Splendid Sun » Gambling with Your Child’s Life

Gambling with Your Child’s Life

By: Chris - September 09, 2006

At 2:00 Tuesday morning I was up and running out of options. The baby whose bedside I was standing at was barely 24 hours old and despite pumping obscene amounts of supportive medications and fluids into him, he was still deteriorating. I could walk away for a few minutes to attend to the other 45 neonates in the NICU, but it wouldn’t last long before my phone would ring and his nurse would be back on the line reading off another disturbing lab value that needed correcting. This played on until the next afternoon when he was taken to MRI to assess the inevitable. The image that played on the tech’s screen in the dark workroom was sickening: his entire brain had been devastated.

The infant boy died this morning. He was the only child to his parents and only grandchild to his grandparents. It was probably a blessing, because had he survived, he would have been profoundly disabled–unable to speak, walk, or interact with his environment. The unkind label would have been “vegetable.”

Babies’ dying in the NICU is not an uncommon event. In my short career I have had to withdraw life support many times because to continue care would have been cruel and/or futile. But this one was different. This one didn’t need to happen. The pregnancy had progressed without complication, followed closely by an OB. At 34 weeks, however, his parents abandoned obstetric care for the services of a midwife and opted for a home delivery. At term when labor began, the mom progressed quickly to completion and began pushing. She was allowed to push for 11 hours before the midwife finally felt something was amiss and had her go to the hospital. Fetal monitoring immediately showed the baby in distress and she was taken for emergent c-section. At delivery he was aggressively resuscitated because of prolonged oxygen deprivation, and he was brought to my NICU that night.

Earlier this afternoon I sat in our section meeting and heard some more disturbing news. A former 29 week preemie who had been discharged home having had an uneventful hospital stay, died downstairs in the PICU a few weeks ago. She was 3 months old and had contracted pertussis. We had been called to take the infant up to the NICU to place her on ECMO (heart-lung bypass), because the disease had made her lungs nonfunctional. But as we were preparing the machinery, she arrested and couldn’t be revived.

Why am I posting this? Because I need to know something. By observation it seems there is a growing subculture within the Church that embraces an anti-institutional (for lack of a better descriptive) approach to medical issues, especially those pertaining to childbirth and vaccines. I have read the Word of Wisdom carefully and can’t find anything in the text that would lead me to believe that immunizations are verboten or even discouraged. Nor can I find any teachings condemning the Obstetrics community in their handling of deliveries. Yet there they are, seeking a more fulfilling experience with childbirth that can only be achieved at home or an extra-hospital location, and denying their children vaccinations. Can someone please explain to me why?

Admittedly, I hold latter-day saints to a higher standard and am therefore more critical of their imprudent decisions. But the bottom line is this: that newborn boy died because his parents decided on a home delivery. You could argue that maybe the midwife showed poor judgment, but had they been in a hospital, their child would have been delivered at the first sign of trouble and would be alive and well. Next, the little girl didn’t die because she didn’t get her shots. She was too young for her immunizations to have full effect. She died because other people around her didn’t get theirs. At a time when we have been blessed with innovations that can and have saved millions of lives, how can we turn a blind eye and seek safety in ignorance? I have yet to hear a satisfying explanation as to why someone would risk the lives and well being of their family to this folly.

Comments (143)

143 Comments

I am sorry. I can’t imagine being in that position.

Medicine in the Church has an interesting history. There was a time in Utah when faith and folk healing was prized above medicine, but that didn’t last very long (thankfully). I think that there are those that have fundementalist propensities in the Church (and outside it)…these propensities take some interesting and disturbing turns.

Comment by J. Stapley — 9/9/2006 @ 8:52 pm
Do you think that maybe some are taking “Trust in the Lord…and lean not unto thine own understanding” a little…directly? We should DEFINITELY trust in the Lord, but I firmly believe that the Lord expects us to do all that we can–and I think that using the medical knowledge out there is part of doing all we can.

However, I’ve seen similar attitudes elsewhere–not just in Mormon-dom. Could this be a product of “too much” success–too much comfort and wealth? We just aren’t used to losing a child the way all previous generations have been forced to be. Maybe the lack of personal experience with death have forgotten WHY we don’t have to worry as much about childhood mortality as in the past.

Comment by Keryn — 9/9/2006 @ 9:49 pm
I am sorry for your horrible experience the past days, and grateful for the time you spend trying to save lives.

To address your question, however, I think we have to consider a logical flaw in your assumptions. It is NOT true that a hospital is the safest place to give birth. Please do a quick Pubmed search and look up the results of the National Birth Center Study, which was published in several peer-reviewed journals from 1989-1992, including the New England Journal of Medicine, and concluded that, “There is no evidence that hospitals are a safer place for low-risk births.”

Oh, there was also a study in the American Journal of Public Health more recently (2003?) that also spoke to the safety of birth center births, but that was a study just with low-income women, where the NBCS was a wide ranging, very solid study with more than 11,000 births (who knows when that will be replicated).

So the “anti-institional” choice to birth with midwives in a freestanding birth center may well be based on evidence published in medical journals, and parents who make that choice are doing the BEST thing for their baby.

The fact is, hospital births also bring risks with them (as well as a lot of unnecessary indignity).

Unfortunately, in many localities birth centers are not legal (usually as a result of protest from the medical establishment), and so parents do face a difficult choice between the extremes of a home and hospital birth. Given that in many Western European countries, home births are the norm and much safer than birth in the US, I think a much fairer assessment is that in the case you recently experienced, the midwife did not handle the birth well.

So if you want to prevent this from happening again, please do some reading, break ranks with your medical brethren, and support the establishment of free-standing birth centers.

Comment by Naismith — 9/9/2006 @ 10:12 pm
Even between hospital providers, it’s a night and day difference between different doctors. I know that some want more control over the birthing process. For instance we ditched on our first doctor because he treated my wife like a womb with legs. We are going with our second one now because he was personable and talked to her, not at her. I think some people try to avoid this, thus ending in tragedies like those above. The personal behavior of the doctor can make a big difference in some of us non-professionals making the correct decisions about our health and our childrens health

Comment by angrymormonliberal — 9/9/2006 @ 10:34 pm
I have read the Word of Wisdom carefully and can’t find anything in the text that would lead me to believe that immunizations are verboten or even discouraged

Is the reason for this due to anachronism? I mean, was the American public at large engaging in immunization in or near upstate Ohio in 1833? Did immunization even exist yet?

I think a lot of the decision to go with a midwife comes from the Mormon desire to augment the family bond at all cost, even from the very beginning (birth). Perhaps some mothers feel that “institutionalized” childbirth removes what could be a special and stronger bond. I know of mothers who don’t like the “in and out” emotionlessness of a doctor who only comes in for a few minutes to simply “catch” the child and perform a quick episiodomy (sp?).

Going with the “institutionalized” birthing procedure might be best for the infant. After all, what’s the difference to the infant? It’s not like it’s going to remember being born at home vs. in the hospital. The logical conclusion, to me anyway, is that mothers choose to stay out of the hospital where emergency care is available for personal reasons, perhaps at the expense of their infant’s life.

My wife and I are expecting baby #3, and she was talking about going with a midwife. I gave her this same pitch, and she’s back on the “institutionalized” wagon, which is where I’d like us to be for the very reasons you state in your post, Chris. It’s not all about my wife, it’s about the health of our baby. But who knows, if she pushes me hard enough, I’ll do it her way.. 😉

Good post. I’m glad you’re doing this and not me.

Comment by David J — 9/9/2006 @ 11:09 pm
“Did immunization even exist yet?”

Smallpox immunization dates at least back to colonial times.

Chris, one thing that the medical establishment has not dealt with well is the rise of medical information (and, of course, pseudo-information) on the Internet. You get people who have to make a decision, are lucky if their doctor will talk to them for five solid minutes, and so they go home and read a few abstracts online and then put the full fury of their own insecurity behind their defense of their decision because it is all they have to go on. My sense is that doctors usually weigh evidence, make a conclusion, and then tell the patient why the conclusion is best (i.e., mentioning advantages). They don’t mention the disadvantages because they are remote. But when the patient gets home and finds some website honking about the disadvantages that their doctor didn’t even mention they go nuts with fear and mistrust.

And I hope no one misses the parallels to missionary work and anti-Mormon stuff on the net.

Comment by Julie M. Smith — 9/9/2006 @ 11:27 pm
Chris,

I think the “growing subculture” is not unique to Mormons; it’s a trend across America. What makes the LDS style different is that some use (incorrectly, in my opinion) LDS doctrine to support their decisions. (“I Nephi, having been born of goodly parents…” See, it didn’t say “goodly doctors“!)

I don’t buy your argument that the child died because he was in a birthing center. Couldn’t that argument be flipped around on you every time a child dies because of a doctor’s carelessness?

I’m curious whether any of David J’s (#5) concerns were addressed by Naismith’s (#3) post. Specifically, given the statistics that birthing centers have the same success rate as hospitals for pregnancies determined to be low-risk, is there still a concern that parents who choose birthing centers do so “perhaps at the expense of their infant’s life”? All else being equal (which, apparently, it is), why not opt for what makes mom happy?

Re: Vaccinations. Christian ministers and churches fought against smallpox vaccinations. A prevailing argument was: “Disease is the way God punishes the wicked. Vaccinations are an attempt to escape punishment; ie. encroaching on the domain of God.” (See, for example, Edward Massey’s 1772 sermon titled The Dangerous and Sinful Practice of Inoculation.) In 1721, the people of Boston wanted to try Dr. Zabdiel Boylston for murder after he innoculated his son.

Comment by BrianJ — 9/10/2006 @ 12:09 am
Re 7

I don’t buy your argument that the child died because he was in a birthing center.

I am sorry for introducing confusion by bringing up the issue of birthing centers, but they are the safest place to have a baby. The baby in the original sad story was born at home, assisted by an inept midwife (11 hours of pushing? And adequately qualified midwives should be doing fetal monitoring several times an hour).

But I do think it is an important point to bring up that option, because as #4 mentioned, when people can’t get the kind of safe birth they want, people are forced to resort to home births.

We may be dealing with this in our family. One of my daughters birthed her first in a hospital, and even though I was there throughout and brought some sanity to the process, she will never go through that again. Fortunately, they will likely move before their next pregnancy, and hopefully to a place with birth centers. But if she does not have that option, next time will be a home birth.

Comment by Naismith — 9/10/2006 @ 12:22 am
Naismith,

Thanks for the correction. I either missed the detail that the boy was born at home or, as you suggest, your talk of birthing centers confused my weak mind. What are the stats for home birth? Without those numbers, I’m still suspicious of Chris’ argument.

(Incidentally, two of my friends just delivered at home. One of them lives in the same apartment complex as I—and I wonder, what were the neighbors thinking during the labor?)

Comment by BrianJ — 9/10/2006 @ 12:58 am
Not vaccinating? Silly.

Home delivery? Maybe risky. (Or riskier.)

But midwifery vs. obstetrics? Dunno, Chris. Almost all births in the UK are done with midwives, and I’m not aware of a higher infant mortality rate because of it. They are usually done in a hospital though, with OB’s available should there be a problem.

We’ve had three hospital births. Two were with midwives (in the UK), and one was with an OB (in the US). It’s anecdotal, of course, but the US birth was the most stressful, mostly because the OB was AWOL (doing a C-section upstairs) when my wife had to push. The nurse was in a blind panic, desperately trying to get the doctor. In the UK, the midwife was with us every step of the way. Of course, this may have more to do with the chronic lack of OB’s in Maryland.

Anyway, that’s my shout out for hospital midwifery.

Comment by Ronan — 9/10/2006 @ 1:44 am
I’m going to print this and run it off for my daughter. She’s constantly arguing with her mother in law about these issues. Her husband’s 10 month old niece recently got the measles. That poor baby suffered. They never did take her to the doctor. She survived but it was so sad.

Comment by annegb — 9/10/2006 @ 12:32 pm
We’ve had 3 hospital births and never really considered anything else, but we’ve loved our physicians. 2 with one and the third with another. One thing that I really don’t like is the transitioning from doctors because of Insurance reasons. My employment changes, why does that mean my family needs to change doctors. Also, with the growing Health-Care costs many are finding that acceptable lower cost solutions exists out there. Also, personal managmenet of our health is become more incentivized. Business/Insurance/Government are finding ways for people to spend less on health care. The Medical Profession used to be ruled by the Doctors with practically no controls. Now HMO’s and Insurance companies are making our medical decisions. Now the trend seems to be towards a person’s direct involvment.

Comment by John Shaw — 9/10/2006 @ 2:12 pm
One shouldn’t conflate homebirth advocates and anti-vaccination advocates.

We’ve had one home-birth and one hospital birth. I can say the home-birth was infintetly better in many, many ways. It was more personal, and the pregnancy was treated as natural rather than like a disease that needed to be eradicated at some point.

However, we love vaccinations and make sure our kids get all the required ones a few extras besides.

Comment by Ivan Wolfe — 9/10/2006 @ 2:54 pm
Re 5

Going with the “institutionalized” birthing procedure might be best….

It is tempting to assume that institutional policies are optimal and based on the “state of the art,” but in the case of childbirth as practiced in US hospitals, institutional policy is generally driven more by malpractice concerns than best practices according to medical research. Some examples:

– nothing by mouth. At the hospital where my daughter birthed last year, and when I birthed our last child in the 1990s, there was a strict policy of nothing by mouth while women are in labor. This is due to concerns of aspiration if general anesthesia is needed (which is vanishingly rare in a birth that starts out low-risk). But there are risks of dehydration, including slowing down labor. The medical answer is to have an IV (which brings its own problems as noted below) but that’s not near as good a solution for a woman who is using breathing as a form of pain relief–being able to hydrate the oral tissues directly is far better. I liked sucking on fruit popsicles.

– continuous fetal monitoring. Numerous studies show that intermittent fetal monitoring, checking 3-4 times per hour, is optimal. It results in fewer unnecessary interventions, while catching problems as effectively and allowing mom to move around, spend time in a hot tub, etc. But most hospitals require continuous fetal monitoring, which may limit a woman’s mobility and thus her ability to manage labor. I got my doctor to write an order specifying intermittent monitoring. My daughter’s hospital tried to use a remote system which didn’t work.

– IV line. I can’t even begin to explain how difficult it is to push a baby out with an uncomfortable IV stuck into your hand. You go to grasp something when you push–and can’t hold on with that hand because it hurts, which means it takes longer to deliver the baby. (I have small hands, perhaps not everyone is as uncomfortable.) My doctor wrote orders that I didn’t have to have one; my daughter talked them into just putting in a heploc and not the full line.

– birth position. Study after study shows that delivery works best when mom is upright. There are birthing stools and chairs designed for that purpose. But many hospitals don’t use them, and mom is on her back for the convenience of a physician.

Of course the common thread in all these decisions is the most conservative choice. Malpractice insurance for obstetricians and hospitals that deliver babies really is out of control, and that tends to be the driving force behind establishment of such policies.

Comment by Naismith — 9/10/2006 @ 4:08 pm
With my own expierence in birthing I am sure grateful that all 3 times I have been in a hospital. If I had been at home with my 1st or my 3rd there would have been two deaths – I cannot dialte but did not know this until after 21 hrs of labor along with having toximia – If I had been at home I still would have been trying to deliver naturally which my body does not allow. The babies head was also stuck because my frame was to small for for the head to pass, which was causing the baby to be distressed. With having the toximia (poison) in my body my platelet levels dropped so low that I could not stay awake and my stats were also low that my body wouldn’t breath on its own. The nurses had to constantly wake me and make me breath even though I had oxygen on my face. It took me a long time to come out of recovery. I thank our Heavenly Father everyday that we are blessed with the medical attention we need. If I had had a home delivery they would never of gotten me to the hospital in time for the medical attention that myself or the baby needed. I also have friends that have midwifes. I’ve seen good and bad come with midwifes. Even if you know you have easy perfect births there may always be a chance one of your birthing expierences may go wrong. I know this can also go with medical doctors, however, they have access to things that can save your life at their fingertips.

I also am proimmunization- I have many friends that do not immunize and I agree with #10 – silly!
I seen much good come from immunizations. When done properly. i.e.- Not getting your children immunized when they are sick or under the weather this cancause problems I have heard.

Comment by kbm — 9/10/2006 @ 5:35 pm
I want to thank Naismith for the invitation to do a Pubmed search. As a subspecialist actively engaged in medical research, it never occurred to me to use the most widely used source to review medical literature on a topic so relevant to my specialty.

