The Delivery Debate

Amidst the trend to rate everything from toothpaste to colleges, Americans might wonder why we didn't think of rating the birth experience of the millions of women who give birth in hospitals around the nation, and visit a diverse assortment of obstetricians, etc.

Certainly, most postpartum mothers are all too willing to share horror stories along with those deemed spectacular in the department of easy births.

This might be a sign of the times today where easy access and communications can help to remind the medical community that there is more to success than profitable hospital rates. New infants and mothers are rarely concerned with price, but terribly concerned with comfort and safety.

Since birthing is such a common experience for women, women are uniquely situated to identify where and with whom they are most likely to get the best hospital, midwife center experience. It's surprising that Newsweek hasn't already taken up the charge for rating our childbirth centers. It could be enlightening for all families.

Amidst the trend to rate everything from toothpaste to colleges, Americans might wonder why we didn't think of rating the birth experience of the millions of women who give birth in hospitals around the nation, and visit a diverse assortment of obstetricians, etc.

Certainly, most postpartum mothers are all too willing to share horror stories along with those deemed spectacular in the department of easy births.

This might be a sign of the times today where easy access and communications can help to remind the medical community that there is more to success than profitable hospital rates. New infants and mothers are rarely concerned with price, but terribly concerned with comfort and safety.

Since birthing is such a common experience for women, women are uniquely situated to identify where and with whom they are most likely to get the best hospital, midwife center experience. It's surprising that Newsweek hasn't already taken up the charge for rating our childbirth centers. It could be enlightening for all families.

All I needed to hear when close to my second child's due date was "her shoulders are measuring large" and there is a risk of breaking them during a vaginal birth. Since my first child was 9 and 1/2 pounds, and I did not suffer from gestentional diabetes and he was on time, my fear of a larger more complicated birth arose. If a c-section promises more safety, I don't understand the comments surrounding the unnecessary surgeries. I was sure to read everything possible about childbirth when making my decision. Instead of choosing one of the leading women's hospitals in the U.S. - I chose a smaller more intimate hospital, where each baby and patient seemed special. I was not the least bit impressed by the treatment of my friends at the large hospital, they were not happy, and I often wondered why they returned. Women need to be in charge of their own bodies and birthing processes. We cannot rely on others to provide us with "all" the information. There will always be the socio-economic disadvantages of others, who are not provided the best healthcare options - but this is an overall problem to the disadvantaged when it comes to woman, child, and overall healthcare. Let's also not forget - the fear of many physicians - being sued when birth complications occur and the high price of malpractice insurance - when they see a potential childbirth problem - perhaps it's more fear than greed when recommending a c-section. I had a horrible time recooperating from the section - but I was happy my daughter was happy and healthy.

You do not mention family practice physicians as an option. In smaller communities, and in some bigger hospitals, a family practitioner can be your OB provider. They deliver thousands of babies and can also provide continuity of care for you and your baby by continuing to be you and your family's physician for many years down the road.
As for vbac's, I am a L&D nurse who is very disturbed by all the unnecessary intervention we insist upon in OB. I am not totally against repeat C-sections, but it provides plenty of risk itself. C-sections under normal circumstances are far riskier for the mother (damage to other organs, more blood loss, risks of anesthesia, etc), not to mention if she wants to have more children later on. Each c section adds more scar tissue which can lead to multiple complications. There are risks to the baby as well. They are far more likely to have breathing problems and require oxygen therapy after delivery. The mother and child miss out on precious bonding and nursing time because the mother is in surgery and then recovery during the initial 2 hrs of the baby's life. The recovery time is so much longer, and the mother will need narcotics for pain control after delivery which can affect breast feeding and bonding as well. There are so many reasons for vbac, not just for the "experience" of vaginal birth. It can be a healthier choice.
Of course, a ruptured uterus can be catastrophic, there is no doubt. But 99% if the time, a vbac is perfectly safe. You should not be induced, and should be monitored closely during labor and delivery if you choose this. And the reason for the prior c-section needs to be taken into account. One reason for the huge c-section rate increase is due to the fact that insurance companies no longer require a trial of labor after c-section, and some may frown on vbac. MD's are afraid of lawsuits so many prefer not to do vbacs.
But women need to be aware of the pros and cons of both sides so that they can make and informed choice on what to do with their bodies and their babies. They should not be forced into a decision either way.

I personally agree with not taking any unnecessary risks when it is not only your own life but that of the baby. I have never been able to understand women insisting on a Vback after a cesarian. Why take such an unnecessary risk? Because you feel you may have missed something? I was pleased that my OB told me the second time around that he would not allow a Vback as it is an unnecessary risk to myself and my unborn child.

