think." If you don't have an OB, then that statement applies to you as much as it does to my husband.

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  96. I always find the argument that if someone is not actively practicing medicine they must know nothing about the literature kind of ironic. There are plenty of practicing doctors who are not critical readers of the literature, and who don't understand study design, and plenty of non-MD epidemiologists who know the literature inside and out.

    The truth is, people hear what they want to hear. If they have convinced themselves that homebirth is better and OBs are knife happy jerkfaces, then no amount of studies to the contrary are going to convince them otherwise (those studies are all part of the conspiracy, don't you know?).

    The same thing happens with the anti-vaccine/autism crowd. I have gotten to the point where I'll present my case, and then if they still want to argue I just walk away. I'm not interested in fighting, and frankly, in the case of homebirth, it's your body and your baby to kill as you please.

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  97. OMDG: I agree with everything you said 100%.

    Two points though:

    1) I find it interesting that not one MD who commented here said they would have a homebirth themselves.

    2) If a midwife who delivers a baby in a high risk situation loses the baby and is up for murder charges, why wouldn't a mother who puts herself in a high risk situation (i.e. homebirth with a really high risk birth) and loses the baby not in any trouble? Not that this is necessarily a good idea (brings up a lot of hairy right to life issues), but it is something to think about.

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  98. I agree with Anon@8:15 - I'm also a med student that absolutely loves Ob-Gyn and is committed to providing patient-centered care. However, I get so discouraged by people that think that we're just out to hurt them or cut them - and yet there are those (like the couple that sued in CT and got the 58.3 million) that are on the other extreme. I know that you can't please everyone, regardless of which specialty you go into, but Ob seems to be one of the worst. To the Ob's that write on this blog: any thoughts on this? any words of encouragement for those of us that have been truly chosen by this specialty?

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  99. Fizzy -- You're talking about the recent case, right? I totally agree with you, actually. My comment was intended more from a personal standpoint rather than a legal one.

    I also found it interesting that all the MDs would have hospital births. I really respected the midwives who practiced in the hospital where I did my OB/Gyn rotation, and thought it was a good compromise for women who preferred that sort of care to an Obstetrician. I think you suggested something like this previously in the comments.

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  100. OMDG: I would personally be fine with being delivered by an experienced midwife in a hospital. I mean, it wouldn't be that different from when I delivered my daughter and was in the care of nurses for the entire labor up until the last 20 minutes or so.

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  101. There is a vast difference between specifically choosing a home birth and giving birth in a hospital with many "routine interventions" - usually ordered by MDs, though also by midwives - often with minimal discussion, even in non-life-threatening situations. This happens to MDs in labor, too, as stated in posts above (pitocin, epidural, episiotomy, etc.).

    There must be something safe and reasonable in between, because neither of those options appeals to me. If you don't care? Well, then, good for you, but I think many women do.

    As for the Skeptical OB: she is not a critical reader of the literature, and though I agree with much she says, I also think she's unbalanced, mentally. Not someone I'd cite as a shortcut to actually reading the original literature.

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  102. It's really intruguing that even in this blog community, with a thoughful, generally supportive atmosphere, the homebirth versus hospital debate gets so personal. The moms who give birth at home are repeatedly accused of "killing" thier babies for the flimsy sake of "experience." Way cruel and unfair, folks. And the unfair stereotype of the OB tapping thier cruel fingernails impatiently for the chance to finally dig the knife is still flaoting around; and I think all readers of this blog should be able to acknowledge that doctors are for the most part caring and hardworking humans who want to do the right by their patients.
    The possibility that I find really inspiring is that of bridging the two camps, if the nastiness and hurt feelings can be transcended. In the hospital, I see no real reason why women shouldn't be allowed to eat, drink, and move around whenever they want. Pushing could happen in other positions besides supine, if the mother prefers- not only for her selfish experience, but for the improvement in birth circumstances (shortening and widening of the birth canal in squatting). I know EFMing is one reason why a birthing mother would be expected to be immobilized and in a certain position, but what do y'all think of this study: http://www.ncbi.nlm.nih.gov/pubmed/7675390
    (Dear gods of the shitstorm that's about to rain down on me- please make it a warm, gentle rain.)
    And as for midwives being less trained and equipped to deal with emergencies- why not advocate for further training of certified (nurse and non-nurse) midwives in helpful strategies and technologies? One risk of homebirth that's been repeatedly brought up is hypoxia. How hard would it be to have a portable oxygen tank handy at home? I'm genuinely asking- if there's a good reason it can't be done, I'm open to hearing it. Also, pitocin... why not have midwives trained in how to give injections and licensed to administer it in the worst case scenario?
    If the concern is for all the poor dead babies, then why not expand the medical options available rather than condemn the mothers who feel they make informed and reasonable choices?