As tempting as it is to engage in a literature battle, I am going to resist. I will, however, qualify my opinion. As a physician whose recommendations can be quoted as a source, I take very seriously the amount of preparation involved with such conclusions, including:

– Current peer-reviewed literature
– Professional experience
– Familiarity with the patient population
– Familiarity with available resources
– Recommendations made by interested organizations (like ACOG)

The term “extra-hospital location” applies to any facility or place where child birth is supported without immediate emergency intervention nearby (I’m talking within minutes). I am well aware that many birthing centers are right next to hospitals and have qualified staff and can safely deliver low risk pregnancies. However, I cannot issue a sweeping statement endorsing all birthing centers, as all centers, like physicians, are not created equal. The same applies to midwives. I do not condemn all midwives as incompetent, and am comfortable with them delivering low risk pregnancies under the right conditions and in the right places (not your living room).

A reoccurring theme that I can’t help but notice through this thread is parents’ personality conflict or discomfort with their OB that defines their birthing experience. You know, there are a lot of OBs that I don’t like either. Believe me, neonatologists and OB’s don’t always see eye-to-eye, but I value and depend on their judgement. If you don’t like yours, get a new one. Like it or not, delivering a baby involves risk assessment, and if your health care provider (including midwife) doesn’t practice avoiding unnecessary risk, then he/she is inviting disaster. The benefits of enduring indignity, peripheral IV’s, continuous fetal monitoring and not eating far outweigh the risks. Quite frankly, having a baby is about delivering an intact infant with as little damage to mom and baby as possible. Warm fuzzies, good feelings, popsicles and activists attitudes aren’t a priority.

Comment by Chris — 9/10/2006 @ 5:40 pm
Re 9

What are the stats for home birth?

That’s a topic for a book, not a blog response. It’s hard to understand the research findings, because it’s easy to fall into an apples-to-oranges trap: Of course hospitals are going to have “worse” mortality rates overall, since they get all the tough cases. The best way to assess this issue would be to do a randomized trial, in which low-risk moms were randomly assigned to do either a home or hospital birth, then comparisons made of the outcomes. However, this never has been done; it was tried and failed because few women were willing to be randomized.

So then there are retrospective studies which look back at birth records, etc. and these have some problems because often unintended home births are inadvertently included. The retrospective studies generally find that home births are slightly less safe than a hospital.

Then there are prospective studies, in which women are enrolled during pregnancy and followed through their prenatal care to an outcome. These have found that home births are as safe as hospital births. The weakness of these is that the providers who are willing to participate in such a research project may or may not be representative of all providers.

One important prospective cohort study is Johnson & Daviss, British Medical Journal, June 18, 2005. “Outcomes of planned home births with certified professional midwives: large prospective study in North America.” There are two bits of objectivity about these authors: (1) they are epidemiologists, not midwives, so they don’t have an agenda to promote home birth and (2) they are from the Canadian CDC, but 98% of the births in the study were in the US. It was published in peer-reviewed journal, which is also available online to anyone, so you can read all the charts, etc. They have some discussion (which Ronan might appreciate) of how the American system compares with other places around the globe. Their conclusion was that, “Planned home birth for low risk women in North America using certified professional midwives was associated with …similar intrapartum and neonatal mortality to that of low risk hospital births in the United States.”

There is another study mentioned in their references, Murphy and Fullerton, Obstet Gynecol 1988. That study found similar rates of infant mortality, and they included a very helpful, detailed section about the training and equipment the midwives had available, which I intend to use as a checklist when discussing home birth with family members.

Shifting from the research to my personal opinion, I tend to think home birth is slightly less safe than a hospital birth, simply because of the length of transport. Most midwives will do homebirths up to 30 minutes from the hospital, whereas the birth centers in my town are across the street from the hospital. And of course, I’ve already stated that I think birth centers are the ideal location. But a home birth with a certified nurse-midwife is clearly not as risky as some would make out, either.

So if you don’t want to “gamble with your child’s life,” you will find a competent certified professional. That is more important than the decision of where the birth takes place.

Comment by Naismith — 9/10/2006 @ 6:55 pm
As a nursing student, my thoughts are that most OB’s just practice midwifery. The MD qualification is really not necessary for what they do- they normally refer high-risk cases to specialists and just handle regular births. A certified nurse-midwife is a registered nurse with special training in midwifery. Most of them will work with you like a midwife- through the whole pregnancy, and through the whole delivery. They usually prefer birthing centers or (gasp!) hospitals to home births, but they are ADVOCATES for the patient. If the mom wants to use a hot tub or a birthing chair, a good CRNA will help her get that choice. If a doctor is needed, a CRNA-attended hospital birth will allow for that, and I see that as the best of all worlds. (But, obviously, I’m biased.)

Comment by Ariel — 9/10/2006 @ 7:39 pm
Naismith, Thanks for the summary. I appreciate the difficulties of reviewing a large amount of literature and of conducting the studies in the first place.

I got a kick out of this line: “…few women were willing to be randomized.” That’s the reason they are avoiding the hospital and the study.

Chris, “warm fuzzies…aren’t a priority.” Why not? I agree that they should not be top priority, but your statement places no value on them at all. Is that really what you mean?

Comment by BrianJ — 9/10/2006 @ 9:03 pm
My preference for midwife attended births at birthing centers has virtually nothing to do with my Mormonness. Mostly it has to do with me choosing which risks I will take with my births. I have no interest in getting into a literature volley, but to speak as if hospital births have no associated risks, and an out-of-hospital birth do is somewhat unreasonable.

It sounds like the midwife in question was not using best practices, and was a tragic choice as the birth attendant. The main problem with choosing who will deliver your baby is not really having a good way of knowing beforehand who is competent and what they will really do in the moment, whether it be a doctor or midwife. It is a serious concern for me. Doctors are somewhat constrained, for better or worse, by hospital policies; perhaps bringing midwives more into the mainstream, at least by making birth centers for low-risk pregnancies a viable option, could offer something similar.

Comment by Gina — 9/10/2006 @ 9:28 pm
I know my sample was biased, but I covered a birthing center adjacent to the delivery suite in my life as a pediatric resident. We could usually take our time if we were called to the OB ward deliveries, often our services were a precaution. On the other hand, if we were called to the birthing center, we ran. We knew that in likelihood help had been called to late. This seems to be a hazard of the whole not wanting to ruin a natural birth experience mindset. But at the same time I know that the centers were right together. It seems easy to ask, “What’s the difference.” I can tell my horror stories just as Chris can, but they stand out because the are “naturale” gone bad. I’ve seen some horror stories with OB’s as well. I guess the moral is, choose your OB or midwife very carefully (assuming you have a choice and its not just a matter of who’s on call.)

Comment by Doc — 9/10/2006 @ 9:31 pm
that embraces an anti-institutional (for lack of a better descriptive) approach to medical issues, especially those pertaining to childbirth and vaccines

They’ve been around for thirty years or more. Had a friend who was suing them back in the early ’80s.

You need to realize that the AMA started it all by stopping public health nurses from going door-to-door doing vacinations and such (Insurance companies were paying them). Ever since there has been a building public distrust and a core of truth that allows people to feed and prey off of the distrust for the medical profession.

Or the doctor/midwife conflict in France when 90% of the women treated by doctors died, so the doctors had legislation passed blocking access to midwives (rather than wash their hands).

Not to mention, critical path studies show doctors breaking even in the 1980s, the late 1980s. I still remember doctors treating whiplash with muscle relaxants and bed rest for an eight week course — which we now know will make you recover worse than no treatment at all.

Or heart patients being told to avoid all aerobic exercise (as my grandfather was), which will kill you faster.

But still, you are not at fault for any of this (which is all in the past — and pretty much a non-issue, except for the handwashing part), and you will note I refer to the people as preying on others, not serving them — serving them would be preparing them for immediate transfer to proper health care.

Interesting how Marion Zimmer Bradley used to be a big fan of home delivery. She ende up in a hospital right when she almost bled out. She would have died at home.

Comment by Stephen M (Ethesis) — 9/10/2006 @ 9:56 pm
Err, “ended” up, not, ende up.

Anyway, I’m very much a fan of vaccinations, though I appreciate that some people had bad results from DPT, I’ve read the literature and all my kids got theirs.

And I’m all for CRNAs and nurse mid-wives in proper facilities.

And for real medical care. Since 1990 there is no real excuse to avoid it, especially the basics. Would you let a homeopath set a broken bone?

Comment by Stephen M (Ethesis) — 9/10/2006 @ 10:01 pm
I have a question regarding a preference for home births. Who cleans up the mess? And do you ruin your mattress?

My SIL’s sister has not vaccinated her son because she believes vaccinations cause autism. Of course, if she would read up on the vaccination-autism link, she would find out that the possible culprit is thimerosal, which is a preservative and not the actual vaccine. And the CDC started phasing thimerosal out of faccines in 1999, so her son wouldn’t get thimerosal anyway. But she doesn’t know the details, just the conclusion.

Comment by Melinda — 9/10/2006 @ 11:23 pm
Thimerosal (a form of mercury) has not been in children’s vaccinations in years. It is still found in adult flu vaccines.

I skipped a lot of the comments. This subject always makes me ill. Putting your own fears and/or politics above the welfare of your child is just plain wrong. Spend one night in the NICU or PICU and see what a baby with whooping cough looks like, and I guarantee you’ll toss that half-@$$ information you got off the internet and give your baby that dang shot.

Comment by tracy m — 9/11/2006 @ 1:46 am
Re 23
And I’m all for …. real medical care.

I think the catch is that there is no such thing as “real medical care.” Medical decisions are often based on tradition or what a doctor is comfortable doing rather than what research shows is a best practice.

And “real medical care” varies from place to place. If you lived in the Netherlands, your family would probably give birth at home, and you wouldn’t think it risky (and it wouldn’t be) because that is the standard of care, it’s what you are used to, and it is what works for them (and birth is safer there than in the US, so who are we to argue).

In Brazil, they have had a high rate of C-sections, about 80% at one time, and so that is what you would expect for a birth, and you might feel it is not “real medical care” if you are expected to go through labor.

For example, It was 1979 when researchers first suspected that ulcers can be caused by bacteria, and 1984 when the first article was published establishing that fact. However, a study conducted in the US in 1990 found that only 1% of US doctors were using antibiotics to treat ulcers, and it was actually 1994 before the NIH changed the recommendation. The guy who did much of the work got a Nobel prize in 2005, but you can still find physicians who don’t prescribe antibiotics because they think stress is behind it and a bland diet is the best remedy.

Comment by Naismith — 9/11/2006 @ 6:26 am
Naismith, you are doing an admirable job, you have said everything that came to my mind reading this post.

I’ve had three births, all good, all safe, one in the hospital and two at home. My choice to birth at home is completely unrelated to being LDS.

In the hospital I was in a foreign, sterile environement surrounded by medical staff who were trained to think of all the things that can go wrong and to see me as a likely surgical candidate.

And Melinda, my midwife cleans up, does the laundry, orders protective pads for whereever you are birthing.

Chris asks, Why?

Instead of being expected to lay in a way that serves the doctor, I’m in control and can labor and birth where and when I choose. My midwife will get on her hands and knees to assist me, not stand, white-gowned and poweful as I prostrate myself for her comfort on an elevated platform like I was expected to do in the hospital.

I feel safe at home, like all mammals, in the nest I have prepared. I am attended by a woman who has confidence that my body is strong, able and designed to give birth.

I rest in my own bed in peace for days afterwards, my husband and mother protecting and sheltering me and our child, rather than being required to place her in a plastic box and hand her over for pokes and prods in a nursery and similarly being awoken at all hours of the day and night for my temperature to be taken and my hemmeroids examined on a schedule.

I am not a statistic. I am not sick. I am not a number. I am not a malpractice claim waiting to happen.

Comment by claire — 9/11/2006 @ 7:29 am
Erm, that was supposed to be CRNM. Sorry to all, especially Stephen, for the typo.

Comment by Ariel — 9/11/2006 @ 9:36 am
Claire,

I will be the first to state you are not a statistic, but the question remains, if a person’s wants and comforts are to be taken ahead of the baby’s needs, then we become no worse than those pro-choice people who believe that it is the mother’s body and therefore her choice. What about the baby’s desires? What about the baby’s choice?

Comment by Craig S. — 9/11/2006 @ 11:28 am
Why do people seek alternatives to doctors and hospitals? Two reasons I see, which many have already commented on, so here’s my “me too.”

First, medical doctors won’t accept responsibility for anything. Malpractice insurance payments go through the roof and it’s everybody else’s fault: greedy lawyers, stupid juries, ungrateful patients, poorly managed insurance funds. That it could have anything to do with the medical industry’s failure to police itself or with shortcomings of individual doctors is an unthinkable concept for an MD.

Second, hospitals can have a hospitality right up there with airports and require a similar surrender of autonomy. So some people decide they’d rather drive themselves.

Now my war story: My two-year-old had difficulty breathing, so my wife and I took him to the UCLA emergency room. As is usually the case in such places, there were many other people whose problems were more severe and immediate than my son’s, so the bulk of the hours there didn’t involve examination or treatment, but just waiting. In the course of those hours, the young resident made three different diagnoses and was irritated at the lack of deference to his authority when I asked the basis for his judgements. As the respiratory therapist applied useful treatment, I tried not to think of the murderer in nearby Glendale who had recently been charged with killing 50 patients by deliberately maladministered respiratory therapy. As the night wore on, the doctor wanted to keep my son overnight for observation. I felt more trust in the ability of my wife and me to watch him at home. This really got the young doctor angry, but my son went home “against medical advice” and we watched him through the night, ready to apply medicine as the therapist had shown us and bring him back in if trouble breathing resumed. A couple days later, as I walked north on Westwood Blvd., the emergency room doctor crossed in front of me. My first impulse was to let him know that his patient had been OK since we took him home, but I realized that news would have actually annoyed him, so I let him pass without saying anything.

Comment by John Mansfield — 9/11/2006 @ 11:31 am
John, you are right on! I love the analogy of driving ourselves. Women have had the domain of childbirth taken over, dominated and perverted by the medical establishment, to our detriment. Wow, I sound like such a flaming feminist, but I really believe that. Of course, I’m not arguing that we should all have unattended home births in our back woods. But the European models of midwives attending most births and OBs being around for the ones that need help is one we would benefit from greatly for just the reasons John mentions.

Craig, I guess I’m looking at things from such a different point of view I can’t see what you are asking. Are you saying that a baby would choose to be born in a hospital if given the choice? I find that laughable, so I’m hoping you mean something else I’m missing.

What’s good for the mother is good for the baby. People discount what is a central factor to me: Mother being allowed to labor in her own time, own house, own clothes, eating her own food and drink if she chooses, surrounded by people she knows, feeling free to move in the ways she chooses, all lead to a safer birth. Chris is taking the easy way out by not acknowledging the literature: the BMJ study is clear that for low-risk pregnancies, home births attended by a Certified Professional Midwife are as safe or safer than hospital births. And women are much happier with the outcomes. And if we could survey the babies, I bet they are too. I can tell you my 10 year old is put out she wasn’t born at home like her two younger sisters were 🙂

Comment by claire — 9/11/2006 @ 12:02 pm
I am saying that a baby would choose to have every access to lifesaving personnel and technology.

I guess I just don’t necessarily with your statement that what is good for the mother is good for the baby. That is certainly not the case with abortion, nor was it the case in Chris’ experience above. I think that equating things like feeling at ease with access to lifesaving equipment is just irresponsible.

Luckily, in your case, there was no need for lifesaving measures, but what if there had been that need?

I have had as many bad experiences with hospitals and doctors, but I understand that despite these weaknesses, my son has the use of his arm and my wife is living and breathing and sharing my life with my children. In both of these cases, there were aspects of malpractice and suboptimal hospital care, but despite these there was also the access to the things they needed.

Comment by Craig S. — 9/11/2006 @ 12:10 pm
It is my assertion that the need for lifesaving equipment is greater when low-risk births happen in a hospital.

Of course babies and mothers are saved because they have access to this equipment. But many of the babies are saved by the OBs and equipment were put at risk by the very same. High intervention leads to complications. Intervening when no intervention is called for causes problems that would not have happened otherwise, and the OBs and hospitals are now the heros. There is NO WAY of knowing in any particular case if the emergency would have happened otherwise, but the studies prove the trend.

Since you asked: I chose a caregiver that I trusted to know if things were not going well in my labor. I had back up medical care if my child or I needed to transfer to a hospital. My midwife is trained in infant resucitation and is experienced and trained to recognize and treat emergencies such as post-partum hemorrage, etc.

I have not had ‘bad experiences’ with hospitals and doctors. This is not a personal vendetta: My one and only hospital birth was a good, safe birth. My ob was a good man, but he was trained to be a surgeon, not attend normal births.