Why do we put our children in carseats? Is it because we believe ourselves to be dangerous drivers... or because we believe that if we go out on the road we will be in an accident? No, it is because we want our children to be safe in the EVENT of an emergency. Motherhood is the most unselfish act a human can accomplish... I personally believe it is a selfish thing to put your child at risk to have the experience that YOU desire (such as spurning life-saving medical care that saves lives on a daily basis). Chances are, you and the baby will be safe... but chances are, if you go to the grocery store you will not be involved in a fatal accident- so, again, why do we put our children in carseats?

In September I delivered a happy, healthy 9 lb boy in the front room of my home, nine years after the hospital birth of my first son. It was intensely intimate and ultimately low-stress. My second pregnancy mirrored my first - no complications or even blips, and both of my babies arrived exactly on their due date. Why then the need for the intensive intervention taken with my first? Despite objections, my waters were manually broken, pitocin was administered in IV upon admittance after I'd only been in labor 30 minutes. I was monitored the whole time and not allowed to leave my bed. After having my son in a hospital at the tender age of 20 and having no one listen to any of my concerns, this was the only place I would choose to have my baby. I am lucky to have uncomplicated pregnancies/births. I realize that anything can go wrong, and made an emergency plan. My midwife was certified as a nurse and had attended over 1500 births. My doula was a registered EMT. What could a doctor have done that these women could not? My entire pregnancy - all the tests, check ups and birth cost $5,000, not a penny of which was covered by health insurance. Some how a $20,000, possibly unnecessary cesarean is better, more educated, more justified? This is foolish. Human beings are not sardines. Every birth is different, just as every child and parent. Each should be evaluated on an individual basis. My freedom to birth as I choose is very important to me. This freedom should never be withheld from any woman.

Clearly, Bacteria don't respect women's choices,, are trying to undermine midwives, and monopolizing birth.

1: Health Policy Plan. 2000 Dec;15(4):394-9. Links
Training traditional birth attendants in clean delivery does not prevent postpartum infection.Goodburn EA, Chowdhury M, Gazi R, Marshall T, Graham W.
Centre for Sexual and Reproductive Health, John Snow Inc., London, UK.

OBJECTIVE: To compare the maternal outcome, in terms of postpartum infection, of deliveries conducted by trained traditional birth attendants (TBAs) with those conducted by untrained birth attendants. METHODS: The study took place in a rural area of Bangladesh where a local NGO (BRAC) had previously undertaken TBA training. Demographic surveillance in the study site allowed the systematic identification of pregnant women. Pregnant women were recruited continuously over a period of 18 months. Data on the delivery circumstances were collected shortly after delivery while data on postpartum morbidity were collected prospectively at 2 and 6 weeks. All women with complete records who had delivered at home with a non-formal birth attendant (800) were included in the analysis. The intervention investigated was TBA training in hygienic delivery comprising the 'three cleans' (hand-washing with soap, clean cord care, clean surface). The key outcome measure was maternal postpartum genital tract infection diagnosed by a symptom complex of any two out of three symptoms: foul discharge, fever, lower abdominal pain. RESULTS: Trained TBAs were significantly more likely to practice hygienic delivery than untrained TBAs (45.0 vs. 19.3%, p < 0.0001). However, no significant difference in levels of postpartum infection was found when deliveries by trained TBAs and untrained TBAs were compared. The practice of hygienic delivery itself also had no significant effect on postpartum infection. Logistic regression models confirmed that TBA training and hygienic delivery had no independent effect on postpartum outcome. Other factors, such as pre-existing infection, long labour and insertion of hands into the vagina were found to be highly significant. CONCLUSIONS: Trained TBAs are more likely to practice hygienic delivery than those that are untrained. However, hygienic delivery practices do not prevent postpartum infection in this community. Training TBAs to wash their hands is not an effective strategy to prevent maternal postpartum infection. More rigorous evaluation is needed, not only of TBA training programmes as a whole, but also of the effectiveness of the individual components of the training.

PMID: 11124242 [PubMed - indexed for MEDLINE]

Take a look ahead at the step backwards you all are advocating. If it becomes widespread, this is what we will start to see. I am astounded by the indifference, if not outright callousness of this midwife lobbying group. Some women and babies have serious problems. But since you didn't you don't care.

This is like a bunch of people driving down the freeway past a terrible car wreck. Since the vast majority doesn't need a doctor in their cars, they don't care that one guy bleeding out on the roadside desperately does.

