The Delivery Debate

The problem is that women have NO good options. Most births are full-term and normal. These are seen as little more than easy money for both doctors and midwives. These women could have unassisted home birth and do just as well. Should you actually need medical help, all groups fail miserably.

Midwives (lay or nurse) often don't recognize problems and/or overestimate their ability to handle them. Then, there is the delay in getting to a hospital. But hospitals, nurses, and doctors also have similar problems.

OBs claim that all pregnant women should labor in a hospital because of unforeseeable, sudden emergencies. Yet, in most community hospitals the Obs take call from home, so there???s a huge delay in an emergency there too! OBs manage most of the labor by pre-written protocols and by phone. That coupled with malpractice concerns leads to the massive amounts of unneeded and unwanted interventions that drive low-risk women out of hospital birth.

Women deserve better than what we're getting in the hospital: higher rates of maternal mortality, high rates of c-sections, higher rates of preterm and near term babies due to inductions out of convenience (not medical necessity), increase in problems w/ future fertility and pregnancy/birth complications after c-section.

Making sure we have choices in terms of care and birth environment - CPM (at home or in birth center), CNM (in birth center or in hospital), OB (in hospital) - is vital to making sure we can choose the best individualized care for ourselves and our babies. Clearly "Dr." Amy isn't into supporting a woman & her baby in getting the best, safest care -- she's into forcing ALL women into the obstetric machine, warts and all, regardless of its safety or efficacy.

Dr. Amy Tuteur, do you have nothing better to do with your time than to go around browbeating people with how you hate anything other than OB-attended, hospital-based birth? You don't even practice anymore. You're not even licensed. Why are you so bent on trying eliminate viable birth options for women and their babies? Are you really not able to see where current OB care falls short in so many ways, and I'm not talking about "a mom's experience" - I'm talking about the very real health and safety of the mom AND baby during the pregnancy, labor, birth, AND postpartum periods. You might not have a problem with the typical induce, augment, cut 'n gut, postpartum stress and feeding issues -- but a lot of us do. Women deserve better than what we're getting in the hospital - lower rates of maternal mortality, lower rates of neonatal mortality, lower rates of induction and sectioning. Period.

Comment: Reposted for better readability:

Or maybe, not so much! i apologize for the translation problems that have added question marks where parentheses and commas were supposed to go.

Katie Prown:

"The Wisconsin data cited here doesn't distinguish between Certified Professional Midwives and 'Other' Midwives, a category that also includes unassisted births, unplanned out-of-hospital births and births assisted by midwives who are not CPMs, Amish grandmothers and anyone who might want to claim to be a midwife."

That is simply false, and I can't imagine why you keep repeating something that is factually false. The Wisconsin data divides attendants into doctors, CNMs, other midwives, and other non-midwives. The "other midwife" category does NOTincluded unassisted births and it does NOTinclude unplanned out of hospital births. Anyone who would like to check for themselves can do so at the WISH Query Infant Mortality Module(http://dhfs.wisconsin.gov/wish/measures/inf_mort/long_form.html), which is an interactive data query system.

"However, because all Wisconsin CPMs participated in the BMJ 2000 study ..."

The BMJ 2000 study (Johnson and Daviss, published in the BMJ 2005) is a nationwide study that CLAIMED to show that homebirth is as safe as hospital birth. However, it never compared the neonatal death rate for homebirth in 2000 with the neonatal death rate for low risk women in the hospital in 2000. When you do compare the two, you find that homebirth has an increased rate of neonatal death almost TRIPLE the hospital neonatal death rate, just like the Wisonsin statistics.

"One benefit to CPM licensure is that it helps us to collect more accurate data on out-of-hospital births to distinguish between planned home births attended by trained professional midwives and all other out-of-hospital births in the state."

That's not true, either. MANA is already collecting statistics on all CPMs and has been since 2000. The 2000 MANA data was the basis for the BMJ study. The data from 2001-2007, which is probably the largest existing database on homebirth, is being withheld from the public.

"Another benefit of CPM licensure is that it requires anyone who works as a home birth midwife to undergo the education and training necessary to gain the skills required to provide safe and competent out-of-hospital maternity care"

CPM education and training is grossly deficient in all respects. It is important that women understand:

We already have midwives (certified nurse midwives). This is about creating a SECOND class of midwives with less education and training.

The standards for direct entry midwives, in terms of educational requirements and clinical training, are far below those of ANY other midwives in the industrialized world.

Direct entry midwifery credentials were created by direct entry midwives without input from medical or public health sources. These credentials are the ???seal of approval??? of some DEMs in regard to other DEMs. There is no independent objective basis for these credentials.

As I said before, and as you continue to demonstrate, homebirth advocacy is about mis

Thanks for such a wonderful article, I just want to address a couple point about the new law in Wisconsin and the statistics that are available. The law is working well and I am quite sure if the Bureau of Vital Statistics or the Department of Regulation and Licensing were contacted they would agree.
The Wisconsin data cited here doesn???t distinguish between Certified Professional Midwives and ???Other




Midwives,??? a category that also includes unassisted births, unplanned out-of-hospital births and births assisted by midwives who are not CPM???s, Amish grandmothers and anyone who might want to claim to be a midwife.

However, because all Wisconsin CPMs participated in the BMJ 2000 study (as a condition of recertification), we can compare their statistics during that year to those of ???Other Midwives.??? In the year 2000, Wisconsin CPMs had a neonatal mortality rate of 0 per thousand births, while ???Other Midwives??? had a neonatal mortality rate of 11.83 per thousand births.

One benefit to CPM licensure is that it helps us to collect more accurate data on out-of-hospital births to distinguish between planned home births attended by trained professional midwives and all other out-of-hospital births in the state.