When I knew I had a choice, I chose an option that worked better for my family. When people like you and Chris call this choice gambling with my child’s life and irresponsible (something I would NEVER dare to say to someone choosing a hospital birth), I am understandably a bit rankled.

Comment by claire — 9/11/2006 @ 12:29 pm
The people that I know who have embraced alternative medicine usually feel that “Western Medicine” has let them down. One anecdote of note: My friend has Lupus. The doctors could not diagnose the illness and so she did extensive research, self-diagnosed and then took it to her MD, who verified her diagnosis. Then, after seeing the prognosis, she decided that alternative methods were worth a try. So, she heads over to Young Living Essential Oils and it changes her life. Now she doesn’t do vaccinations and avoids most perscription drugs. Having said that, she still strongly believes that MDs are very important and necessary. While my experience is within LDS circles, I believe that it is a very strong micro culture in the U.S., not just in the LDS Church.

Comment by WaterCat — 9/11/2006 @ 12:33 pm
“It is my assertion that the need for lifesaving equipment is greater when low risk births occur in the hospital.”

see comment #21.
We may be overutilized by the OB docs but at least we are there when seconds matter. I cannot tell you how sickening it is to arrive in a room where the infant should have been on a respirator 10 minutes ago and then see them wade through permanent brain damage and multi-organ failure in the NICU. In my experience, a total focus on a good birth experience delays care in the unlikely event it is needed even when help is a minute away. Yes, increased utilization happens because of being at a hospital, have you ever heard of “better safe than sorry?”

Even if studies show no diffence in delivery complications you cannot EVEN begin to tell me that shows any of the exposure to hospital neonatal resuscitation put the baby at risk. Not only is that not supported at all by any evidence anywhere, but it reveals your own prejudices. That attitude is reactionary. Both I and Chris have given you real life examples of how counterproductive(i.e. lead to harm of the child) this is when things do go awry.

John Mansfield(#30)-
If increased malpractice were accompanied by any an increase in complications of medical care in epidemiologic data your argument might make sense. It is a really easy statistic to prove or disprove. The truth is there is no accompanying increase in complications with increased malpractice claims.
You may want to consider that those arrogant MD *******s might have some logic to their arguments.

I am glad to hear that your son is doing well. I am sorry the young doc felt threatened and treated you so poorly. It seems apparent to me that the issues you had stemmed from poor communication and trust on either side more than anything.

Comment by Doc — 9/11/2006 @ 1:29 pm
I personally know a LDS couple who’s child died as a result of being at home and not having access to medical technology. If they had been in a hospital he would be alive today.

I know another LDS couple who labored for 10 hours at home and had to be life flighted to a local hospital and both mother and child barely survived.

Its seems better to play the odds and have access to medical equipment rather then risk havinga n experience lik the 2 above.

Comment by bbell — 9/11/2006 @ 2:15 pm
“I have read the Word of Wisdom carefully and can’t find anything in the text that would lead me to believe that immunizations are verboten or even discouraged.”

The Church officially supports immunization and counsels members “to protect their own children through immunization.” :

http://www.providentliving.org/content/list/0,11664,2408-1,00.html

Comment by Allison — 9/11/2006 @ 2:34 pm
What is the cause of the alarming increase in c-section rates in the US? “Nearly 1.2 million C-sections — 29.1 percent of all births — were performed in the United States in 2004, according to the National Center for Health Statistics. In 1996, the rate was 20.7 percent.” (http://www.medicinenet.com/script/main/art.asp?articlekey=63565) As technology improves I would expect the need for c-sections to decrease. It’s a tragedy when a woman who desires to have a large family has her uterus permanently damaged unnecessarily. Some c-sections are unavoidable but far too many are the result of over managing the process (i.e. induction, epidural, pitosum, etc). I concede the previous statement is supported principally by anecdotal evidence I’ve gathered from talking to others about their birth story, but I’ll continue to hold to the belief until someone shares facts that debunk my opinion. I agree that OBs perform an important role in the birthing process for high risk pregnancies. However, birth centers located in close proximity to hospitals are a great option for low risk pregnancies. I assert that the c-section rate would decrease significantly if all low risk pregnancies birthed at a birth center.

Comment by Jeff — 9/11/2006 @ 2:37 pm
You know, I think the super natural home birth statistics have put such a negative spin on the doctor and hospital births as to be almost removed from reality.

I have had three babies in a hospital/birth center with an OB/GYN attending, and folks, I was able to make ALL THE CALLS!! No one forced anything or any position or any medications on me. With an OB in a hospital, I had a vaginal birth in what would likely have been a c-section with less skilled personanel. I was able to birth med-free. I was able to have meds when I asked. I was able to use water, birthing balls and alternative possitions to labor. I was able to decide when to push, and how much…

For some reason the “naturals” have painted doctors and nurses to be evil, manipulative machines, and in my experience this is just NOT the case. They are kind people who, when you communicate with them honestly, listen and honor your requests.

Never would I risk my childrens health, even the tiniest bit, on the altar of my personal politics.

Comment by tracy m — 9/11/2006 @ 2:38 pm
Jeff,
Unnecessary C-sections are a legitimate issue. I have found that they are largely consumer driven. The difference in C-section rate at a well to do suburban hospital compared to an inner city hospital is bizarre and surreal. Granted, the lifestyle of the doctor is also improved by scheduled deliveries, inductions, etc. but I have a hard time imagining any OB pushing an induction or an elective C-section on anyone. For the record there is a push in the academic medical community to try to reduce these statistics as well.

Comment by Doc — 9/11/2006 @ 2:45 pm
Yep…there are a ton of people who go for elective C-sections. Consumer demand.

Comment by J. Stapley — 9/11/2006 @ 3:01 pm
Both I and Chris have given you real life examples of how counterproductive(i.e. lead to harm of the child) this is when things do go awry.

I appreciate your willingness to share those stories. However, the plural of anecdotes is NOT data.

I’m not being sarcastic; I really don’t understand why, if non-hospital births are as risky as you claim, that studies show that home birth is just as safe for low-risk births, and birth centers are safer. And why women in the Netherlands, who have been delivering at home for generations, do not have the same problems that US women and babies apparently do.

Comment by Naismith — 9/11/2006 @ 3:03 pm
Bringing it back to an LDS perspective, I think one of the crucial things is that we recognize that each family is entitled to receive revelation about their own situation.

There are several families in my ward who have homebirthed, and they are pretty low-key about it. They share their experiences when asked, stressing that it was right for THEM, and for THIS BIRTH. They don’t proselytize.

In contrast, some years ago I was greatly offended by a home teacher who told me that I was making a mistake to give birth in a hospital, that the baby would be marked with the sign of the devil, etc. I wasn’t surprised when he was excommunicated later. And as a new convert, I was a bit confused.

Comment by Naismith — 9/11/2006 @ 3:08 pm
“I have read the Word of Wisdom carefully and can’t find anything in the text that would lead me to believe that immunizations are verboten or even discouraged.”

Why would you look in the Word of Wisdom for an explanation?

Comment by Kim Siever — 9/11/2006 @ 3:12 pm
Naismith,
Please read comment #21. I granted that my sample was biased. Its just hard to ignore devastating results that can come from an anti-intervention attitude. In these rare situations, life and death decisions have to be made very, very fast. Any delay is bad. I am not arguing that there are more complications, I am arguing that those rare complications are made more severe when they do happen secondary to an attitude that delays intervention.

Comment by Doc — 9/11/2006 @ 3:16 pm
I had a low-risk pregnancy and a short and relatively easy labor and delivery (four hours of active labor plus two hours of pushing and there was the baby). I had my baby in a hospital – I thought it would be more comfortable and convenient to have the mess somewhere besides my house, and I felt safer. My labor nurse was a gem. She stayed after her shift was over to see me through the delivery. My doctor showed up only 15 minutes before the baby did, but I wasn’t worried about that. It just didn’t bother me. And once I was in labor, I didn’t to eat anyway, so that wasn’t an issue. The only minor annoyance was that blood pressure cuff was set to go off every five minutes. The second time it coincided with pushing contraction, I pulled it off and that was the end of the cuff. They put it back on after the baby was born.

No one forced me to do anything I didn’t want to do. I could get in any position I wanted to be in, or I guess I could have. I just wanted to lie there, so being on my back or side was just fine. My husband would have had to carry me to a hot tub or brace me to be able to sit up and that much movement just did not sound attractive. And I got ice chips whenever I asked for them. I’ve never liked popsicles anyway.

If a woman has thought it out and wants a home birth, that’s fine. But hospitals are not evil manipulative machines designed to suck the joy out of the birth experience. They’re full of nice people who like babies.

And I am puzzled by the argument that childbirth is not a medical procedure. I guess I have a lower threshold of what constitutes a medical procedure, but if I’m gasping with pain and bleeding, I consider that a good time to have a doctor around. It’s for my own peace of mind. I understand others might have peace of mind about a different choice.

Comment by Melinda — 9/11/2006 @ 5:21 pm
We are clearly at an impasse about what is risking our child’s health. I have chosen not to risk my child’s health for the sake of preserving or furthering the status quo. Naismith is right on again; the data speaks for itself. Read the BMJ article she referenced- it’s peer-reviewed, prospective, clean data from the US.

For every home birth horror story, there are counter stories of births gone bad in a hospital because of the domino effect of interventions. These horror stories turn into hero stories and we-would-have-died-if we-were-at-home stories that end up being used against the very option that could have prevented many of them.

I don’t doubt that Tracy had a great experience- good on you for being prepared. But out of hospital births attended by a CPM are a safe choice.

Comment by claire — 9/11/2006 @ 5:25 pm
Again, avoiding the temptation to literature bash…

This post was not meant to be a referendum on midwifery. It was about risk and risk-taking at the expense of your child’s welfare. I appreciate all the effort that has gone into painting a lovely warm picture about how wonderful a home delivery is and how cold and sterile hospitals are with uncaring egotistical physicians paternalizing the birth process. The literature cited is nice, but it does not tell the whole story. Naismith was good enough to explain the limits of the current studies, which is valid. However, there is one more limitation that needs to be explained. The studies conducted were powered to detect statistically significant adverse outcomes, like increased number of procedures. Unfortunately, the most adverse outcomes, like mortality and long term disability, are too infrequent in low risk pregnancies to be evaluated to significance by the listed studies. A good example of this is a 2002 study published in the Canadian Medical Association Journal comparing home deliveries attended by midwives and hospital deliveries attended by midwives and OB’s. On the surface, the study had an impressive n and concluded that there was “no increased maternal or neonatal risk associated with planned home birth under the care of a regulated midwife.” CMAJ. 2002 Feb 5;166(3):315-23. However, the reality is that there was a trend toward increased serious adverse events, but the study was not powered well enough to detect them. Perinatal death, ventilation > 24 hours, blood transfusions and obstetric shock happened 11 times in the home birth group to the 2 times in the hospital group. Taken separately, these aren’t considered statistically significant, but even the authors admitted that a trend existed and further investigation is necessary. So, if perinatal death occurred only 3 times in 862 home births when compared to 1 in 571 hospital births, why should we worry? It’s not a statistically significant risk, right? Therein lies the judgment call I wrote about in #16. Home deliveries do represent an increased risk for mortality. That is not open for debate. All the inadequate publications cannot change that.

My question still stands unanswered. Why would you subject yourself and your child to a greater risk? Please spare me the comfort and well-being argument. That does not hold water with me. Your child doesn’t care where he/she is born unless you want him to. I agree, choosing a qualified professional to attend the delivery is paramount. But I’m sorry, the location for delivery does matter.

Comment by Chris — 9/11/2006 @ 5:44 pm
This post was not meant to be a referendum on midwifery.

Sorry, but you don’t get to control the direction in which comments head off, and you started it with a false assumption about the risk of other brith venues.

It was about risk and risk-taking at the expense of your child’s welfare.

It was. There are all kinds of risks that parents take, like the risk of a car accident on the way to the hospital, and the risk of picking up an iatrogenic infection in the hosptial.

We have a baby in our ward who was killed from an infection picked up in a hospital. Should we avoid hospitals after hearing that horror story? I don’t think so, but that is the exact same logic you are applying.

I appreciate all the effort that has gone into painting a lovely warm picture about how wonderful a home delivery is and how cold and sterile hospitals are with uncaring egotistical physicians paternalizing the birth process.

For the record, my problems were far less with my physician (who after all, wrote orders to allow me to avoid some hosptial routines) than with the hospital, with their policies that contravene best practices.

I’m sorry to report that my hospital births were not as positive as Tracy’s, but for example when I was laboring with my 4th, I told the nurse I was ready to push, and she shook her head, told me I must be mistaken, and sat down on the couch on the other side of the room, announcing that I would not be delivering for at least another three hours. Fortunately, as my husband was heading out the door to get help, our doctor walked in (stopping by on his way home), and the baby was born two contractions later. One of my gripes about hospitals is that nowadays the staff doesn’t know how to deal with an unmedicated birth–they don’t mean to be unsupportive, they just don’t know how.

So, if perinatal death occurred only 3 times in 862 home births when compared to 1 in 571 hospital births, why should we worry? It’s not a statistically significant risk, right? Therein lies the judgment call I wrote about in #16. Home deliveries do represent an increased risk for mortality.

No, they don’t represent a statistically significant risk. Are we going to believe in statistics or aren’t we?

You are correct that for some rare instances, the sample sizes may be inadequate. But that’s the point, the samples are inadequate, and so you can’t infer that they would go in the direction you prefer, if we just had more cases.

I can’t tell you how many times during a data collection process we thought we were seeing a trend, but when the end came and we had everything in and analyzed properly with a decent final sample size, those trends often disappeared.

I second your call for larger sample sizes, but I can’t endorse your interpretation of the data.

My question still stands unanswered. Why would you subject yourself and your child to a greater risk?

You are defining “greater risk” one way. Other folks prefer to rely on statistics. Who is to declare which is more valid?

Please spare me the comfort and well-being argument. That does not hold water with me.

I think your disdain of any possible consideration but your perceptions of neonatal risk is part of the problem.

The dynamics of childbirth are much more profound than “comfort.” Childbirth is an incredible spirtual, sexual and psychological experience for a woman. That should be respected and not scoffed at. It is a very rare thing for women, just a few times in their lives, and any interference should be carefully weighed. I would describe it as a simultaneous sacramental moment, a better high than amyl nitrate, with some aspects of an orgasm (particularly the time stopping/other worldness thing).

If our current hospital system *did* respect and support that experience, then I don’t think women would seek birth elsewhere. I wouldn’t recommend birth elsewhere. My daughter really did try a hospital birth. I was there, and it was very over-medicalized.

Chris, before you lecture me to get a new OB or communicate better, I would beg you to keep in mind that the health care you and your family receive is not the same level of health care that us average folks get. Physicians and their families have shorter waits, private rooms, optimal surgery times. From the minute you or you wife is wheeled onto the floor, they know who you are and you get the best treatment. Don’t assume that we get the same.

Your assumption that, “had they been in a hospital, their child would have been delivered at the first sign of trouble and would be alive and well” may or may not be true. It depends on who the nurse was and how busy they were.

Comment by Naismith — 9/11/2006 @ 7:40 pm
Perhaps because I am a male of the species, I don’t appreciate the birthing process the same way. Perhaps my choice of profession has skewed my perspective on the subject. But I don’t see the miracle of life as happening with the birthing process. The miracle of life is when I come home and my daughters are at the top of the stairs shouting “Daddy’s home!” with big smiles jumping up and down. The way they passed through the birth canal is important only in that they came though safely.

And the whole orgasm analogy…that creeped me out a little.

Comment by Chris S. — 9/11/2006 @ 8:22 pm
Chris S, your first line: exactly.

Chris: it’s not that your question remains unanswered, just that you refuse to hear the answer.

Comment by claire — 9/11/2006 @ 8:52 pm
Clarification: Chris and Chris S. are the same person. Sorry, blog mishap.

Comment by Chris S. — 9/11/2006 @ 8:56 pm
Naismith, #49: Well said. No, very well said.

Claire, #51: I hope that’s not true, that a male of the species just can’t appreciate childbirth. Sure, it’s not in the same way as for my wife, but I can relate that the birth of my daughters and the labor of my wife was a profound experience for me.

Comment by BrianJ — 9/11/2006 @ 11:13 pm
“

The way they passed through the birth canal is important only in that they came through safely”

AMEN!