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  103. Anon: You think this is brutal? This is downright *polite* compared to arguments you'd see here if an extremely pro-homebirth doula or midwife got thrown into the mix. I think most of the OBs were respectful in stating their point of views, which is that they don't agree with homebirth, but support the decision of the woman. And the pro-homebirth people acknowledged there are many cases where hospitals are the better choice.

    As to your other question, I'd hope midwives already are certified in dealing with some medical emergencies, like BLS training. As for pitocin or administration of other drugs, someone mentioned a huge lawsuit where there was a baby harmed by inappropriate administration of pitocin in a hospital setting. I think the last thing we want is for non-physicians to be giving this drug at home. Plus, I thought the homebirth community thought pitocin was devil juice :)

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  104. This debate has defintiely been more civil than some I've seen. That's why it's interesting to me that everyone's still a bit catty... I really don't want to go back for quotes right now, but there was the false dichotomy presented between 'mother's selfish experience' and 'healthy/living baby.' Also, OMDG said something along the lines of "I don't care, it's your baby to kill."
    I can't speak for "the homebirth community," but as someone who's had a homebirth (which went really well and absolutely would've been a c-section if I had hospital care*), I would rather see hospitals become more comfortable for people and reasonable in the standard of care while homebirths also get increased access to medical interventions when they are truly lifesaving and necessary. I may be naive, but I really can't understand why nobody (yet) has jumped at the chance to engage in dialog about those basic patient advocay issues of allowing a mother to eat and move while laboring.
    Oh, and I do plan on becoming a doctor. I'm sure I'll see good births turn bad, and that will scare me. But, and I think this is crucial- the hospital model of care won't be the only experience of birth I'll be exposed to.

    *I'm happy to go into detail if there's any curiosity.

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  105. [Still the same Anon posting again]
    Oh, and I'd like to reiterate that I do have the utmost respect for doctors, and I think medicine in general is miraculous and noble. However, I think we're still working out the kinks on how to deal with this risky thing called childbirth. The problems with hospital birth don't come from the bad intentions of doctors, who work hard for people according to how they're trained and how they fit into the overall hospital system.

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  106. It is completely not worth arguing with pro-homebirthers. All MD's here have uniform opinion - we stand for patient/baby safety. Yet, we are accused of some secondary agenda toward the patient victim. It is just like some people choose "natural" remedies over safe proven to save lifes medications, when they actually need medications. This time greedy pharma companies are to blame for pushing medications on the market and doctors - for pushing medications onto people. Why nobody is crashing on holistic providers who administer potentially harmful treatments for tidy sum of cash? ('Cause its natural?)Many people choose to take advantage of progress civilization made, and some want natural (presumed better) choices. Good luck to both parties. (I will go with high-quality modern medical care which I consider the most important achivement of this society).

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  107. Anyone on the immobilized, supine, no-food-or-drink laboring mom? Anyone?

    I can understand why the EFM study might be threatening enough to ignore.

    (Pay no attention to the pro-homebirthers. They don't care about baby safety.) Seriously?

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  108. Anon and Conflicted, I think maybe you're not getting any responses because you're looking for a fight/debate where there is none and making some false assumptions.

    Our hospital policy recommends intermittent auscultation for low-risk women. When women require continuous monitoring, we have cordless monitors so that they can walk around and get in the shower. Women are not automatically npo in labour, and they're encouraged to change positions during pushing.

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  109. That's actually wonderful! It's big news to me! Several of my friends who've given birth recently didn't experience those luxuries. I wonder if there's any source of information to find out details of individual hospital policies.
    I'm even more curious as to how these policies change... Does consumer demand have an effect? Is it all based on EBM?

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  110. To Conflicted - yes, consumer demand drives the market. I would like to think that woman in delivery is not a consumer but a patient, and medicine is not a market but a service.I would like to assume a patient will take their doctors advise as to what is in their best interest. Otherwise, if consumers want to dictate their own care (as is already happening a lot), please assume liability/risks also. Thanks.

