You'd be amazed how little some medical techniques used in birth were studies before they were introduced and how poorly they performed once they were actually exposed to scientific scrutiny. Epistotomy was introduced routinely into many maternity hospitals with no scientific study of it's value. Once it was exposed to scientific scrutiny it was found that it's actually harmful in all but a small proportion of emergency situations. The majority of the time if a woman as allowed to tear naturally the tear will heal more quickly and better than a epistotomy would. Even after this has been shown, women are still being cut by their obstetricians for no good reason.
I'm not interested in low intervention birth because I'm some hippy who trusts homeopathy and snake oil rather than science. I'm interested in low intervention birth because scientific studies have shown that the methods being used by a lot of obstetricians are not the methods most likely to lead to good outcomes for mother and child. Here is a statement by the Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists (complete with references to peer reviewed scientific papers) which reviews the evidence and comes to the conclusion that home birth is as safe as hospital birth for women experiencing uncomplicated pregnancies. Interestingly enough the American College of Obstetricians and Gynaecologists are still opposed to home birth, despite there really not being any scientific evidence that home birth is more risky for low risk pregnancies. Even more interestingly they do not bother to site any scientific studies to support their opposition in their statement instead relying upon what appear to be quite crude scare tactics.
As for why they built maternity wards. Some women require medical treatment whilst birthing their baby. Sometimes this treatment is most easily administered in a hospital setting (although quite a lot can be done in a domestic setting, for example, stitching tears, some pain relief). Why the vast majority of US births happen in maternity wards, well that's actually more to do with giving obs something to do and steady source of income to them and the hospitals they work in. They've being pulling the 'there's no scientific evidence for it but home birth is Bad' act for the last 100 years.
ACOG is unscientific. That's why I wouldn't trust their members to be in charge of my maternity care.
I dunno. It seems to me that if OBGYNs were capable of performing home maternity care, then they could make a lot more money for themselves doing that, while still ending up charging women less (because of a lack of hospital fees). Why aren't they doing this? It'd keep them busy and keep them with a source of income.
Even more interestingly they do not bother to site any scientific studies to support their opposition in their statement instead relying upon what appear to be quite crude scare tactics.
If, "You should do it in a hospital to have easy access to emergency care in case you need it" is a scare tactic then so be it. But it seems to me a pretty salient reason to have it done in a hospital. I do not agree with hospitals forcing procedures down a patients' throat simply because it garners more money (I'm assuming an epistotomy is a Caesarian, I can't find a definition anywhere offhand), but as far as I know that's sort of illegal in the United States if the doctor cannot properly assess the risk of alternate procedures for a patient or give a good reason; aren't they required to at least recommend a doctor/hospital willing to perform that procedure?
Finally, perhaps unfortunately in the United States, it is the onus of the patient to be well-informed. I'm all for medical journals being more accessible so patients can be informed, but this is a general strategy for healthcare reform and less specifically on topic. I frequently use a number of websites to determine problems to, and home remedies of, many small maladies and as long as I have contact with a consistent GP, there's nothing wrong with this. Ultimately it is the woman's choice to do a home birthing or not and that's all well and good.
I just believe that, whether or not this is the case now, it's just not possible to put home births under as much scrutiny as a hospital, not with the distributions of hospitals now.
"You should do it in a hospital to have easy access to emergency care if you need it" is a scare tactic because it does not acknowledge that: a) the appropriate care for a lot of emergency medical situations which can arise during birth can be performed by a medically trained birth attendant in a domestic setting. In England (where I live) a midwife attending a home birth brings with her equipment and is trained to deal with situations such as a infant needing resuscitation, haemorrhaging in the mother and shoulder dystocia. b) a normal uncomplicated pregnancy is unlikely to end in a birth which requires emergency care. c) problems during birth which require hospital based care can usually be detected early enough during labour that there is plenty of time to get to a hospital if you live within a reasonable distance of one. In fact, in England at least, hospitals usually require half an hour to prep the surgical theatre for a C-section, so if you live within half an hour of the hospital and call ahead, attempting to give birth at home does not increase the time it will take for you to get to having a C-section if the need arises. d) there is some scientific evidence to indicate that the procedures used in a lot of US maternity wards actually increase the probability that a woman will require emergency medical care during her labour. On top of that there are risks associated with hospital delivery even if the doctors were observing best practice, for instance the mother and baby are more likely to contract serious infections such a MRSA in a hospital setting.