Comment by tracy m — 9/11/2006 @ 11:37 pm
I would like to point out something I think some of you may be missing with regard to morbidity and mortality statistics related to home birth. Studies that have been done on these births in Europe and elsewhere involve only low risk births, with qualified (usually nurse-midwife) attendants, and emergency equipment readily available for neonatal rescusitaion or other emergencies. In Britain, the practice has been to have an ambulance standing by outside the patient’s home to provide immediate transport. In the United States, home births are generally done by lay midwives, who have virtually no medical training and very limited ability to intervene in an emergency, if they even recognize that a problem exists. Like the other MDs that have posted, I have seen several horrible and entirely preventable tragedies that have occured with home births. In my conversations with lay midwives and their clients, I have been impressed with how well-meaning but clueless they are. So while it may be possible (in theory) to have a home birth that is almost as safe as a birth center birth, in the US this isn’t really available, because appropriately trained people (expensive!) and equipment (expensive) aren’t going to be there.

Comment by E — 9/11/2006 @ 11:41 pm
The picture often painted of doctors and hospitals by home-birth advocates is, I think, highly distorted, but I would like to also add, that if you are truly convinced that doctors exist only to torment women, there are probably excellent nurse-midwives in your community, who deliver at hospitals and would love to care for you during your next pregnancy and delivery! You’ll get good medical care AND can still feel that superior feminist-y satisfaction of using a midwife! And I promise, no one will force you to get an epidural.

Comment by E — 9/11/2006 @ 11:51 pm
Re #50:

No, it isn’t because you are male. I’ve birthed three times: once (unfortunately) naturally and twice (blessedly) by elective c-section. None of the above were mystical, emotional, certainly not sexual, experiences.

[However, I did enjoy a particularly fun birth with #2, where everyone in the room (except my husband) was female (including OB and anesthesiologist). What was most delicious about this was the two MDs discussing a shoe sale at Nordstrom’s at length–now that’s a post-feminist moment for you.]

Comment by Julie M. Smith — 9/12/2006 @ 12:06 am
Than heavens for Naismith.

(i don’t get any superior feminist-y satisfaction out of homebirth, being a man and all).

We’re going with a hospital birth this time around due to insurance reasons, but it’s not enjoyable. The nurses refused to give my wife a rhogam shot because the paperwork wasn’t in the file – except it was and they were just too busy to look for it. The doctor was too busy to be bothered and now we’re wondering if we should have thrown a temper tantrum in order to get that shot. My wife kept insisting on it, and they ignored her and sent her away. We had analagous experiences on our first birth (also at the hospital – plus, the doctor made cow jokes in the delivery room).

Compare this with the Certified Nurse-Midwife we used on our last birth – plenty of time, no hassles, lots of personal care and attention.

Chris’s refusal to believe that comfort and care are significant factors – all that matters is we bow to the whims of the superior doctors who have the power of life and death over us and refuse to explain their reasoning (compare Chris’s rather condescending and disdainful attitude). The Nurse-Midwife, on the other hand, carefully explained everything and made us feel a part of the process – and made the process seem much more natural.

But that’s my own personal, sunbjective answer. I should just say: Read all of Naismith’s posts.

Comment by Ivan Wolfe — 9/12/2006 @ 11:00 am
Chris/Chris S.:-)

Thank you for recognizing that you are seeing this from your own. BrianJ, I did NOT mean to imply that he can’t, only that I appreciated him admitting to the fact that he percieved birth differently. I am so glad you were able to have that profound experience, whatever your birth experience was. Chris, by his own admission, has not.

E, please give us, or at least me, some credit. I know what my options are. CNMs in my area, and under my insurance company, are under a strangle hold and are unable to fully implement the midwifery model and are almost indistinguishable from the standard OB practice. Other states are much more progressive, thought, so thanks for pointing that out to those reading the thread.

Julie, I LOVE that story.

On the original topic of whether this has religious aspects for some people: yes, I have seen some women (not LDS, but then I don’t live in an area with very many LDS) who choose a homebirth for religious reasons. It’s too bad that groups like the AMA in Georgia do everything they can to make sure lay midwives can’t be licensed and that nurse midwives can’t attend homebirths. This gives these women very little choice and clearly some of them are choosing substandard caregivers.The safety of these women and children is clearly not the AMA’s first concern, leaving us only to assume that they are “looking out for number 1.”

ANYONE can call themselves a midwife. If the state won’t hold them to any training/testing standards and license them, and the CNMs loose their licenses if they do home births, it leaves the midwifery community to police themselves (which they are doing an admirable job of doing with those who comply voluntarily).

Comment by claire — 9/12/2006 @ 11:01 am
My wife insisted on doing a homebirth, and I agreed. Baby came on August 21, 2006, without a hitch. Don’t have time to contribute to this discussion at the moment. Maybe later.

Aaron B

Comment by Aaron Brown — 9/12/2006 @ 11:10 am
I don’t see how the initial example illustrates the risk of homebirth, actually. Clearly, pushing 11 hours without fetal monitopring is not the standard of care even among homebirth midwives. And being willing to stick it out so long is amazing on the part of the parents as well.

So I wonder 1) Was it really a midwife? maybe from your NICU vantage point, you don’t know her name and credentials. or do you?
2) Is your state legally unfriendly to midwives? If so, those who do practice may be less trained, less profesisonally monitored, and even face arrest if caught. Obviosuly, these increase risk to mom and make it les sliekly that porblems wil lbe caught on time and transfered.

But unless you assert the home was too FAR to transport, or that midwives generally don’t monitor fetal heart tones, I don’t see what you can generalize from this tragic case.

Comment by cchrissyy — 9/12/2006 @ 11:48 am
Ivan,

Quick question. If you don’t like your doctor, then why is he/she a doctor? I don’t mean to be combative in any way, just wondering why so many people see a doctor they don’t like.

Comment by Tim J. — 9/12/2006 @ 12:17 pm
I meant why is he/she YOUR doctor? Though you may wonder why they are A doctor. Damn Dr. Freud!

Comment by Tim J. — 9/12/2006 @ 12:19 pm
Easy –

The crappy insurance I have won’t let me see another doctor and I can’t afford different insurance, being a grad student and all.

Comment by Ivan Wolfe — 9/12/2006 @ 12:45 pm
There is nothing “progressive” about handing out licenses to people who are unqualified to practice obstetrics, and I would be the first to support the “stranglehold” doctors and certified nurse midwives have on licenses. Putting the state’s stamp of approval on lay midwives is unfair to the patient, who has a right to assume that if someone is licensed, they are qualified!

With regard to the management of the case in this post, it seems supremely ironic for you to criticize the midwife for not delivering “standard of care.” I’m sure in her mind and in the mind of her patient, she was “not putting arbitrary time-limits on the pushing stage”, “showing faith in the woman’s ability to give birth without the use of drugs and surgery” and “working with the woman to achieve the natural birth she can do herself because she is powerful and doesn’t need arrogant doctors to yank the kid out for their own convenience”. After all, if she had gone to the hospital and used an adequately trained midwife all that unneccesary monitoring would only have led to an unneccesary c-section, and she would have had to take her neurologically intact newborn home with her after 3 more days of torment at the hands of the medical establishment, and be left to mourn for the remainder of her days the natural, orgasmic experience she missed out on.

I know I sound bitter, but the tragedies I referred to in an earlier post cause an emotional reaction that leads me to rant. Bottom line, please do not take a chance on your baby’s well being because of your romantic ideas about natural childbirth.

Comment by E — 9/12/2006 @ 1:02 pm
My question still stands unanswered. Why would you subject yourself and your child to a greater risk?

Why do you care, Chris? Other than to make a snide rhetorical back-handed jab at anyone who, after careful research and soul searching, decide to do things differently for their own reasons (most of which have lots to do with the welfare of their children).

The entire attitude of this post is smug, self-righteous, condescending, and arrogant. I hope I never have to meet you in real life, Chris. You sound like a class-A jerk.

Comment by Jordan — 9/12/2006 @ 1:44 pm
The entire attitude of this post is smug, self-righteous, condescending, and arrogant.

First of all, the subsequent name calling isn’t appropriate for this forum. To me it sounds like someone who has had to spend his life watching babies die, and working like crazy to prevent it.

Comment by J. Stapley — 9/12/2006 @ 1:49 pm
(But then, you’re a doctor. What was else was I expecting?)

Comment by Jordan — 9/12/2006 @ 1:49 pm
Fine. Then delete my post.

Comment by Jordan — 9/12/2006 @ 1:50 pm
And I suppose that all of the babies dying in good Doctor Chris’s NICU have been born at home, right? Because those mean, careless parents are so busy sacrificing their children on the altar of their own politics, right?

How do we know that Dr. Chris’s faulty care is not to blame for some of those?

Comment by Jordan — 9/12/2006 @ 1:53 pm
Look- I am sorry to sound so vehement here.

It’s just that my wife and I have four beautiful children who, according to Dr. Chris, we apparently do not love and whose lives we are said to have sacrificed on the altar of our own politics. According to Dr. Chris, we care so little for the apples of our eyes that we are willing to risk their life and limb for our own selfish little whims.

Dr. Chris does not care, really, WHY we do it- his opinion is already made up: it is “FOLLY”. So I ask again- other than to rile up people who see things differently, what is the point of this post? Clearly you are not truly seeking people’s reasons, which you will just dismiss with a handwave. After all, as a well-trained and educated medical professional, you already know everything. So what’s the point of asking?

Comment by Jordan — 9/12/2006 @ 2:12 pm
Well said, E.

By way of clarification, it was indeed a certified nurse midwife who attended the delivery, and she did use limited fetal monitoring.

Let me attempt once again to corral this in. Risking sounding disdainful and condescending, I don’t care about the experiences with good or bad feelings during the birthing process. As has been said, anecdotes do not data make. And I don’t think all midwives are incapable of delivering babies safely. In the right circumstances they are safe and a great resource. You just can’t convince me right now that home births are as safe or safer than in a hospital or qualified bithing center.

I can at least repsect Naismith for using current literature (however limited it is) to establish some semblance of statistical evidence for safe home births. The disagreement is in the interpretation of the data, and I don’t have the energy to engage in a lecture about statistics in medical research. I never did like stats classes anyway. But like I said earlier in #16, there is more to this issue than questionable statistics. There are variables and faulty study designs that cloud the picture. There is also disagreement about the priority of having a special experience with the process. As has been pointed out, I am an uncaring, cold SOB who is interested only in furthering the stronghold that physicians have over the reproductive rights of struggling women everywhere.

In reality, I am a baby doc. I take care of babies when things don’t go well. So obviously my perspective is very different than most peoples’.

Comment by Chris — 9/12/2006 @ 2:12 pm
You sound like a class-A jerk

Then again, so do I…

I can see where you are coming from now- we never have done an actual “home birth,” but we have always used CNMs in the hospital.

Comment by Jordan — 9/12/2006 @ 2:21 pm
I would like to point out something I think some of you may be missing with regard to morbidity and mortality statistics related to home birth. Studies that have been done on these births in Europe and elsewhere involve only low risk births,

I’m not sure that point has been missing. I certainly attempted to stress the point in everything I posted. And I don’t know anyone has advocated home deliveries for high-risk births. If you want me to say that would be “gambling with your child’s life,” I’ll say it. I consider (and the literature supports) the idea of home birth to be safe only for low-risk births, which make up about 90% of births.

In my conversations with lay midwives and their clients, I have been impressed with how well-meaning but clueless they are.

And of course the cluelessness goes both ways. One of my visiting teachees a few years back was a midwife trainee at a program in our town. As part of their training, they do rotations at the university teaching hospital (and the fact that the hospital would participate in the training program and it is required every year suggests that their training is perhaps not as lacking as you suggest, but I digress). Anyway, this midwife apprentice is at the hospital observing, and they discuss a likely C-section candidate, a posterior presentation (head-down but facing the wrong direction) failing to progress. The midwife apprentice naively asks if they have tried a certain technique, I forget the name but it involves a harness and applying pressure for a gentle manual manipulation. The attending physician was an older guy, who had seen this work in his early years. He beamed! “You know how?! Great, show them how!!” and walked out. This was bad because under the terms of their training agreement, the observing midwives aren’t supposed to do anything. And she was early in her training and didn’t have that much expertise. But she rolled up a blanket, showed the nurses how to position it, and it worked and the mom avoided a c-section.

When I hear about the outrageous c-section rates, I think of that story, I think of the outrageously high C-section rates in the US. And I think of the Netherlands, where home births attended by midwives are an integral part of the health care system, and physicians work together with midwives for the best care for moms and babies.

So while it may be possible (in theory) to have a home birth that is almost as safe as a birth center birth, in the US this isn’t really available, because appropriately trained people (expensive!) and equipment (expensive) aren’t going to be there.

They aren’t? Murphy & Fullerton (Obstetrics & Gynecology 1998) found that among the midwives in their study, “All carry oxygen, oral suction equipment, intravenous setups, oxytocin, and methylergonovine to the home….All but one carry an Ambu bag for resuscitation and reported having formal certification in neonatal resuscitation. ”

The list is longer than that, but I think it gets the idea across that training and equipment are available to many parents.

Comment by Naismith — 9/12/2006 @ 2:53 pm
The picture often painted of doctors and hospitals by home-birth advocates is, I think, highly distorted,

So what do you think I am distorting? Did the nurse really NOT ignore me when I told her I was ready to push? Or do you think I failed to communicate that point effectively?

but I would like to also add, that if you are truly convinced that doctors exist only to torment women,

Which nobody has suggested. I believe that doctors exist to treat medical conditions. They’re really good at it. I’m grateful for the surgey I have had, and the set bones and stitches.

Low-risk birth, by contrast, is a natural process.

there are probably excellent nurse-midwives in your community,

Or there may not be, depending on the local laws and whether physicians let them practice.

who deliver at hospitals and would love to care for you during your next pregnancy and delivery!

If you have insurance that lets you deliver at their facility. You might be stuck with insurance like Ivan and my daughter.

And I promise, no one will force you to get an epidural.

Amazing how you can make that promise for other hospitals.

Last year my daughter (yes, a graduate student) gave birth in the only hospital available to her, a university medical center. Her membranes had ruptured, but labor hadn’t really begun, so they gave her a choice to start pitocin or have a C-section in 18 hours. She agreed to the pitocin as the lesser of two evils.

Now, the MDs will know that in medicine the past few years, there has been a lot of buzz about “lowest possible dose (LED).” You don’t give more of a drug than is necessary. This has been fueled by concern over drug-resistant microbes, drug interactions among senior citizens, and the Women’s Health Initiative (turns out that the dosage used was several times that needed to alleviate symtoms).

Although we had expected them to use the pitocin sparingly in an LED fashion, to simply coax her body into commencing its own birth process, we were informed that, no, they would blindly turn the drip up every 30 minutes for at least 2 hours, and she wouldn’t be checked for progress for a few more hours.

It was brutal. Clearly her poor little body was being slammed into labor at a higher rate than is optimal. At the end of the 2.5 hours, she had dilated 4 cm, several times an acceptable rate of “progress.” So I asked them to stop the pitocin and see what she did on her own. They refused, but grudgingly agreed that the rate didn’t have to be increased.

Then they offered her an epidural. She was in tears, because she didn’t want an epidural, but she couldn’t cope any more.

I asked about a narcotic shot just to take the edge off. They admitted that yeah, they would do that if she really preferred. It worked well; she slept for an hour. The nurse asked if she wanted another shot. I asked if she could please be checked, because I’d been watching the conractions on the monitor and it looked like transition to me. No, they couldn’t bother to check her for another 20-30 minutes (the nurse wasn’t allowed to do it). When they did, she was 8 cm dilated. She was happy that the epidural was off the table, and she did great with the last few hours of labor and fully in control of her faculties for the pushing. She has a good idea of what unmedicated birth is like, and I am sure could do fine with a birth center or home birth if they choose that next time.

She had in her birth plan (which was in the chart) that she wanted as natural an experience as possible, and preferred NOT to have an epidural. So if hosptials are so wonderful and supportive as is claimed, why did they not offer her other alternatives to begin with? If I hadn’t asked, I am not sure what would have happened.

So technically, you are correct that the hospital did not actually force her to have an epidural. But it was the only option they offered her, and they gave her a pitocin in a manner that defied current best medical practice and made the labor unmanageable through usual methods.

Comment by Naismith — 9/12/2006 @ 3:31 pm
My question still stands unanswered. Why would you subject yourself and and your child to a greater risk?–Chris in comment #48

Several answers were given you. You don’t like the answers. You think the answers are stupid. You disdain them to the point of preferring to not acknowledge that they were voiced. This method of confronting concerns seems like a serious professional liability if you want people to trust your judgement and benefit from it.

Comment by John Mansfield — 9/12/2006 @ 4:00 pm
Naismith, #75 is an interesting comment for someone who introduced us to the great quip that the plural of ‘anecdote’ is not ‘data.’