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  111. As a former L&D nurse and a mom who gave birth in the late 70's when "natural" was all the rage, I think Anon335 and Dr. Whoo hit the nail on the head. This has become all about the "experience" of having a baby. Starting with all of the celebrities out there flaunting a "baby bump" like it was a new fashion accessory rather than a new human being, and shows like "Pregnant in Heels", which follows a Maternity "Concierge" and her wealthy, vapid NYC clients, we are looking at pregnancy as all about me-me-me.

    We have a new generation of mothers, many of whom are so centered on themselves that the health and well being of the their CHILD goes out the window. Whether it is chosing an "experience"as if giving birth were an adventure vacation, or the oposite of demanding a C/S at 36 weeks to preserve a belly that needs to be flat and free of stretch marks by four weeks post-partum...baby takes a backseat.

    My bottom line is responsibility...how would I tell my child that he had CP, or no use of an arm, or was forever in the "slow" group just because I wanted an "expereince"? If I were told that I had to do a handstand in the snow for an hour to have a healthy child, that is exactly what I would do. I do bemoan the rise of c/s's due to the cascade of intervenions that usually starts with induction, but the very first lesson of motherhood is that the child and his needs comes first...always.

    Pattie, RN

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  112. Pattie, RN - you rock !

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  113. PattiRN: I agree with you. But totally *hypothetically*, what if someone replied to your comment that statements like "the child and his needs comes first...always" is triggering to women who have experienced "birth trauma"? Not that someone *cough* said that to me or anything.

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  114. Will someone please explain this "birth trauma" thing to me? I seriously don't get it. As long as you get a baby in the end- where is the trauma? So confused...

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  115. "Any provider that has a c-section rate on par with the "average" in the US is performing unnecessary c-sections, period":
    I would like to point out that while 'unneccessary' csections happen, the patient pool is different in many areas of the US some high risk, some low risk and some prohibitive risk (eg my county hospital that has a large HIV/Poor, drug using population with NO prenatal care) -much more diverse than the Netherlands lets say....

    Like anything in life, there can be a happy medium....BUT I can say that after practicing medicine in many regions of the world, there is NO other country that has as much litigation as the US all directed towards the physician and hospital (midwives, CNM are pretty much exempt from medical liability except to face criminal murder charges); that I doubt that happy medium will be explored. It is hard to win a lawsuit against a doctor for having a bad 'birth experience' but way too easy to win one for having a sick/dead/disabled child regardless of the cause...and since these settlements are in the millions, odds are the CSection rate will remain high for a while...

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  116. "I also found it interesting that all the MDs would have hospital births."

    I'm a MD(FP) who had a midwife assisted homebirth. As a healthy, fit patient who wanted to avoid c/s and intervention, I felt that it was the right decision for me. My decision to birth at home was based on my interpretation of the available research that birthing at home might help me avoid intervention and would be just as safe as delivering in a hospital.

    My main goal in choosing to home birth was my health and the health of my baby, not the "birth experience."

    I have 2 physician friends who've had homebirths. We are all happy with our decisions and I plan to have my next at home as well.

    It's certainly not right for everyone but I believe it's a reasonable option for many low-risk healthy women.

    As a resident, I practice obstetrics and I wish I could offer my a patient's the options that I had with my delivery. However, I live in a city with few out of hospital midwives and no birth centers. 95% of my patients get epidurals and about 20% end up with c/s. 100% have EFM. I practice routine care due to the constraints of the system I work in.

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  117. I think one difficulty (among many) is defining unnecessary c-section. Seems like outcomes in birth fall into the following categories:

    1. uncomplicated vaginal birth

    2. vaginal birth despite clinical factors that indicate c section

    3. c section without clinical indication

    4. c section with indication based on clinical factors

    We can all agree that c section without clinical indication is wrong. If this is the way that you practice you deserve to be called knife happy.

    Homebirthers want to have #1 at home. Some physicians fear that sometimes they instead have #2. Why could this happen? Certainly by accident if things do not go as expected. Granted statistically this is unlikely. (It is also unlikely you will develop listeria from lunch meat.) Birth by #2 could also happen intentionally if your birth attendant disagrees with the current standard of care. I believe that for women having babies at home with this mindset, the risk is higher than for #1.