1: Bull World Health Organ. 2007 Oct;85(10):783-90. Links
Are skilled birth attendants really skilled? A measurement method, some disturbing results and a potential way forward.Harvey SA, Blandón YC, McCaw-Binns A, Sandino I, Urbina L, Rodríguez C, Gómez I, Ayabaca P, Djibrina S; Nicaraguan Maternal and Neonatal Health Quality Improvement Group.
Quality Assurance Project, University Research Co LLC, Bethesda, MD 20814, USA. sharvey@urc-chs.com

OBJECTIVE: Delivery by a skilled birth attendant (SBA) serves as an indicator of progress towards reducing maternal mortality worldwide -- the fifth Millennium Development Goal. Though WHO tracks the proportion of women delivered by SBAs, ***we know little about their competence to manage common life-threatening obstetric complications.*** We assessed SBA competence in five high maternal mortality settings as a basis for initiating quality improvement. METHODS: The WHO Integrated Management of Pregnancy and Childbirth (IMPAC) guidelines served as our competency standard. Evaluation included a written knowledge test, partograph (used to record all observations of a woman in labour) case studies and assessment of procedures demonstrated on anatomical models at five skills stations. We tested a purposive sample of 166 SBAs in Benin, Ecuador, Jamaica and Rwanda (Phase I). These initial results were used to refine the instruments, which were then used to evaluate 1358 SBAs throughout Nicaragua (Phase II). FINDINGS: On average, Phase I participants were correct for 56% of the knowledge questions and 48% of the skills steps. Phase II participants were correct for 62% of the knowledge questions. Their average skills scores by area were: active management of the third stage of labour -- 46%; manual removal of placenta -- 52%; bimanual uterine compression -- 46%; immediate newborn care -- 71%; and neonatal resuscitation -- 55%. CONCLUSION: ***There is a wide gap between current evidence-based standards and provider competence to manage selected obstetric and neonatal complications.**** We discuss the significance of that gap, suggest approaches to close it and describe briefly current efforts to do so in Ecuador, Nicaragua and Niger.

Take a look ahead at the step backwards you all are advocating. If it becomes widespread, this is what we will start to see. I am astounded by the indifference, if not outright callousness of this midwife lobbying group. Some women and babies have serious problems. But since you didn't you don't care.

This is like a bunch of people driving down the freeway past a terrible car wreck. Since the vast majority doesn't need a doctor in their cars, they don't care that one guy bleeding out on the roadside desperately does.

1: Bull World Health Organ. 2007 Oct;85(10):783-90. Links
Are skilled birth attendants really skilled? A measurement method, some disturbing results and a potential way forward.Harvey SA, Blandón YC, McCaw-Binns A, Sandino I, Urbina L, Rodríguez C, Gómez I, Ayabaca P, Djibrina S; Nicaraguan Maternal and Neonatal Health Quality Improvement Group.
Quality Assurance Project, University Research Co LLC, Bethesda, MD 20814, USA. sharvey@urc-chs.com

OBJECTIVE: Delivery by a skilled birth attendant (SBA) serves as an indicator of progress towards reducing maternal mortality worldwide -- the fifth Millennium Development Goal. Though WHO tracks the proportion of women delivered by SBAs, ***we know little about their competence to manage common life-threatening obstetric complications.*** We assessed SBA competence in five high maternal mortality settings as a basis for initiating quality improvement. METHODS: The WHO Integrated Management of Pregnancy and Childbirth (IMPAC) guidelines served as our competency standard. Evaluation included a written knowledge test, partograph (used to record all observations of a woman in labour) case studies and assessment of procedures demonstrated on anatomical models at five skills stations. We tested a purposive sample of 166 SBAs in Benin, Ecuador, Jamaica and Rwanda (Phase I). These initial results were used to refine the instruments, which were then used to evaluate 1358 SBAs throughout Nicaragua (Phase II). FINDINGS: On average, Phase I participants were correct for 56% of the knowledge questions and 48% of the skills steps. Phase II participants were correct for 62% of the knowledge questions. Their average skills scores by area were: active management of the third stage of labour -- 46%; manual removal of placenta -- 52%; bimanual uterine compression -- 46%; immediate newborn care -- 71%; and neonatal resuscitation -- 55%. CONCLUSION: ***There is a wide gap between current evidence-based standards and provider competence to manage selected obstetric and neonatal complications.**** We discuss the significance of that gap, suggest approaches to close it and describe briefly current efforts to do so in Ecuador, Nicaragua and Niger.

The point for me is that we are supposed to live in a "free country" so why can my wife and I not be "free" to choose where and how we want to birth our children. Abortion activist talk about "It's a choice" so why can we not have a choice as to who attends us in childbirth. These are children we actually want, love, and desire. We live in Missouri and pray that our Legislature listens to us when we tell them this is what we want. Dr. Amy NEEDS to attend a home birth just to get a glimpse of what childbirth should really be like. We have chosen homebirh for the last 17 years not as a "trend" but as a way to protect the mother and child from all the unwanted indignities forced upon an unsuspecting participant who signs "consent for care" when one enters their doors.

I made the decision to have homebirths with both of my children with a Certified Professional Midwife because of the large amount of studies I easily found on reliable web sites and in unbiased books. There is also an overwhelming amount of information from European countries that support homebirth with a midwife whose training is equivalent to CPMs. My first birth would have definitely been an unnecessary C-section if I had been in a hopsital and my second baby would have spent weeks in the NICU if I had chosen hospital birth.