And while I’m sure the MDs and/or birth activists and/or lawyers here will correct me if necessary, I’m pretty sure there is no way one could FORCE a woman to get an epidural.

Comment by Julie M. Smith — 9/12/2006 @ 4:04 pm
Naismith, it sounds to me like your daughter got excellent medical care. The reason pitocin is used to induce or augment labor when membranes have ruptured is that the longer the baby remains undelivered, the higher the risk of infection. Pitocin is not “evil”, it is a useful drug that prevents prolonged rupture of membranes in this circumstance. If pitocin had not been used, the risk of infection (possibly necessitating c-section) is much higher. It has been demonstrated that outcomes for mother and baby are better, on average, when this protocol is followed. Another way the risk of infection is reduced is to minimize vaginal exams when membranes are ruptured. This is evidence-based and is good care. I agree with you that the nurse should have discussed all options for pain relief with your daughter, not just the epidural. Dosing of pitocin is also done by protocol, based on best evidence. It sounds like everything went well and an optimal outcome was achieved. I truly don’t see much that could have been done better.

Comment by E — 9/12/2006 @ 4:39 pm
Naismith,
ditto E (#78).
Again, the real issue here seems to be one of trust and communication. Had the doctors stopped to explain why they do what they do a lot of acrimony could have been avoided.

Problems occur when you assume they are doing it because they are lazy, vindictive, and don’t think things through. Likewise problems occur when they assume you are nutty, irrational, fanatical, or unable to comprehend their reasoning and therefore not worth the effort required for good communication. Add to that the stress your wife is in and it can make for one giant ball of hard feelings against the establishment. I am sorry you both went away from the experience feeling so poorly about it.

I don’t think the anecdote leads one to the inescapable conclusion that OB’s are a bunch of cretins that have medicalized the birth process into some Frankensteinian nightmare.

Comment by Doc — 9/12/2006 @ 4:56 pm
I have read and studied the comments in these blogs relative to the emotional and scientific arguments regarding the birthing process of low risk babies. I find that I am profoundly disturbed by the constant reference of “low risk”, intimating that the comments are relative to all babies.

I ask the question “what about the questionable or high risk babies”? The decision as to the risk is often made as the birthing proceeds, so the need for the highly trained physician and standby life-saving equipment is often not known until the need presents itself. As a biochemist, I know well that metabolic and critical needs are often not known until the child is available for presentation for “in hand” examination by one (or more) specialized and highly trained doctors. It seems to me that to not avail one’s self is to deny the very knowledge granted to us by a loving “FATHER”.

Comment by rbs — 9/12/2006 @ 5:49 pm
No, John, I don’t like the answers. Not because they are stupid, but because they are unsatisfacory. Like you, they have repeated personal stories about arrogant doctors or bad experiences, from which they came away thinking the system is broken and they know a better way. It is a dangerous road to travel that can lead to risk-taking, whether intended or not, with untried or questionable alternatives. That is why I included both examples in the post. Do I think modern medicine has all the answers? Nope. But should I respond to every anecdote and apologize for my collegues’ behavior or give endorsement to attitudes I disagree with because it might make someone feel bad if I don’t?

In our banter, I have at least gained some respect for Naismith, who has presented, as I said before, an attempt at real data. You? You complain. I have only contempt for that.

Comment by Chris — 9/12/2006 @ 9:28 pm
I am responding to a couple of similar posts so as not take up room with two similar responses.

Again, the real issue here seems to be one of trust and communication.

Well, I’ve had 9 semester hours of graduate work in Health Communication, and am famillar with the current research on provider-patient interactions. It is true that some malpractice insurance companies give a discount when doctors take courses to improve their communication skills.

I think in that particular situation, we did everything “right” that the textbooks recommend. The problem was only partially with communication (the doctors’ failure) and much more with inflexible hospital policies.

Please remember that a doctor being a Great Communicator is not always a Good Thing, if the information being communication is Just Wrong. Every year there are news stories about bogus doctors, practicing all kinds of medicine (even plastic surgery!) without licensure or adequate training. How do they pull it off? Well, a lot of the patients thought they were really good doctors, because they were Great Communicators.

Had the doctors stopped to explain why they do what they do a lot of acrimony could have been avoided.

I don’t see how. They did explain why they did it: because of hospital policy.

Pitocin is not “evil”, it is a useful drug that prevents prolonged rupture of membranes in this circumstance.

Exactly. Midwives also use pitocin in such situations. But midwives are more likely to adjust the dosage according to how each particular mom does, not necessarily follow a pre-defined schedule, and they are more willing to consider stopping pitocin once labor is established.

It has been demonstrated that outcomes for mother and baby are better, on average, when this protocol is followed.

That is simply not true. That may well be what was in your textbook, but new developments are why we all have to do continuing education, neh? There is much controversy in the medical literature surrounding prelabor rupture of the membranes at term, as to whether inducing immediately (with greater rates of C-sections and those risks) is better than waiting (and various lengths of time have been tried). I would agree with you that waiting 48 hours or more to induce labor increases risk. But numerous studies find that waiting 24 hours is better or the same as immediate induction.

We would have been happy to induce after 12 hours (after my daughter got some sleep while on a fetal monitor), or even induce at a natural rate, with my daughter’s reactions being monitored and dosage adjusted according to how she was actually doing. Rather than being slammed with a one-size-fits-all dosage policy.

I really don’t think those were unreasonable requests to consider, they are well within the range of mainstream birth care, but were denied because of the standard policy at that hospital.

Problems occur when you assume they are doing it because they are lazy, vindictive, and don’t think things through.

And where did I suggest they they were vindictive, lazy, or don’t think things through? I would say that they were inflexible, following their policies rather than listening to mom or considering her situation.

Since this was at a teaching hospital that relies on house staff (my daughter never saw an attending until a few minutes before the birth), I assume that those iron-clad unbreakable policies were put in place for liability issues. Defensive medicine is not always good medicine.

Likewise problems occur when they assume you are nutty, irrational, fanatical, or unable to comprehend their reasoning and therefore not worth the effort required for good communication.

I was very calm throughout, I can assure you. As a mere grandmother, I was there on sufferance, and knew I could be kicked out at any time. But the nurses and residents clearly didn’t like being asked about alternatives or reasons. If that made me seem nutty, so be it.

I don’t think the anecdote leads one to the inescapable conclusion that OB’s are a bunch of cretins that have medicalized the birth process into some Frankensteinian nightmare.

When did I ever refer to cretins or Frankenstein?

Please note that I was responding to another comment that promised that we could have a wonderful hospital birth. Only we didn’t. It claimed that the picture of hospital births “painted” by homebirth advocates was “distorted.” My point in telling my story is that my attitude about hospital birth is based on actual experience.

Yes, we got a healthy baby, and I appreciate how wonderful that is. If there was no other way to birth safely, I would do it again. But there are other ways to give birth.

Comment by Naismith — 9/12/2006 @ 9:36 pm
Naismith, I can only shake my head in wonder at how far ahead of all the doctors and hospital nurses you are in your knowledge of good medicine! If only we had your superior, up to the minute knowledge of best practices! If only I had access to current research and if those ignorant nurses only knew how to do their jobs! Although, like all doctors, I am an arrogant jerk, I truly marvel at your astounding confidence in your opinions. I guess I will need to consider trying some of that CME. I haven’t bothered with that before, because, naturally, I assumed that the textbook I used in med school is all I need. Thanks for showing me the light.

Comment by E — 9/12/2006 @ 10:06 pm
Naismith, I can only shake my head in wonder at how far ahead of all the doctors and hospital nurses you are in your knowledge of good medicine! If only we had your superior, up to the minute knowledge of best practices!

I don’t claim to have ANY knowledge of medicine. I am just stating what researchers in peer-reviewed journals are reporting.

I am not making any of this up; it is there for anyone to see. If you have a problem with the research findings out there, then why don’t you tell your colleagues to stop debating and exploring those issues? PubMed is our tax dollars at work. Anyone with an internet connection can at least read the abstracts. As Julie pointed out earlier, dealing with a more informed public is just part of the medical landscape nowadays.

I understand the limits of research and noted those in my review a few days ago. I totally appreciate the importance of never relying on one study only. But when there are trends in study after study, when other countries have great success doing things differently, then I think that is worth asking some quesitons about.

I guess I don’t understand the sarcasm. In your opinion, should a patient just believe what you say because of the white coat? Exactly what have I done to cause this ire? Is there a way to state things more palatably?

If only I had access to current research

More like the time to read the journals, if you are like most hard-working clinicians I know:)

Although, like all doctors, I am an arrogant jerk,

Sigh. I have never said that all doctors were arrogant jerks. I certainly don’t believe it. I work with doctors and am grateful for those who have saved the lives of myself and grandchildren.

I truly marvel at your astounding confidence in your opinions.

Well, yes, I’ve had to risk my life on them.

Some years ago, I was diagnosed with a condition that impaired my everyday life. I went to the “best” doctors at a well respected teaching hospital. And one of them really was the best for me, because when I asked him questions and came up with an alternative hypothesis for some recent studies, he was very open-minded and agreed that I could be onto something, that it may be possible to interpret those data in that way, and maybe some of the assumptions by some of the other docs seeing me might be off.

Based on our discussions along those lines, I decided to consider a surgical procedure that has a good reputation in the literature, but is not recommended at the teaching hosptial where I lived. I consulted a highly trained surgeon in a respected hospital six hours away, he was interested in my theory and was confident enough that at least some benefit would come of the surgery that after some prayer we decided to go ahead.

It was the most marvelous thing. Within weeks, I felt 10 years younger. All my symptoms disappeared, and have stayed gone for 5 years. My hypothesis seemed to have been correct in my case. It was absolutely the best choice for me.

The local teaching hospital still does not recommend that procedure.

So are you saying that I shouldn’t have done it–that I shouldn’t have confidence in my opinions and the published research, but trusted the doctors instead?

Well, if this discussion has degernerated to sarcasm and accusations of personal attacks, then I guess I have nothing left to say.

Comment by Naismith — 9/12/2006 @ 11:27 pm
Naismith,

You suggest laziness when you say they are too uninformed on their CME to keep up with your lay knowledge. You suggest vindictiveness when you imply they had ability to go against the policy if they wanted to, clearly didn’t like being questioned and that you checked your behavior to avoid being thrown out. You suggest nothing is thought through when you assume the policy is about defensive medicine and that people are unnecessarily inflexible.

The examples were meant to show mostly unfair assumptions that may also have just a tinge of truth. I am sorry. I merely offered some advice on how perhaps things could have been worked out better. I did not realize you were a professional health communicator. Nor did I realize that when I strive for good health communication, my only motives are to reduce liability or to pass off decisions that are just wrong.

I left out the reference to trust, which is critical for patient satisfaction and good healthcare (IMO), for acouple of reasons;

1) it needs to be earned and is not when communication is poor

2) I feared offending you if I suggested that you thought you knew more than these doctors, however, you seem quite comfortable explaining that this is the case.

I hope you can understand the anger and frustration we feel when we see the lack of trust end up harming or killing a child as in the examples we shared.

The cretin and Frankenstein comments were admittedly exaggerated and not necessarily directed at yourself. I think the perception we MDs held in this regard by the alternative medicine movement is the root of some of our defensiveness. I also think it is not uncommon in the populace in general and can be very harmful to good healthcare.

IMO, there is both a science and an art to medicine. In real life, different physicians may handle the same situation differently and either way may be reasonable. I agree a one size fits all policy may cause some difficulty. I was just trying to suggest some strategies to help it go better next time. You need to have the medical staff on your side if you are ever going to get some flexibility to go your way, however. If they were doing everything by the book, as you agreed, you are also at some point going to have to defer to their judgement short term and find a more “compatible” hospital or provider long term (in the ideal world, of course.)

Comment by Doc — 9/12/2006 @ 11:37 pm
As long as a bunch of doctors here fielding complaints about their profession, one that comes up among engineers is that medical doctors are so committed to and dependent on memorized procedure that their analytical reasoning is weak, at least as applied professionally. They don’t understand testing and data analysis. Diagnosis depends so much on the patient discovering the magic code words. If he doesn’t, well, better luck next time; maybe the next contestant will do better. Is this an issue that concerns physicians, or is it just something that engineers tell one another to feel superior?

While I’m on my superiority kick, some of my impression of doctors’ reasoning abilities comes from the time that my wife was in a PhD program in the Johns Hopkins School of Medicine. The PhD students had a low opinion of the medical students’ abilities, probably fed by jealousy of their respective futures. An MD/PhD is known to be a weak PhD, but you need a few around if you want to experiment on humans.

Comment by John Mansfield — 9/13/2006 @ 7:13 am
I dont believe this post was intended to create a midwife vs. doctor slugfest. What I got out of Chris’ original post was a neonatologist who had lost two babies due to parents who made poor choices based on a perceived anti-institutional subculture. I don’t know about anyone else, but I assume the post was spurred by the pain this “unfeeling, uncaring and allknowing” professional felt when he had to call the death of these innocent children.

I hope that this post has caused those whose minds are not closed (you can read hard hearted and stiff necked if you wish), to reevaluate decisions about God’s children over whom they have a stewardship. In these cases, the parents made poor decisions that ended in the children’s deaths.

The basic question remains, wouldn’t you do everything you could, afford every chance there was, to insure the best outcome? Even if it entailed some discomfort or less positive experience, I feel it is our resposibility as parents to provide every extra opportunity for our children.

I already know I fall down on those responsibilities on a daily basis, but hopefully I don’t make choices which raise the risk of life and limb on them as often.

Comment by Craig S. — 9/13/2006 @ 8:14 am
It’s also interesting that the lack of immunization hasn’t really been discussed much. Does Utah still have all of the billboards up advocating immuniziations?

Comment by Tim J. — 9/13/2006 @ 12:05 pm
Thanks, Craig for bringing back a more civil tone to the discussion.

Naismith, I must admit I’m a little disappointed you had to resort to tit-for-tat bantering with Doc and E. You had some great arguments above, and you really didn’t need to go with personal family experiences. I still don’t agree with you or your interpretations, but I admire your command of the topic.

Doc and E, I think you might have taken things a little too far. Now, I’ll admit that I do appreciate good sarcastic prose (myself being a frequent practitioner), but this doesn’t need to get as personal as it has. I agree with your position, I just think we need to take a higher road.

Comment by Chris S. — 9/13/2006 @ 2:06 pm
Does Utah still have all of the billboards up advocating immuniziations?

Yes. My sister’s SIL is opposed to immunizations (her boy has not been immunized). She is LDS and her opposition to immunizations has nothing to do with being LDS. In fact, she and her husband shook their heads at President Hinckley’s stupidity when he proudly announced in GC a few years ago that the LDS Church was funding measles vaccines for children in Africa.

Question about malpractice and babies. If a doctor goofs up a delivery, you can sue the doctor. If a midwife at a home birth goofs up, can you sue her? Or do you have to sign all sorts of waivers and agree not to sue a midwife no matter what? Just curious.

Comment by Melinda — 9/13/2006 @ 5:14 pm
Melinda,
homebirth midwives used to be able to get malpractice insurance but I think they can’t anymore. “Baby Catcher” by Peggy Vincent chronicles how this put her out of business after decades in the San Fransico area. One by one, every company that would insure them just stopped offering coverage, at any price. And I believe it’s true in all states.
So now, you do usually sign waivers, and/or the midwife is exposed to personal risk.

Comment by cchrissyy — 9/13/2006 @ 8:35 pm
In comment 75, Naismith said, “Low-risk birth, by contrast, is a natural process.”

The assumption behind this statement (and behind much of the anti-institutional rhetoric I’ve heard over the years from many sources) is that “natural” is “better.”

It has been widely noted in retort that malaria, diabetes, cancer, and meningitis are also “natural.”

Comment by Bradley Ross — 9/13/2006 @ 9:39 pm
Gina, in 20, very wisely states, “Mostly it has to do with me choosing which risks I will take with my births.”

Everything in life has risks. Raising the quality of our lives sometimes involves the risk of losing our lives. Chris seems to be working with the assumption that minimizing the risk of death is the greatest good. I disagree with that assumption.

TracyM accepts that assumption when she wrote, “Never would I risk my childrens health, even the tiniest bit, on the altar of my personal politics.” While it sounds like a noble sentiment, I don’t think it holds up under scrutiny. My personal politics are very much in favor of trampolines and playgrounds. I hear ER doctors like those things less. Is it worth having a life where we do nothing just so we can be “safe”?