    Another point I would like to make, if you have a c section due to #4 and everything goes swimmingly, what is the result? Perfection and “Thank you Dr. OB?” Or instead “My baby was fine, and you cut it out of me now I must suffer from post operative recovery, I will always regret being subjected to this unnecessary intervention.”

    Honestly, what you really want in an OB is someone who is so good they deliver safe babies when the clinical picture is cloudy. When they are able to “pull the trigger” at the right time. This may mean proceeding with section due to a summation of subtle findings or waiting it out a little longer than maybe another MD would have. Guess what, OBs do this every day. And when the shit hits the fan they do not have time to sit down with white out and pencil and revise the birth plan.

    The field of OB is difficult to practice due to fear of litigation and all of the comments listed above. The women and men who do this, by majority feel it is their calling. They proceed bravely despite long hours, call nights (really, 50% of babies come at night?!?!!) and $1,000,000 a year malpractice premiums. My friends share with me that they love what they do. They love mothers, they love babies, they love families. They also carry grief and regret for every outcome that was not perfect. You can understand why they fear home births. When they go bad they end up in their laps- and the sorrow associated with tragedy is theirs also. From the physician perspective they would much rather have control. A natural point of view from someone who is responsible for making tough decisions and responsible for the outcome, whatever it may be.

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  118. Im a pediatrician, and though my first child was born and DID fall under the "cascade of unnecessary interventions", I will still not EVER be comfortable giving birth outside of a hospital (everyone thinks Im nuts as Im attempting VBAC this time, Im 25 weeks). I have seen TOO MANY poor neonatal outcomes even from "perfect, textbook, low risk" pregnancies. And Im sorry, but a midwife, however trained, is NOT a pediatrician, NNP or neonatologist. I dont feel comfortable leaving the potential emergent care of my neonate in the hands of someone with LESS training that I have.

    however, I ALSO see the NCB point of view.

    In my first pregnancy, yes, Im a bit fluffy, yes I technically had GDM. I never had an out of range number, but I did end up on 10 units of insulin at dinner at the end. Hardly surprising, I was rotating in the PICU and NICU at the end of my pregnancy - cortisol, anyone? My biweekly NSTs were picture perfect, he was not measuring large, there was no fluid issue, no blood pressure issue,e tc.

    However, my OB and her group were insistant that I could not be allowed to go even 1 day over my EDD because he *might* be big. So... into induction we went. Bishop score of 2 and a baby who had been persistantly OP. Early AROM, 19 hours of pit chained to a bed unable to move around - without an epidural. An additional 9 hours with 3 FAILED epidurals. All this culminated in a c-section with a failed spinal that I was awake for (yeah, not so pleasant). My son was NEVER in distress. He was 6 lb 6 oz at birth. ON HIS EDD.

    Seriously? Please tell me how waiting a day or 2 in this situation would have been HARMFUL. It's not like I was refusing medical care, eating bon-bons and running around with sugars of 250 and a 10 lb baby. I was contracting when I went for the induction - not hard, but maybe just MAYBE it would have been enough to turn him OA so he could have gotten out on his own. But the OBs werent willing to wait (I had already fought them off an induction at 38 weeks "just because" I TECHNICALLY had A2GD.

    And yes, Im STILL having a hospital birth this time. It is with midwives (CNMs), across the street from the premier childrens hospital in our area. I will be refusing interventions that are done "just because you have a label", which is what I feel happened last time. Obviously, if an intervention is NEEDED, it will NOT be refused.

    Even a birthing center is too risky, IMO. Luckily, the CNM practice and their backup OB are on board with things like waterbirth, etc.

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  119. Hospital for sure. I had twins, but if I had only one child, I would have been the textbook case for a home birth. Uncomplicated pregnancy, very healthy, small kid, head down etc. I had a vaginal septum that no one knew about, so when kid 1 started to make her apperance, I started to bleed vaginally. My fantastic OB used forceps to help guide out kid 1, kid 2 came out in only a few pushes, then the work to fix me up begain. I needed to be transferred to the OR, be knocked out and stiched up, and have 4 units of blood transfued, along with medication to regulate my blood pressure cause I passed out at some point after the birth. If I had not been surrounded by medical professionals who could give me the help I needed right away, the outcome could have been a lot different. The bleeding would have happened with one kid, so I could have been in trouble if I was at home.

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  120. You want to know why OB's get a bad rap for c-sectioning too soon?