To put it bluntly, it's scare tactics because it fails to acknowledge that the risk from home birth arising from the possibility of having to transfer to hospital are balanced out by the risks of hospital delivery, which is why the general conclusion from scientific studies is that the two choices pose roughly the same level of risk to a woman who has had a healthy pregnancy.
I'm sorry, I misspelt the procedure. It's called a episiotomy and it involves cutting a woman's perineum during vaginal labour.
I think patients should be well informed, but I also think that medical professionals should be well informed and should not advocate procedures which scientific evidence suggests will be harmful to your patient. I also think that the professional associations of medical professionals shouldn't have unscientific policies.
My objection to your original comment was that you implied that the only reason to favour low intervention birth was superstition. As the links I provided indicate, there is actually scientific evidence to support the choice of natural birth and home birth for women who are low risk, and many aspects of medicalised birth are based upon unscientific superstition.
My objection to your original comment was that you implied that the only reason to favour low intervention birth was superstition.
I'm sorry if I implied that. In my experience, that's just the most common reason. I have talked to people before about hospital care pushing dangerous surgeries because they are expensive and wanting a home birth for that reason, and that's valid.
Let me, for a second, bring in some quotes from your article:
"2.5 A proportion of women who plan a home birth are transferred to hospital ,9,13,14,19 most commonly for slow progress or needing pain relief not available at home, such as epidural anaesthesia. The most serious reasons for transfer are maternal haemorrhage, concerns about fetal wellbeing and the neonate born in an unexpectedly poor condition. Delay in transfer under these circumstances may have serious consequences. Owing to poor collection of maternity data, the comparative statistics for women being transferred in labour are unclear."
"2.2 Randomised controlled trials to assess the safety of home births are not currently feasible."
Emphasis mine.
This is sort of what I'm talking about. 99% of the time, if the doctor OKs you as a low-complication pregnancy, and you have a home birth, you're going to be fine. It also might even save you some money. However, 1% (made up statistic, but it is >0%) you can put yourself and your baby at serious risk with medical delays. Low-complication pregnancies that could be completed at home can be completed in a hospital, including that 1%, or whatever it is. The benefit is marginal, especially if, and this is sort of my main point here:
Hospitals DO need to be fixed. Dangerous procedures enacted out of greed need to not happen, lawsuits need to be filed, and women need to be better informed. But there's nothing de facto wrong with a medical facility in terms of delivery, and there are in fact some benefits, such as reliable record-keeping, testing, and statistics if these things can be fixed. While you're waiting, and IF you have a low-complication pregnancy, sure, get home births. Like I've said, nothing wrong with that. But there's nothing inherently better with birthing at home. That's all I'm trying to say.
"9.1 The RCM and RCOG support the provision of home birth services for women at low risk of complications. If the service is provided by midwives committed to this type of practice within continuity of care schemes and appropriately supported, outcomes are likely to be optimal. Services need evidence-based guidelines, where possible. Good communications, adequate training and emergency transfer policies are vital."
Nothing in this statement is wrong. All of these things benefit all procedures; good communication, good policies, good education for midwives (so that they are capable of handling all problems with a pregnancy to the extent that any other OBGYN or emergency care physician is). But I think that if there is a problem with hospitals, then hospitals need to be fixed, not ignored.
looking at the RCOG's statement, they actually say that randomized controlled trials aren't possible, and therefore no firm conclusion on home birth safety can be reached. They point out that there's no data available on homebirth outcomes where the women are rushed to the hospital for complications. (reading between the lines of their statement, it looks like the only numbers they have are pure homebirth vs. hospital, and the "hospital" numbers include the situations where women rushed to the hospital after homebirth complications).
They stress that home birth is better not from a safety standpoint, but because some women prefer homebirth emotionally.
Similarly, I don't really see why the ACOG's conclusion is unscientific. It doesn't contradict anything the RCOG said, it just stresses that home birth places the birth process over maternal and fetal safety. I think that's pretty uncontestible, frankly. If a woman hemorrhages - not uncommon, my mother did - she can bleed out in a matter of minutes. A placenta previa could go undetected; placental abruption could occur; labor could be blocked (mine was); the baby could go into distress; etc., etc. birth is fraught with potential peril.