Comment by Bradley Ross — 9/13/2006 @ 9:53 pm
I have been rightly chastised for my sarcasm, and I apologize for it. Contemplating Chris’s original question, I think that people who take these risks usually do it with the very human attitude “it won’t happen to me”. Somehow they become convinced that the risks of childbirth are trivial.

There was a time not really that long ago, when most women were cared for at home by midwives who learned their art in an apprentice system. I guess you could say they implemented “the full midwife model of care”, whatever that is. Presumably, they did the best that could be done under their circumstances. There were no monitors, IV’s, drugs, or surgeons to interfere with mother nature’s processes. Childbirth was the number one cause of death for adult women, usually from infection or hemorrhage. It was a fortunate couple who never had to bury a stillborn or briefly living baby, usually from asphyxiation or again, infection. There are legitimate critisisms of our health care system in the US, but I simply cannot comprehend how anyone could conclude that the hospital is not the safest place to have a baby. I believe that some people become so committed to the idea of “natural is better”, that they simply cannot believe otherwise, regardless of the evidence. It becomes necessary to attribute malevolence or ignorance to the medical establishment because, in their world view, what other explanation could there be?

I think the same type of thought process is usually involved in vaccine refusal. Many people have never known a child to die of a vaccine-preventable disease, and develop interesting beliefs that again, rely on “research that the medical establishment is trying to suppress”. Again, it becomes necessary to theorize about ignorance, malevolence and conspiracies in order to explain the recommendations of the government and medical establishment. Ditto “natural cures for cancer” (the AMA wants you die?) etc. etc.

For those of us with more conventional views, it is wrenching to watch anyone suffer permanent injury or death due to what seem like needlessly risky choices, but especially children. I have struggled with my feelings when I have to deal with this. It is a horrible feeling to have to search for what to say to a grief-stricken mother who is asking “This isn’t my fault, right?”.

Comment by E — 9/13/2006 @ 10:23 pm
Melinda,

While there may not be link between being LDS and refusing immunizations, there is a relationship. The pro-immunization billboards just aren’t found in too many other places.

Comment by Tim J. — 9/13/2006 @ 11:11 pm
While there may not be link between being LDS and refusing immunizations, there is a relationship. The pro-immunization billboards just aren’t found in too many other places.

I’m not so sure about that. Just a few years ago, I heard a talk by Vicki Freimuth who was then director of health promotion for the US CDC. She had met with the producers of the television drama ER, and they agreed to consult with her to produce three episodes of their show with pro-health-promotion story lines. One was about safe sex and HIV, I forget the third, but one was about a toddler who died of measles. The parents were highly educated professionals who were disdainful about vaccination. It was kind of surreal because Carter is having to look in a textbook for a picture of a measles rash, and nobody on staff had seen that before. I found that unbelievable, because unimmunized kids show up in poor charity hospitals all the time–when my daughter had an allergic reaction to a drug, the doctors worried about the rash being measles even though they had given the shots themselves.

That episode ran in spring 2001, so not so long ago. And that fact that a CDC official would consider vaccinations one of the top priorities when given “three wishes” kinda says something about the national priority.

Although you are right that Utah seems to be lagging behind other places in rates of immmunization. See here and if the link doesn’t work, google “National Immunization Study.”

Comment by Naismith — 9/14/2006 @ 6:13 am
I was writing a great post about the midwifery model when my 10 month old grabbed the mouse and it disappeared. But while I was writing it I came up with a great question to stir this up even more: there are demonstrated risks to NOT breastfeeding, yet our culture, even doctors, have a ‘no guilt’ policy about that choice. (Okay, yes, lots of people are made to feel guilty, but no one is made to think they are putting their child’s LIFE at risk). Chris and others who are qualified to interpret the research, if the mortality rate in breastfed infants is lower, doesn’t that mean that babies are DYING because they aren’t breastfed? It would be hard to say that any particular baby died for that reason I’d imagine, but from a statistical viewpoint, probably dozens of babies in your care have died from lack of breastmilk (nec, etc), right?

Comment by claire — 9/14/2006 @ 7:40 am
Naismith,

It does look like Utah is near the bottom, but still ahead of a few states.

Funny thing is that a few years ago my sister and her baby were on one of those billboards advocating immunizations, and, ironically, her kid was not immunized.

Comment by Tim J. — 9/14/2006 @ 8:44 am
Claire,

I am acknowledging your post against my better judgement. Your analogy is a poor tactic at arguing your case. First, because you have no idea how we handle feeding in our NICU and what the mobidity/mortality statistics are for breastmilk usage. Second, and more important, it has nothing to do with the topic. You are using diversionary and entrapment tactics that are effective only at making you look poorly.

Comment by Chris — 9/14/2006 @ 11:58 am
Chris,
Not to defend the analogy, but I don’t think, with the exception of an ill informed reference to nec, she was referring to the NICU specifically, but to the fact that she does not feel doctors take the hard line on breastfeeding that we have on this post regarding Hospital birth. Her reasoning being that since breast fed babies are healthier and therefore some babies must be dying somewhere that would not have if they had been breast fed.

The primary difference I see is staunch cause and effect. Claire gave an example of statistically higher mortality, but any individual case is going to be multifactorial. Breast feeding is simply not what comes to mind when a baby dies from sepsis. The case you outlined, asphyxiation during the birth process without access to resuscitation was clearly THE cause of the baby’s problems.

Claire also acknowledged that lots of people are made to feel guilty. I am pretty sure you would be very hard pressed to find a doctor who did not state flatly that breast milk is best. There is also a definite move in the pediatric world to do everything we can to encourage breastfeeding. I think if you were to assert your baby has a greater risk of dying if you don’t breastfeed and you are a selfish mother if you don’t, you would quickly lose a patient. But I have to point out, that MD would still be technically correct.

Clair,
I realize that guilt is not always the best motivator. I can see how sharing these experiences may be offensive to the natural birth advocates. But the impact is so gruesome, so tragic, so preventable that it tears us up inside to watch it. If we come across as disrespectful, I apologize. Please realize that anger is coming from this inner pain having watched this scenario powerlessly first hand.

Comment by Doc — 9/14/2006 @ 1:13 pm
I am acknowledging your post against my better judgement. Your analogy is a poor tactic at arguing your case.

Oh, I dunno. The statement which she was addressing was (#87) “Even if it entailed some discomfort or less positive experience, I feel it is our resposibility as parents to provide every extra opportunity for our children.”

I also thought of breastfeeding when I read that, since it fits the same description. I wondered if the writer’s wife had been forced to breastfeed all their babies for a year, whether she wanted to or not.

First, because you have no idea how we handle feeding in our NICU

This didn’t seem to be intended at you personally, but rather the general principle that nowadays there are so many studies which establish the superiority of breastmilk for human babies.

It’s been an interesting thing about milk banks for preemies, through which breastfeeding moms donate milk to be used by other babies. In the 1980s, milk banks were pretty much abandoned due to fears of HIV. But more recently they have been re-introduced.

Why is that? I’m assuming because a decision was made that the benefits of breastmilk (as demonstrated in morbidity/mortality statistics for breastmilk usage) for preemies outweigh other concerns.

and what the mobidity/mortality statistics are for breastmilk usage.

How do you know she doesn’t know that? It’s easily enough looked up.

Second, and more important, it has nothing to do with the topic.

The topic of parents making risk management decisions on behalf of our children? It certainly does. Breastfeeding is a way of minimizing risk.

I’m not supposed to tell stories about my family, so I won’t tell you about my grandbaby who was diagnosed with leukemia at 4 months old, and has thrived when 85% of such babies with his diagnosis die, which the doctors attribute in part to having been breastfed throughout his course of treatment

Comment by Naismith — 9/14/2006 @ 1:27 pm
Clair,you may not be aware that all professional medical organizations in the US (and world, I beleive) are strongly in favor of breastfeeding because of the overwhelming evidence favoring it. Not because it is natural. In my practice, almost all mothers choose to breastfeed, and when they don’t, I do try to make sure they are informed about the risks, but I have never had any success changing anyone’s mind. I think change has to originate in the larger culture, but I agree with you that doctors could do more in this area.

Comment by E — 9/14/2006 @ 2:00 pm
Naismith,
85%? what type of leukemia was it?

Comment by Doc — 9/14/2006 @ 2:01 pm
85%? what type of leukemia was it?

Sorry to really get off the topic. It was ALL with a genetic rearrangement. His white blood count was “grim” when he was admitted and his liver very enlarged, and he was only four months old. After a few weeks of tolerating chemo and responding to transfusions, they did say it was more like a 50% chance of surviving to age 2.

Of course that was a few years ago, he was in a clinical trial, and I hope survival rates are better now.

Comment by Naismith — 9/14/2006 @ 3:31 pm
Wow, Chris, I was really trying to play ‘dumb’ in my breastfeeding quote and it backfired! No need to be so defensive. My comment was nothing personal to you and was truly only something I thought would contribute to this thread. Thanks to those who defended me. I was actually thinking about what I thought was the point of your original post… why do we do things, as parents, that could have risks? ie trampolines, like someone mentioned? I thought that breastfeeding (which is my true passion, not homebirthing or midwifery) was an interesting comparison because it’s something that is best for the baby but requires a lot of the mother. As an aside, yes E and others I’m fully aware of which medical associations endorse breastfeeding, and I’m not so sure why my reference to nec was so ill-informed. I’ve read enough to know that is a real concern in NICUs, it has a high fatality rate and that changing hospital policies to those encouraging human milk has turned those stats around.

As for diversionary and entrapment tactics, I’ll just point out that I REALLY wanted to jump all over you for your abortion references as highly inflammatory, but I resisted. Until now 🙂

Comment by claire — 9/14/2006 @ 3:38 pm
I apologize for getting off topic. I am glad to hear your grandson is doing so well. Best of luck.

Comment by Doc — 9/14/2006 @ 3:44 pm
See, I told you. Against better judgement. Now this has turned into a discussion on breastfeeding, which, by the way, I totally endorse. My point had to do with introducing a topic that you are obviously passionate about that cannot be realistically compared to the one at hand. Yes, there are benefits of breatmilk feeds on the rate of necrotizing enterocolitis in preterm infants, which is why we do all we can to obtain breastmilk from mom. But it sounded like you were implying that we don’t consider feeding risks while condemning home births. Perish the thought! The issue, however, is too complex to make a reasonable parallel.

Curses! now you’ve got me talking about it!

And, by the way, I didn’t make the reference to abortion. That was someone else.

Comment by Chris — 9/14/2006 @ 4:14 pm
Chris,

I think Claire’s point is a legitimate one: if the risks of homebirth to an infant are such that you would discourage it, are the risks of bottlefeeding such that you would discourage it? What about trampolines? Bike riding? Snow skiing? Jumping on the couch? Eating unhealthy foods?

While I agree with you in principle that parents should not take risks with the health of their children for their own convenience and/or desires, I do wonder where (or if) you would ever draw the line.

Comment by Julie M. Smith — 9/14/2006 @ 4:30 pm
Chris, my apologies for pinning you with the objectionable abortion reference.

You’re right… It is hard for me to be objective about breastfeeding because that’s what I ‘do’. Although I’ve been a bit hot under the collar, I’ve enjoyed this thread a lot. And it has helped to humanize doctors a bit. When I see families agonizing over getting breastfeeding established, it is easy to get emotionally involved, and these are generally babies who will do fine even if it turns out to be a trainwreck and they don’t end up breastfed. I can only imagine how heartwrenching it must be to see sick and dying babies on a daily basis. I really am grateful to live in an age where I can avail myself of good medical care (heaven knows my oldest has seen enough specialists in her 10 years to last a lifetime).

Comment by claire — 9/14/2006 @ 4:53 pm
Oh, and I just reread your post to remember what you had written about vaccinations. My children are vaccinated, but I always feel uneasy about the idea of vaccinating my children (and putting them in harm’s way, granted the chances are EXTREMELY REMOTE) in order to prevent another child from getting sick via ‘herd immunity.’ Am I just looking at this from a countercultural standpoint? Does anyone else have this qualm? How do you get over it?

Comment by claire — 9/14/2006 @ 5:01 pm
claire,

You didn’t say what the problems were that sent your own 10yo to many specialists, but I would think that if it were something that meant she couldn’t be vaccinated herself, you’d have something to say about the idea of putting your own children at risk to achieve herd immunity.

FWIW, we delay a few vaccines because I judge the risks of giving the vaccine to a newborn to outweigh the risks of a newborn getting the disease in question. But that’s just us. I wish we could NOT do chicken pox, but since everyone else does it, I felt/feel that we don’t have a choice there.

Comment by Julie M. Smith — 9/14/2006 @ 6:17 pm
I feel euphoric every time my children get vaccines, imagining them never getting the disease in question. Kinda weird, I admit.

Comment by E — 9/14/2006 @ 7:09 pm
The concerns of putting your child in harm’s way by getting them immunized is a very common one and understandable. I mean, someone is injecting a substance into your child that is supposed to have some future benefit, and you have to take their word for it that no harm will come from it. Being a paranoid parent myself (no, we don’t own a trampoline *shutter*), I can sympathize, as outlandish possibilities even cross my mind when my children get their shots (like, “what if all those crazy autism activists are right?”). In reality, they are by far the safest medications we use in children, much more so than things like Tylenol. And the benefits far outweigh any risks, any serious of which are so rare that their mere existance can’t be proven. When I find my thoughts wandering the paths of paranoia, I have to remind myself of the virtual mountain of data that has been amassed about childhood immunizations. They are also the most widely used medication in children, so you can immagine the numbers available for research.

Comment by Chris S. — 9/14/2006 @ 7:25 pm
Chris, that is comforting. Those are excellent points, I hadn’t thought of several of them. Just knowing other people, esp. doctors, have that little paranoid concern, is comforting! My best friend growing up is now a pediatrician and she gave me SUCH a hard time when she found out I vaxed my kids on a non-standard schedule (a la Julie- I hear ya about the chix pox!), I have wondered if other doctors felt as stridently as she did and never had that little nagging doubt as you present your kid to have toxic substances injected into their sweet little healthy bodies.

Julie, I must be tired because I’ve read your first paragraph several times and I’m still not quite sure what you meant. My 10 yo has a variety of fairly minor, apparently unrelated medical conditions that have required her to be monitored or evaluated by several types of pediatric specialists like allergist, pulmonologist, gastroenterologist, cardiologist, pediatric surgeon… hmm, is that all?

I’ve been really thankful to find mainstream, respected doctors in my community for both myself and my children that have treated me like an thoughtful, intelligent adult consumer and have always been willing to answer my questions.

Comment by claire — 9/14/2006 @ 7:48 pm
claire, I assumed your 10 year old had *one* condition requiring all those visits, and I was just suggesting that *if* that one thing had meant that she couldn’t be vax’ed, then you might have had a different thought about the benefits of herd immunity.

Chris, everything you say in #113 sounds so incredibly reasonable. But I assume you would have given the same speech in 1998. I had my first child in that year. By the time he was three, he had already had 3 vaccines (on schedule) for which the recommendation was changed because a safer protocol had been developed. (One change was from pertussis to acellular pertussis, another from oral polio to injectible polio, and it is too late at night for me to remember the third.)

I ‘get’ the idea that science advances and we do the best we can at the moment with the data that we have, but this experience made it *very* difficult for me to have much confidence in a system–despite its mountains of data–that would inject my sweet, perfect little babe with three things and then change their minds about the advisability of doing so within just three years.

Comment by Julie M. Smith — 9/14/2006 @ 10:14 pm
Julie,

In both of the cases you mentioned, the medical community did not “change their minds about the advisibility of doing so”, in both of these cases, a better option became available or more beneficial. At the time your sweet, perfect little bay was injected (or orally administered), your child was receiving protection with low risks that the medical community had established as best given the then current level of research. Your child still received the benefits, even if there might had been other factors which led to newer drugs or protocals.

Comment by Julie — 9/15/2006 @ 8:10 am
Sorry Julie,

Blog error!

Comment by Craig — 9/15/2006 @ 9:15 am
Julie (I feel like I am talking to myself),

As I mentioned in my initial comment on this, I ‘get’ the semantic distinction, but it doesn’t change the fact that it is very, very difficult to have confidence in a system that changes with such frequency. Sure, they did the best they could, but those ‘other factors’ that you casually mention in your last sentence translate into English as ‘some people were getting POLIO from the oral polio’ and similar for the other ones. Until the very moment the recommendation was changed, you were a kook if you were concerned about it. Then the next day, you were in the mainstream. I point this out not to defend kooks per se, but to indicate that the lines are not as hard and fast as we would like.

Again, I understand that we do the best we can as we can, but the frequent changes speak to a system less sure, absolute, safe, and refined than the one Craig describes in #113.