    This.
    http://blogs.courant.com/connecticut_insurance/2011/05/in-medical-malpractice-case-ju.html

    Not exactly sure how OB's are supposed to come out unscathed when they are burned at the stake for c-sectioning too early without letting women "try for longer" but then when they do go longer with waiting to do one...that happens.

    It is this kind of thing that makes me reconsider going into OB.

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  121. Home birth is selfish, period.

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  122. For more statistically useless anecdotal evidence, see http://hurtbyhomebirth.blogspot.com/.

    There was, until recently, a corresponding "hurt by hospital birth" site, but it quickly became clear that they couldn't find anyone who was *actually* hurt by hospital birth, only women who were pissed that their fetal monitors were too tight.

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  123. Whoa! Are you going to actually read all of these comments before you get to little ol mine?

    There is a whole middle ground here that BEGS to get attention, but doesn't. A good, trusted doula--one who doesn't have her own agenda, one that can help prevent unnecessary interventions, and one that can work with the necessary ones (few doulas do all of these things, yet there are some of us out there).

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  124. I am a surgeon (not O&G though),

    the absolute risk of infant death/disability is low (however the relative risk is about 300% higher).

    comparatively the intervention rate is reasonably high (one can never know which ones were unnecessary - you can only wish you'd intervened earlier if you didn't
    ).

    an earlier comment about choosing the common risk vs the rare is like russian roulette; why worry about the bullet in the head, the risk is only 1/6, whereas the risk of the empty chamber is 5/6 - much more likely!

    there is a guidance principle for medical intervention called decision analysis, where you decide by "risk of a" x "utility of a" vs ("risk of b" x "utility of b") and see which is worse. (utility is a measure of how good or bad an outcome is).

    so, say infant death/disability risk is 3x higher at home, maternal Csection risk 1/5 in hospital. From the article quoted earlier, the courts estimated a child with CP from a complicated birth should be compensated 50million dollars, how bad comparatively is an necessary c-section...

    All these people trying to claim logical reasons for homebirths cannot do math. ultimately birth is always gamble, and small time gamblers are in hospital, and the big-time gamblers are having homebirths.

    the fundamental difference is hospital mothers are betting with their health, and the homebirth gamblers are betting with a child health - the child unfortunately doesn't get a say.

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  125. Oh goodness. I almost don't want to leave a comment, after finding that pro-homebirthers, midwives, and doulas are expected to be uncivil.

    I'm an ND student, and just about 9 weeks along. (third pregnancy, but first baby. still. we hope. bloodwork/sonogram look great and normal.) I plan to have a waterbirth at a birth center with a midwife- who has 15 years of lay-experience and 12 years after formalizing her education. I fully trust that she will allow me to labor without intervention if possible, and that I will be sent to a hospital if needed, and that the center has some intervention tools, like anti-hemorrhagic drugs.

    I've done an awful lot of research, because I'm constantly defending my decision (of natural medicine in general, but especially) of a non-hospital birth.

    A recent book that has lots of great, empirical evidence is "Pushed: The Painful Truth About Childbirth and Modern Maternity Care" by Jennifer Block. There are literally hundreds of good study references in the back of her book.

    Just because I want a non-intervention birth doesn't mean that I don't have a hospital picked out for if/when things get complicated. Nor would I trust an unregulated, unlicensed midwife. Nor would I expect incivility from people that prefer an alternative method. There's a middle ground somewhere in here, I promise.

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  126. I wonder how much your opinion would change if you knew how midwives were trained or practiced? The comment about whether we "could" carry oxygen is a pretty clear indicator a number of the comments are being made without much information. Of COURSE midwives carry oxygen. They also carry pitocin and methergine for hemorrhage and they are all licensed in neonatal resuscitation. Also, most midwives don't attend births alone. They practice in pairs or have a student midwife or registered nurse with them. Also, it's rare for birth to devolve into emergent status with no warning. Midwives are extensively trained in spotting potential poor outcomes and transferring BEFORE they become emergent.
    Home birth is not and should not be for everyone. The screening process for accepting patients into this setting is well established. Those who trust the medical establishment more than their bodies would not be good candidates for a home birth. Likewise, those who trust their body and only their body are also not good candidates. A patient who refuses the recommendation to transfer is an excellent way to lose your licence.

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  127. http://www.ncbi.nlm.nih.gov/pubmed/19720688

    A study to look at and consider.

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