The RCOG's statement frankly said that it was placing maternal fulfillment via homebirth above potential safety considerations (given that the chance of death is fairly small). The ACOG frankly said that it placed safety considerations first, even though the chance of death may be small.
I personally don't care what a woman chooses. If she wants to take the (small, but certainly existant) chance of bleeding to death at home, that's her body and her right, in my book. But I don't think informing her of that risk is somehow evil quackery.
I'm not interested in low intervention birth because I'm some hippy who trusts homeopathy and snake oil rather than science. I'm interested in low intervention birth because scientific studies have shown that the methods being used by a lot of obstetricians are not the methods most likely to lead to good outcomes for mother and child. Here is a statement by the Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists (complete with references to peer reviewed scientific papers) which reviews the evidence and comes to the conclusion that home birth is as safe as hospital birth for women experiencing uncomplicated pregnancies. Interestingly enough the American College of Obstetricians and Gynaecologists are still opposed to home birth, despite there really not being any scientific evidence that home birth is more risky for low risk pregnancies. Even more interestingly they do not bother to site any scientific studies to support their opposition in their statement instead relying upon what appear to be quite crude scare tactics.
As for why they built maternity wards. Some women require medical treatment whilst birthing their baby. Sometimes this treatment is most easily administered in a hospital setting (although quite a lot can be done in a domestic setting, for example, stitching tears, some pain relief). Why the vast majority of US births happen in maternity wards, well that's actually more to do with giving obs something to do and steady source of income to them and the hospitals they work in. They've being pulling the 'there's no scientific evidence for it but home birth is Bad' act for the last 100 years.
ACOG is unscientific. That's why I wouldn't trust their members to be in charge of my maternity care.
Reply
Even more interestingly they do not bother to site any scientific studies to support their opposition in their statement instead relying upon what appear to be quite crude scare tactics.
If, "You should do it in a hospital to have easy access to emergency care in case you need it" is a scare tactic then so be it. But it seems to me a pretty salient reason to have it done in a hospital. I do not agree with hospitals forcing procedures down a patients' throat simply because it garners more money (I'm assuming an epistotomy is a Caesarian, I can't find a definition anywhere offhand), but as far as I know that's sort of illegal in the United States if the doctor cannot properly assess the risk of alternate procedures for a patient or give a good reason; aren't they required to at least recommend a doctor/hospital willing to perform that procedure?
Finally, perhaps unfortunately in the United States, it is the onus of the patient to be well-informed. I'm all for medical journals being more accessible so patients can be informed, but this is a general strategy for healthcare reform and less specifically on topic. I frequently use a number of websites to determine problems to, and home remedies of, many small maladies and as long as I have contact with a consistent GP, there's nothing wrong with this. Ultimately it is the woman's choice to do a home birthing or not and that's all well and good.
I just believe that, whether or not this is the case now, it's just not possible to put home births under as much scrutiny as a hospital, not with the distributions of hospitals now.
Reply
a) the appropriate care for a lot of emergency medical situations which can arise during birth can be performed by a medically trained birth attendant in a domestic setting. In England (where I live) a midwife attending a home birth brings with her equipment and is trained to deal with situations such as a infant needing resuscitation, haemorrhaging in the mother and shoulder dystocia.
b) a normal uncomplicated pregnancy is unlikely to end in a birth which requires emergency care.
c) problems during birth which require hospital based care can usually be detected early enough during labour that there is plenty of time to get to a hospital if you live within a reasonable distance of one. In fact, in England at least, hospitals usually require half an hour to prep the surgical theatre for a C-section, so if you live within half an hour of the hospital and call ahead, attempting to give birth at home does not increase the time it will take for you to get to having a C-section if the need arises.
d) there is some scientific evidence to indicate that the procedures used in a lot of US maternity wards actually increase the probability that a woman will require emergency medical care during her labour. On top of that there are risks associated with hospital delivery even if the doctors were observing best practice, for instance the mother and baby are more likely to contract serious infections such a MRSA in a hospital setting.