Comment by Julie M. Smith — 9/15/2006 @ 2:11 pm
Ran across your blog this evening while surfing the ‘net. I am a licensed midwife (LM) in California; here licensed midwifery practice is regulated by the Medical Board. (CNMs are regulated by the Board of Registered Nursing.) I am also a Certified Professional Midwife (CPM) and participated in the major study that was featured a few months ago in the British Medical Journal. I have been attending births for 30 years now and am fast approaching my 900th birth at home. I am also a registered nurse with professional certification in perinatal nursing and have worked in L&D, postpartum and the newborn nursery. I attend homebirths because in my experience they are at least as safe, and probably safer, than hospital births for women and babies. I have never lost a mother or baby at any homebirth I have attended.

It is unfortuanate that you had to deal with such a heart-wrenching situation. Certainly allowing a woman to push for 11 hours is outside any reasonable standard of care and the bounds of good sense. We have worked very diligently over many years to promote excellence of practice in midwifery and to encourage the use of evidence-based practice in midwifery care. The results of well-designed published studies consistently demonstrate that competency in obstetrics can be achieved by different types of practitioners with varying educational backgrounds (direct-entry midwives, CNMs, physicians) and that the place of birth is not the single greatest determinant of safety.

My first grandchild was born in a Salt Lake City hospital five and a half years ago. My daughter, his mother, was not comfortable with a homebirth and planned a hospital birth with CNMs. She had a bout of uterine irritability late in her pregnancy at 36.5 wks and received IM morphine at the hospital late one evening to quiet the contractions down so that she could sleep. Early the next morning she called me, very concerned, and said that the baby wasn’t moving. I left a few minutes later to check fetal heart tones with my doppler. I recommended she drink a glass of juice in hopes of stimulating some fetal movement. Unfortunately, when I heard my grandson’s FHTs, there was no variability present and I could hear subtle late decelerations with my daughter’s contractions (which were occurring about every 6 minutes). I ordered her into the car and called ahead to the hospital, identified myself, described the problem and asked them to ready an OR for a cesarean section. We got there quickly but nothing had been done to prepare for our arrival. It took 2 hours to get the needed obstetrical consult. The fetal monitor strip reflected what I had heard at my daughter’s home. When the OB arrived he took me aside and said, “We’re going to have to ‘crash’ her.” I told hime we’d been begging for a cesarean since before our arrival.

My grandson’s Apgars were 1 and 2 at 1 min. and 5 min. The neonatologist told me that in another hour he would have been gone. My grandson has profound cerebral palsy and cannot walk, sit up or speak or perform any independent functions in spite of years of care and physical therapy and appropriate intervention, although he is bright and clearly “in there.” His chart at the hospital “disappeared” soon after his birth.

I certainly recognize that these things happen and I know that frequently CP is a function of prenatal insult, not intrapartum anoxia. At the same time, it would have helped us to feel better if I had been taken seriously when I called to ask for a cesarean set-up to be readied. It would have helped to have had staff there who could recognize the significance of poor variablity coupled with subtle late decels on a montior strip.

I am deeply concerend that here in California the law mandates that LMs have a supervising physician but that the malpractice insurance companies in the state have threatened physicians with cancellation of their malpractice insurance coverage if they provide assistance to licensed midwives attending out-of-hospital births. I wonder whose interests are being served.

I am proud to be a homebirth midwife.

Comment by Marla — 9/16/2006 @ 12:42 am
With regard to Post #55 per “E”: I would like to offer a few corrections to your statements.

A very significant number of midwives in European countries are actually direct-entry (i.e., non-nurse) midwives. The British system of midwifery education has a long history of educating both nurse-midwives and direct-entry midwives. France and Belgium also qualify direct-entry midwives. In Denmark midwifery education is strictly direct-entry. Actually, it is instructive to follow this link (in English) to read more about education and standards of practice for Danish midwives:
http://www.jordemoderforeningen.dk/index.dsp?arealayout=11

While I cannot speak specifically to midwifery education in each European country, it is probably safe to suggest that standards would be similar between them since the countries enjoy reciprocity.

One of my former consultant physicians was a British obstetrician, a charming gentleman who always said “Cheerio!” at the end of our conversations. He passed away several years ago but in the mid-80s told me that he had worked on the British “Flying Squads” before coming to the U.S. He said they had been disbanded some years before because “it was simply not cost-effective to sit in front of a mum’s flat whilst she laboured away.” I never verified his statement but assume that it was and still is accurate.

I would also like to mention that in California the rules and regulations governing Licensed Midwives are virtually identical to those governing California CNMs. This is because the wording of the legislation for LMs was lifted almost entirely from the CNMs’ rules and regs. California LMs are held to the same standards of practice as CNMs, except that LMs cannot write prescriptions. We can, however, administer IV fluids and medications, including IV antibiotics for GBS, antihemorrhagics, and supplemental oxygen.

And while I do attend homebirths, I am no more a “lay” midwife than you are a “lay” doctor. This is not my hobby, it is my profession. The direct-entry students in our 38-month-long midwifery education program demonstrate that they are qualified health care providers. Our program is undergoing an accreditation process recognized by the United States Department of Education. I don’t know where you live, “E”, but if it is your experience that the midwives you deal with are “well-meaning but clueless” I recommend that you invite them to rounds and offer to assist in training them. And try listening to them as well. If midwives and physicians would actually choose to work together we would learn valuable skills from one another that would benefit everyone–mothers and babies in particular.

Comment by Marla — 9/16/2006 @ 4:03 am
An important addendum:
I should have written in Post #119:
“I attend homebirths because in my experience they are at least as safe, and probably safer, than hospital births for mothers and babies.” A primary key to successful homebirth practice is commitment by the midwife and the client to ongoing risk-screening, evaluation and preventative care.

Well, that’s it for me: I’m off to get whatever sleep I can. Thanks to anyone who read this far.

Comment by Marla — 9/16/2006 @ 4:15 am
All right, once again, please allow me to clarify:

My original post #119 (and the addendum #121) should have read:

“I attend homebirths because in my experience they are at least as safe, and probably safer, than hospital births for low-risk women and babies.”

Perhaps since I was previously bracketing the phrase “low-risk” for emphasis it was eliminated for some reason when I sent the post. Or maybe I’m just more tired than I realized!

Anyway, please excuse the multiple posts on the subject, but I think any reader will agree that this is an important distinction!

Many thanks!

Comment by Marla — 9/16/2006 @ 4:29 am
Marla, thanks for commenting! I have to say your obvious expertise and compassion is impressive, and I am especially impressed that you were able to quickly recognize the problem with your daughter’s pregnancy. Frankly, I don’t think I would be able to do that by auscultation. Were it medicolegally possible, I think I would even enjoy working with someone like you.

Based only on my experience, I believe you must be a very rare sort of person. Do you agree? I mean among direct-entry midwives. The ones I have encountered definitely do not know what they are doing. I do not think anyone’s life should be in their hands and so I would have no interest in trying to help train them.

Comment by E — 9/16/2006 @ 9:04 am
Marla,

Well said and well thought out. However, for the same reasons stated above with Naismith, I cannot come to the same conclusions as you about the safety of home births. The studies quoted are a start, but they are subject to selection bias, insufficient power and unmatched controls. Your personal experience is excellent. Mine has not been so positive, which adds to my reasoning.

The experince with you grandson sucks out loud and the L & D staff at that hospital sounds like a bunch of doorknobs. You were fortunate to have caught the concerning heart tones when you did. I, also, am impressed withyour ausculatory prowess. One question, though. Are you associating the morphine dose with fetal demise? I don’t think they were related other than remotely temporally. I agree that had the L & D staff acted more promptly, there may have been a better outcome, but it is difficult to create a definite timeline under the conditions you described. I also don’t think it has anything to do with home vs. hospital deliveries. Had your daughter not had you to call on, she would have probably gone to the ER or called the OB, gone in for monitoring, had the fetal distress discovered and had the stat c-section. The only question is the timelyness of action, about which we can only guess.

Back to Julie’s comments on immunizations, it is actually the overwhelming success of the mentioned vaccines that has promted the changes you have noted. The oral polio vaccine is actually the more effective of the two options (oral vs. injectable), and it had wiped out polio in the US to the extent that the only reported cases were excrutiatingly rare mild forms as a result of the live attenuated virus in the oral vaccine. The options were wieghed, and it was felt that in the US, where the disease was nearly gone, the lesser effective vaccine would suffice. Of course now that there is rising community of shotless kids, polio is starting to rear its ugly head again.

As I said before, immunizations are the most widely use medications in children. It ammounts to hundreds of millions of doses given. When that happens, it powers your statistics to a point that you are able to tease out even the most remote possible adverse events. In the case of pertussis, the shot was rarely associated with seizures (typically febrile in nature) but not any lasting neurologic damage (as some have tried to claim). Thus the acellular form of the vaccine was created.

Adverse vents are taken very seriously, and as more data is amassed, there will be more changes. Understand that recommended schedules are created to have the most bang for the buck. They address the lowest common denominator. As you can imagine, you can’t have multiple recommendations depending on the availability of parenting resources (schedule A for intact families, schedule B for low-income single parents, schedule C for illegal immigrants and schedule D for consanguinous Arkansonians).

Comment by Chris S. — 9/16/2006 @ 12:33 pm
I agree that had the L & D staff acted more promptly, there may have been a better outcome, but it is difficult to create a definite timeline under the conditions you described. I also don’t think it has anything to do with home vs. hospital deliveries.

I think it has a LOT to do with home vs. hospital deliveries, in demonstrating the lack of integration of homebirths into the US healthcare system. The recommendations of a trained professional were ignored. And prompt transportation and hospital treatment when appropriate is a key ingredient for the safety of home births.

In European countries where midwifery is accepted and home births are the norm, the midwife would probably have admitting privileges, the hospital staff would be used to dealing with professionals like her, and thus respectful of her diagnosis and recommendations.

If she was ignored bringing in her daughter, why would she be treated any differently bringing in a patient?

Or are you saying that is common for hospitals to delay like that, and they might have ignored the call even if she had been an MD?

Comment by Naismith — 9/16/2006 @ 1:18 pm
“They address the lowest common denominator. ”

This may be the most honest statement about vac. that I have heard from a doctor.

And I am sure you can understand that, as a parent who tries to stay as far away as possible from the LCD, why that attitude toward vac. is a little scary to my ears.

Here’s my tale of woe:

The stack of consent forms propped on my huge belly includes one for Hep B. I scrawl REFUSED across it. Later, on the baby’s first Dr. visit, we make a point of telling the Dr. that we want the Hep B vax, just not right away. The Dr. replies that his office doesn’t recommend newborn Hep B anyway. I ask why they gave me the consent form when they knew the baby was his patient. He says it is just easier for them that way. They figure that if you care, you’ll refuse.

What I’m trying to point to here is the “don’t question the system–we know what’s best” attutude is somewhat unpersuasive when it comes to the actual practice of vax administration in this country and that anyone who expects parents to feel 100% confident in a system that changes so frequently, has so many internal inconsistencies, regularly violates the principal of informed consent, acts on matters of convenience, and acts for the best of the “lowest common denominator” is expecting something that no good parent is capable of providing.

Comment by Julie M. Smith — 9/16/2006 @ 1:47 pm
“Consanguinous Arkansonians.” One of the funniest things I have read in a long time!!!

Forgive me, but 38 months seems like an awfully short time to be certified to attend births away from medical facilities and supervisory personnel. Granted, some dental professionals gain their education in a similar amount of time (after completeion of core requirements which usually consist of at least an additional 3 years of schooling), but the difference in possible outcomes is significant.

Comment by Craig — 9/16/2006 @ 2:08 pm
Julie, you missed my point. Just because the schedule fits the lowest common denominator doesn’t mean it is less safe. The Hepatitis B vaccine is given soon after birth not because an infant is going to go out and have sex or use IV drugs and get hepatits B. It is given at birth because it is the time when compliance is highest, and to not get the vaccine before the high risk years is to risk hepatocellular carcinoma. Like in the Church, you teach the correct principle, not the exception. Many people can drink alcohol without problems, but you can’t say, “the Word of Wisdom applies only to those with alocoholic tendencies.” Will your child be harmed by not getting the Hep B shot on schedule? Probably not. But not every parent is as reliable as you, and their kids may be lost to follow-up.

Comment by Chris S. — 9/16/2006 @ 6:02 pm
No, Chris, as I’ve stated from my very first comment on the vac. issue, I get the safety issue. And, I might note, that in general I think vaccines are the best thing since sliced bread. My only opposition here is to the repeated assurances that the system is practically infallible. The repeated assurances that it is do nothing so much as create a glaring contrast to the lived experiences most parents have with the system.

Comment by Julie M. Smith — 9/16/2006 @ 6:24 pm
Thank you, collectively, for your replies to my posts. This is certainly a thought-provoking site. A few responses to issues you have raised in return:
I am not equating the morphine dose with my grandson’s poor outcome. I think the two are likely unrelated, my only hesitation being the beautiful EFM strip we had before and immediately after administration of the MS when my daughter was sent home to rest. But if the MS were enough to “tip the scale,” so to speak, I think there must have been some other unknown, complicating, concurrent factor serious enough to cause the asphyxia which, when combined with the MS, might have created Jack’s CP. There is a part of me that seeks to accept that this was the “script” for Jack’s life and it played out as planned, as Jack agreed before he was born. But it’s still tough.

I do experience frustrations around the questions Naismith raised. It is particularly frustrating not to be taken seriously when the very technology the hospital staff relies on is supportive of my clinical observations.

In order to get a better picture of baby’s FHTs, one can listen with a doppler and count FHTs in 5 sec. consecutive increments, mentally multiplying by 12 every 5 secs through a contraction (and beyond to catch late decelerations). You need to have the values memorized and it helps to have a partner present to write down the values consecutively as you quietly call them out. While this doesn’t equate to beat-to-beat variability, with some experience it does allow a practitioner to get a good sense of the baby’s FHTs.

Re: the length of the midwifery education program: it is based on the length of direct-entry programs in the U.S. and Europe, which are typically three-plus years. For example, CNM programs in the U.S. that accept non-nurses take about three years to complete. The first several months are spent obtaining the RN and the remainder of the program focuses on midwifery. When our family moved from SLC to San Diego, my former midwifery partner in SLC applied to and was accepted to the Yale University program, which took her academically from her previous BA in English to her RN to her MSN/CNM. Clinical requirements for our midwifery program extend beyond the 38 months as needed to achieve completion of competencies. Incidentally, we do seek to provide some high-volume in-hospital OB experience for our students but it has to occur out of the country.

Thanks, E, for your kind remarks about me as a midwife. Honestly, the only thing unusual about me is my persistence in believing that we can create a viable educational system for direct-entry midwives in this country and that licensed midwives can be accepted members of the health care system. Midwives should be trained, and trained well. I know a good many very well-educated, experienced, competent direct-entry midwives. I also know some who shouldn’t be practicing given their present knowledge base and skill level. Commitment to education must be ongoing for any type of obstetrical provider. And it’s important for both “sides” to let go of attachment to being “right” and choose to meet on common ground. Families who desire to give birth at home get to have competent midwives–and access to hospital-based services when they are needed. Other developed nations accept this and integrate it into their health care systems. It’s time we do too.

Thanks for the compassionate listening.

Comment by Marla — 9/16/2006 @ 9:26 pm
Hi John Mansfield, this is Rosalynde Welch; I just used the handle to get your attention on the comment aggregator. I saw your interesting questions way back in #86 about analytical training in medical education, and the value of the joint MD/PhD degrees. My husband is a mud-phud, and we’ve talked about this quite a bit. I think we’d both agree with you that on the whole physicians lack the analytical chops of scientists, though it varies by specialty; surgeons, in particular, are highly-trained and extremely skilled technicians, whereas the medicine sub-specialties tend to attract the more science-minded. Our ward in San Diego was dominated by PhD candidates in the sciences, while our ward in St. Louis is dominated by medical students and residents; there is a marked difference in the intellectual climates of the two wards, and we both think it’s the result of differences between medicine and science.

As for the merit of the MD/PhD, I think it depends entirely on the program. Some programs, including I guess the one with which your wife is familiar, short the PhD by a year or two in order to condense the otherwise arduously long training path. My husband chose UCSD, however, precisely because it didn’t do so: he spent five years in lab just like any other PhD, and met the same expectations for publishing and attending meetings and everything else; there was, quite rigorously, no difference in his training. His MD/PhD took nine years, and now we’re two years into a six year research-track residency—whew! Let’s hope he finds the cure for cancer after all this.

Comment by MD/PhD's wife — 9/17/2006 @ 11:21 pm
It is not my intention to resurrect a horse in order to beat it, but I overheard a conversation at church this last Sunday that gave me reason to pause and reflect. Two couples were talking in the hallway outside the library, confidently congratulating each other on their choices to not immunize their children and fervently demonizing the obstetric practices of hospital deliveries and vitamin K shots. In light of this post, you can see why I took notice. You can also imagine that it was with utmost self control that I did not intervene and berate the offenders for what I deem to be irresponsible behaviors. But what really got my attention was the phrase, “that’s why we have the Spirit.” I took it to mean that they felt safe in their choices because the Spirit whispered to them that what they were doing was good and right.

In my limited understanding of the workings of the Spirit, I have always believed a few important principles: 1) Heavenly Father is very smart and has our best interests at heart, 2) He would never encourage us to do anything wrong, 3) He expects us to do our part before asking for guidance. I understand that historically speaking 100 years ago, when the infant mortality rate approached 20% and medical care was, well, a step down from pig farming, that “doing our part” meant a lot of praying and laying the hands on. Currently in the US, infant mortality is about 4-8 per 1000 live births, thanks in no small part to good prenatal care and vaccines. So I am left wondering at the source of inspiration for these good saints, especially considering the overall endorsement by the Church of immunizations. Would the Spirit whisper different things to different people? Do a few people get a pass and avoid the pitfalls of childhood mortality and the rest of us have to rely on the arm of the flesh to save us? Why are missionaries required to get immunized? As I recall, a lot of children of good pioneers died of diphtheria. Are we just better than them now?

Comment by Chris S. — 11/21/2006 @ 5:46 pm
Right-on.

Comment by J. Stapley — 11/21/2006 @ 5:50 pm
Well their kids won’t be able to go on their missions without being immunized… So sucks to be them.

Since we are pulling old ghosts, I remember having to give immunization shots to Missionaries from foreign countries who had gotten it done pre-mission. I remember one giant very angry looking Samoan who had really tough skin and I practically had to stab…

Comment by Matt W. — 11/21/2006 @ 6:05 pm
Hi

I understand pain and that what you witnessed should never have happened……..but it happens regardless of medical or alternative practice, it happens because all people make mistakes.

I know this because my child’s experience relates to medical error.

If you truly believe in God (regardless of which God) believe in miracles, believe in the goodness of all people and the reality that sometimes things happen, just because they do.

If you want to make a difference, practice medicine well, use studies, but also listen to anecdotal stories of parents because they truly know their child. Look at all the missing parts in medicine and be proactive in patching them eg the learning differences that “miracle” babies suffer.

There are many unsolved medical mysteries, be a leader, let everyone watch your dust, make a real difference. Change happens because doctors stand out on a limb, not because they listen to every “solution” that they’ve been taught.

Good luck and I look forward to seeing where you head next!

Comment by mum — 3/13/2007 @ 8:34 pm
My baby was oxygen deprived because it was a hospital birth. No one directed me on what to do and I was hyperventilating before she came out. The epidural made it so I couldn’t feel what was going on and it slowed down my labor. I got no one on one help and the doctor only came in during the last few minutes. I feel that if I would have had a home birth she would have been much better off. She had to stay in the nicu ten days because of this incident. So I feel that sometimes a hospital is better but in a normal healthy pregnancy it is not always the best thing.

Comment by Gwenh — 6/1/2007 @ 10:06 pm
I’ve just found this little gem. And I must say that without a hospital and many doctors, I would not have my youngest son.
Some of my relations do the home birth thing. I would never.
My baby’s heart rate plummeted in utero during a contraction (I was only there for a non stress test). It was terrifying. I was rushing into surgery, my OB was on-call at the hospital. He used a general, got the baby out in an emergency C section in under one minute. My baby boy had to be revived and put on a ventilator for a few days in the NICU. He survived and he has thrived. He is a big, strong strappling three year old with an adorable obstinate nature.
I would not have him today if I had not been at the hospital.

Comment by rynell — 6/5/2007 @ 8:27 pm
Gwenh, I’m sorry your child had such a rough start. It seems the greatest error was not communicating with you through the process. You describe a choatic situation during which you were left in the dark, to fend for yourself, per se. No one should have to go through that. Though I doubt the outcome would have been better had the delivery happened at home, I’m sure your experience would have been better had the L&D staff been more attentive and empathetic to your needs.

Rynell, you point out the exact reason for my concerns with home deliveries. Rapid response is critical when dealing with fetal distress, and minutes can make all the difference. Your success is my greatest joy. I love to hear back from patients who made it through the rough start and are kicking and screaming and annoying thier parents now.

Comment by Chris S. — 6/7/2007 @ 4:23 pm
I chose not to have my child vaccinated at all until now. ( he is now five years old and healthy) I told my doctor that I would only allow one vaccine at a time( that is one disease at a time) not the cocktail that the drug companies make and doctors deliver to increase compliance as someone earlier stated. When I was a young mom in utah attending BYU I was shocked by the argumentative attitudes of other moms in my ward who thought I was doling out a death sentence to my child for wanting to wa

Comment by Seven — 6/18/2007 @ 4:27 pm
I chose not to have my child vaccinated at all until now. ( he is now five years old and healthy) I told my doctor that I would only allow one vaccine at a time( that is one disease at a time) not the cocktail that the drug companies make and doctors deliver to increase compliance as someone earlier stated. When I was a young mom in utah attending BYU I was shocked by the argumentative attitudes of other moms in my ward who thought I was doling out a death sentence to my child for wanting to wait to immunize my child. My concern was not that vaccines were “bad” but that the idea of shooting my child full of three of four sicknesses at a time was not only unnatural but didn’t seem necessary as most of the things we vaccinate for have been eradicated. AS a world traveller I had every intention of vaccinating my child, just on my time line, not the doctors’. As far as the midwife debate goes, I will always have a special place in my heart for the profession. The length is not an issue to me. A chiropractor only spends four years in school total- and they provide a service to those who are willing to pay for it who deem it necessary. Actually,I think that the entire medical profession needs a major over-haul as it is so steeped in tradition, many of which are contrary to the bodies natural healing powers.I was unfortunate enough to have a child who was born looking healthy, but deep down I knew something wasn’t right. Even at 19 I had that sense that is spoken of. I took my baby to doctor after doctor in Utah, but I was basically told to calm down and that he was just collicky. After waking up in the morning three seperate times with blue lips and feet I was told that my baby “just got cold in the night.” After moving out of state my son was now 18 mos old, he started drinking water all the time. The doctor who had been practicing for 14 years told me that “he was just growing.” 18 hours later I rushed my son to the ER for what I knew was something, but just now sure what. The minute the doctor saw him he was shuch to a children’s hospital for DKA. Diabeticketoacidosis. His organs were shutting, and we almost lost him that night. So the way I feel about it is that just becuase you went to meidcal school, it doesn’t make a good doctor out of you, which in my opinion is what almost ALL doctors think of themselves; it is like they are all really afraid of losing status quo. My son’s condition is as easy to catch as a pricked finger every once in a while. I was told that my son’s pancreas was shutting down for at least three months prior to that time. But I knew it was much earlier than that, as poor circulation(blue lips and feet) is a tell tale sign of diabetes. Something I didn’t know at the time, but call me crazy, I thought that is what doctors go to school for so long for- to LEARN the telltale signs of a disease. Those were my young days; now I don’t really listen to what most doctors say, I just do what they do and look things up on the internet. So as far as gambling with our children, I think that most women with a desire to be good mothers are the last ones to do gamble with their children. In my opinion it is the Doctors who have the lease long term interest in our children who “gamble” with treatments, or in my case, the lack thereof. I do think hospitals are great, but it is not whether home birth or hospital as much as the person attending. I have met more sub-par doctors than midwives, but that is only my experience. For other it is surely opposite in many situations. In reality it is not the training that sets people apart, but it is their desire to become good at what they do, self-educate themselves, and listen to people, that sets good (fill in the blank, doctors, lawyers, accountants, teachers, etc.) that sets people apart. And as one doctor once told me, since doctors go to school they know more than the averge person in medical areas, the idea of elvating people based on how long they went to school is not only shallow, but doesn’t mean as it my experience that they actually learn things. I can see one or two docs not catching my son’s condtions, but six is a gross error and I belive represents the profession as a whole. One ER visit with my son was especially revealing. The doctor tending to him, though I know trained differently than an endocrinologist didn’t know what his insulin pump was. And he was young, not some old geezer. All in all I have no problem with the fact that Doctors and midwives make mistakes, but I do have a problem with the fact that all the ones I’ve known(I’ve known many on account of my son’s condition) ACT like they know everything and then get annoyed of patients who might actually know a medical term or two. (I’ve had this happen) The bottom line: I know my child more that any doctor, and doctors need to respect that bond, not shove it aside for some pragmatic “I am an educated DOCTOR” reasoning. I now have an awesome Certified Nurse Practitioner who knows more than any medical person I’ve met so far, who has said to me, “you know, I don’t know that answer to that, let me get back to you, and you do some of your own research too” my respect for her increased tenfold, not the opposite. And instead of retreating to some corner of the building to look something up online, she gave it to me straight. Unfortunatly, getting straight answers from our past doctors as to their abilities, and functions in our child’s life was, a non-possibility. I guess it was too much to ask. But I guess when so many go into the profession because of the salary, it might be to much to expect that they be good at what they do. okay my rant is coming to an end. Being raised in a very liberal and educated home and city, I had a major culture shock when coming to utah as a freshmen at byu and seeing that there were “alternative” medicine facilities. Having travelled a great deal now I see that that attitude is more pervasive in some places than others. But the idea of looking at something from a new perspective was not only not fostered even at the university wards, but shunned by people steeped in traditions that were not wrong from my own, just different. And the reactions from other moms was that my traditions were not okay. There is a general lack of self-education on many matters, i.e. circumcising. Even though most of the world does not practice this and even in the us it is more 40-60% now, I heard time and time again the same old scare tactics used to promote it as with immunizations. I remember at one mom group when the topic came up and one mom said just think of it this way. “my midwife says that if the just requires it for missions, than why shouldn’t we do it for our children” I sat in awe as everyone shook their heads in agreement. First of all missionaries are full grown adults, and of course the church is going to insist on it as the world is full of sickness one may not be exposed to in the US. Which isn’t really the point. It is as much a liability and preventative measure as it is a tradition. The point is I noticed a lot of people doing things without questioning in utah, and I guess it makes my wonder if that is why some people live the life a a faithful church member and then one day just turn their backs on it. I wonder if it is because they never took the time to really question and search for answers from their God, not others, that makes so many become disillusioned with the faith of their fathers. Afterall, it was from Joseph Smith’s questioning that the Lord asnwered his prayers concerning the priestood, the temple ceremony, to name a couple. I question everything pertaing to my child becuase what is best for yors is not always the best for mine. By the way we didn’t circumcise our son (even though his father is) and he has never had an infection, or a problem with “differences”.

Comment by Seven — 6/18/2007 @ 4:36 pm
I don’t know how this topic sank to the depths of complaining and pride, but it seems that is where it has gone. I suppose we are all capable of making mistakes. Years of schooling and training don’t make a professional any more immune to them than anyone else. It does, however, tend to make those errors exponentially more costly and more visible to the public (and malpractice lawyers). I sorrow at stories of doctors with God complexes who haven’t learned the most fundamental lessons of medicine: listen and understand. But this is not about medical arrogance. This is about risk. And Seven, in your arrogance, you rolled the dice with your child’s welfare at stake. Had you done as you suggested, and searched the internet for evidence and information, you would have learned that waiting until age five to get immunized and “the idea of shooting my child full of three of four sicknesses at a time was not only unnatural but didn’t seem necessary as most of the things we vaccinate for have been eradicated,” is not only false but dangerous. By waiting until five you subjected your child in his most vulnerable years to pathogens that are still very active in the community. Haemophilus and Pneumococcus are a moderate irritant to the older child and adult. To the infant, they cause meningitis, deafness and brain damage. Pertussis will give you a nasty cough. It will kill the newly discharged preemie. Clostridium tetani (tetanus) is a common soil bacterium that doesn’t need humans to grow and is not now nor ever has been eradicated. There is also no evidence to suggest that receiving concurrent vaccinations is not safe (quite the contrary). Getting them one at a time just increases the number of visits to the doctor that end in a poke. If you want natural, infant mortality (death before age 1) in the 19th century was well above 20%, mostly due to infectious diseases we now prevent with vaccines.

Comment by Chris S. — 6/18/2007 @ 9:04 pm
I returned to this discussion to see if by some chance any new comments had been added regarding homebirth. I see that the debate of “home vs. hospital” moves on.

Back in the early 1980s the Church was considering issuing a statement against homebirth, with the goal of encouraging all Church members to birth in the hospital. (I know this because I spoke extensively with the Orem brother charged with researching the topic prior to submission of a statement for consideration by the Brethren.) About this same time an article was published in the January 1981 Ensign entitled, “Staying Healthy: Welfare Services Suggests How.” In this article a 1980 medical study was cited that purportedly provided statistical evidence demonstrating that homebirth was unsafe. When I learned of this situation I became quite concerned. First, I knew the study, which had been published in the Journal of the American Medical Association (Dec. 19, 1980). I realized that the data from the study had been misinterpreted. Second, for logistical, financial and other reasons it was and still is quite unrealistic to encourage Saints from all parts of the world to seek hospitalization for childbirth. So I contacted one of the physicians who had co-authored the study, Dr. C. Arden Miller, M.D., at that time Professor and Chairman of the Department of Maternal and Child Health in the School of Public Health at the University of North Carolina at Chapel Hill. He, too, was quite surprised about the interpretation of the study, which examined the results of “lay” midwives and physicians attending homebirths in North Carolina from 1974-1976.

The following is an extensive excerpt from his letter to Jay M. Todd, at that time the Managing Editor of the Ensign. I retain a copy of that letter in my files for anyone who might wish to read it in its entirety. He wrote:

“Your note places an interpretation on our findings which I think is not appropriate. Our study showed that home deliveries which were carefully screened for low risk, were attended by trained people, and had supervison and consultation readily available were associated with less neonatal mortality than hospital deliveries. The data show that home deliveries which might be hazardous are those which are unintentional, unplanned and unattended by trained personnel. . . .

“An appropriate interpretation of our study would be that childbearing among healthy, well cared for people is a happy and reasonably safe experience, but it is not free of risks. Some risks are associated with well planned home deliveries; different risks are associated with deliveries in hospitals. Women might best be well informed about both kinds of risks and be allowed to elect which kind they desire to assume.”

Dr. Miller’s letter was published in the April 1981 issue of the Ensign. A similarly supportive letter was also published from Joyce Cameron Foster, CNM, who initiated the nurse-midwifery program at the University of Utah and then twice served as its Director.

We can debate the topic of homebirth vs. hospital birth endlessly, bringing emotional “evidence” to the table on both sides. This debate has the potential to wear on in spite of decades of published medical studies from a variety of developed nations, including the U.S., which demonstrate the safety of homebirth with trained attendants (including both direct-entry and nurse-midwives) serving low-risk women. Mothers and babies would be far better served by our obstetrical system if we would instead begin with some simple measures:
First, accept the fact that we cannot divorce risk from childbirth in _any_ setting.
Second, find innovative and workable ways to improve and encourage women’s access to maternity care, particularly prenatal care. Make midwives an integral part of that process, as other developed nations have for centuries.
Third, work together professionally and respectfully to create the safest possible circumstances for women who are giving birth, even if their choices reflect their value systems and not yours. I refer the reader back to Dr. Miller’s conclusion, that “women might best be well informed about both kinds of risks and be allowed to elect which kind they desire to assume.”

Ever hopefully,
Marla Hicks, RN-BC, CPM, LM
Board Certified Perinatal Nursing
Licensed Midwife (CA)

Comment by Marla — 8/30/2007 @ 1:20 am
Marla,

Again, I must say, well said. I apprechiate your direct and evidence-based approach to the topic. Though I must disagree with your interpretation of the data, and I can in no way with good conscience endorse your decision to attend home deliveries, I can respect your thought process. You are quite right that this being an emotional issue, it could be argued endlessly with trained professionals on both sides. You’ll forgive me if I leave out my credentials and extra post title letters.

You do, however bring up another topic that may be worth another blog. Historically, what has the Church’s policy been on endorsing personal health- or other- related decisions (like home deliveries, or maybe driving hybrid vehicles). Any ideas, Jonathan? Has the Ensign regularly been used as a vehicle for such recommendations? Should it? I see a new cottage industy in the making: Bumperstickers reading “What would the Prophet drive?” or “Where would the Brethren deliver?”

Comment by Chris S. — 8/31/2007 @ 2:28 pm

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