To put it bluntly, it's scare tactics because it fails to acknowledge that the risk from home birth arising from the possibility of having to transfer to hospital are balanced out by the risks of hospital delivery, which is why the general conclusion from scientific studies is that the two choices pose roughly the same level of risk to a woman who has had a healthy pregnancy.
I'm sorry, I misspelt the procedure. It's called a episiotomy and it involves cutting a woman's perineum during vaginal labour.
I think patients should be well informed, but I also think that medical professionals should be well informed and should not advocate procedures which scientific evidence suggests will be harmful to your patient. I also think that the professional associations of medical professionals shouldn't have unscientific policies.
My objection to your original comment was that you implied that the only reason to favour low intervention birth was superstition. As the links I provided indicate, there is actually scientific evidence to support the choice of natural birth and home birth for women who are low risk, and many aspects of medicalised birth are based upon unscientific superstition.
Reply
I'm sorry if I implied that. In my experience, that's just the most common reason. I have talked to people before about hospital care pushing dangerous surgeries because they are expensive and wanting a home birth for that reason, and that's valid.
Let me, for a second, bring in some quotes from your article:
"2.5 A proportion of women who plan a home birth are transferred to hospital ,9,13,14,19 most commonly for slow progress or needing pain relief not available at home, such as epidural anaesthesia. The most serious reasons for transfer are maternal haemorrhage, concerns about fetal wellbeing and the neonate born in an unexpectedly poor condition. Delay in transfer under these circumstances may have serious consequences. Owing to poor collection of maternity data, the comparative statistics for women being transferred in labour are unclear."
"2.2 Randomised controlled trials to assess the safety of home births are not currently feasible."
Emphasis mine.
This is sort of what I'm talking about. 99% of the time, if the doctor OKs you as a low-complication pregnancy, and you have a home birth, you're going to be fine. It also might even save you some money. However, 1% (made up statistic, but it is >0%) you can put yourself and your baby at serious risk with medical delays. Low-complication pregnancies that could be completed at home can be completed in a hospital, including that 1%, or whatever it is. The benefit is marginal, especially if, and this is sort of my main point here:
Hospitals DO need to be fixed. Dangerous procedures enacted out of greed need to not happen, lawsuits need to be filed, and women need to be better informed. But there's nothing de facto wrong with a medical facility in terms of delivery, and there are in fact some benefits, such as reliable record-keeping, testing, and statistics if these things can be fixed. While you're waiting, and IF you have a low-complication pregnancy, sure, get home births. Like I've said, nothing wrong with that. But there's nothing inherently better with birthing at home. That's all I'm trying to say.
"9.1 The RCM and RCOG support the provision of home birth services for women at low risk of complications. If the service is provided by midwives committed to this type of practice within continuity of care schemes and appropriately supported, outcomes are likely to be optimal. Services need evidence-based guidelines, where possible. Good communications, adequate training and emergency transfer policies are vital."
Nothing in this statement is wrong. All of these things benefit all procedures; good communication, good policies, good education for midwives (so that they are capable of handling all problems with a pregnancy to the extent that any other OBGYN or emergency care physician is). But I think that if there is a problem with hospitals, then hospitals need to be fixed, not ignored.
Reply
They stress that home birth is better not from a safety standpoint, but because some women prefer homebirth emotionally.
Similarly, I don't really see why the ACOG's conclusion is unscientific. It doesn't contradict anything the RCOG said, it just stresses that home birth places the birth process over maternal and fetal safety. I think that's pretty uncontestible, frankly. If a woman hemorrhages - not uncommon, my mother did - she can bleed out in a matter of minutes. A placenta previa could go undetected; placental abruption could occur; labor could be blocked (mine was); the baby could go into distress; etc., etc. birth is fraught with potential peril.
The RCOG's statement frankly said that it was placing maternal fulfillment via homebirth above potential safety considerations (given that the chance of death is fairly small). The ACOG frankly said that it placed safety considerations first, even though the chance of death may be small.
I personally don't care what a woman chooses. If she wants to take the (small, but certainly existant) chance of bleeding to death at home, that's her body and her right, in my book. But I don't think informing her of that risk is somehow evil quackery.
Reply
Leave a comment