Another benefit of CPM licensure is that it requires anyone who works as a home birth midwife to undergo the education and training necessary to gain the skills required to provide safe and competent out-of-hospital maternity care. In the aftermath of the passage of our 2006 CPM licensure law, most of the untrained women calling themselves midwives stopped practicing. And the handful of non-CPM midwives who were delivering babies have begun the educational and training process necessary to qualify as a CPM.

In light of this, the Wisconsin Guild of Midwives has been working with the Bureau of Vital Statistics to amend our birth certificates to revise the categories for birth attendants to include ???Wisconsin Licensed Midwives??? and ???Other,??? a change that will be complete by May 08, one year after the law took effect. Thanks to our new law and to the subsequent birth certificate revisions, the category of ???Other??? will soon be restricted to unassisted and/or unplanned out-of-hospital births.

So future data in Wisconsin will more accurately reflect the differences in planned out-of-hospital births with trained professional midwives and out-of-hospital births with no trained birth attendants. Another issue on the agenda, which the Guild advocates, is to ensure that LMs sign birth certificates for every patient delivered, including those whose births take place after a transfer to the hospital, which will help address the issue of planned home birth transport outcomes being attributed to physicians or CNMs.

Brilliant! How inspiring to finally see a piece that gives a robust view of women's options for birth attendants. Most articles written on birth are so dishearteningly one-sided, but thankfully this one is not! Women are simply NOT one-size-fits-all, and their care shouldn't be either!

As a mother who has had both a hospital birth with an OB **and** an out-of-hospital birth at home with a CPM, each labor and birth being spontaneous and unmedicated, I strongly believe that EVERY mother should do her own research (looking at the evidence-based outcomes!) and do her own interviewing of many different care providers *and* mothers who have birthed in different environments to come to her OWN decision about where is the safest, healthiest best place to give birth for HER AND HER BABY.

Every woman will have different needs and thus, a different birth attendant and environment. If we shut out CPMs and make it even harder to give birth out-of-hospital or at home, all we're doing is creating a MORE dangerous birth climate for ourselves and our babies. Why would we do that?

The truth is that current OB care is not cutting it for the vast majority of women, from the prenatal through the postpartum periods. Informed consent ONLY happens if a women truly does her OWN homework - most OBs cannot really deliver evidence based care (whether pressured by the hospital, their malpractice insurance, ACOG, their practice members, etc.).

The prenatal care I received from my OB group (and I actually liked my OB group!) was so minimal and piddly compared to the in-depth, lengthy appointments that my family had with our CPM, which included monitoring of the baby, checking in w/ the family (emotional wellbeing), and even nutritional counseling (something barely touched on in my OB appointments). Additionaly, during labor and birth, my CPM provided continuous, excellent care, whereas my OB and nurse (and again, I really *like* the OB and L&D nurse who were at my birth!) were simply not able to provide the continuous labor support that a laboring mom needs for the best possible outcomes - there was too much pressure to be hooked up to machines, too many patients to look after, etc. Luckily, I had hired a doula who was fantastic and provided the kind of support ALL women should be entitled to during labor and birth in a hospital. With my CPM and her apprentice in my home, I had continuous labor support througout (as well as regular fetal monitoring, thank you!).

So... Kantrowitz and Wingert, *thank you* for such a wonderful article with thorough, balanced coverage. If only more articles could follow in your footsteps! :)

I am a home birthing mom and my baby and I had a beautiful safe birth with CPM's who are very well trained and experienced. Unfortunately I had to drive out of state in labor to have my baby with unnecessary interventions. In Alabama, mothers do not have a choice. CPM's are not allowed to deliver babies in our state and MANY moms are driving across borders to have safe births for their babies. We do not want to be cut open unnecessarily, we do not want our babies taken from us after birth, we do not want nurses constantly pressuring us to get an epidural, but we do want our babies to have the safest and best entrance into this world, but we do not get to make that choice.

I am a home birthing mom and my baby and I had a beautiful safe birth with CPM's who are very well trained and experienced. Unfortunately I had to drive out of state in labor to have my baby with unnecessary interventions. In Alabama, mothers do not have a choice. CPM's are not allowed to deliver babies in our state and MANY moms are driving across borders to have safe births for their babies. We do not want to be cut open unnecessarily, we do not want our babies taken from us after birth, we do not want nurses constantly pressuring us to get an epidural, but we do want our babies to have the safest and best entrance into this world, but we do not get to make that choice.

I am a home birthing mom and my baby and I had a beautiful safe birth with CPM's who are very well trained and experienced. Unfortunately I had to drive out of state in labor to have my baby with unnecessary interventions. In Alabama, mothers do not have a choice. CPM's are not allowed to deliver babies in our state and MANY moms are driving across borders to have safe births for their babies. We do not want to be cut open unnecessarily, we do not want our babies taken from us after birth, we do not want nurses constantly pressuring us to get an epidural, but we do want our babies to have the safest and best entrance into this world, but we do not get to make that choice.

Katie Prown:

You are not being honest about the data. Anyone can check and see for themselves. The Wisconsin Department of Health and Family Services provides data on linked birth infant deaths on its website. Let's address your new claims one by one:

"The Wisconsin statistics that Dr. Amy cites are irrelevant. One, they were compiled before Certified Professional Midwives in the state attained legal status (which happened in May, 2007)"

Really? If they are irrelevant, why did YOU mention them: "In the last five years Utah, Wisconsin, Virginia and Minnesota have licensed certified professional midwives ??? These states are seeing good results. If they were seeing bad results, states would be outlawing CPMs." So you thought the statistics were relevant until you learned that they show that homebirth with a direct entry midwife consistently has a neonatal death rate TRIPLE that of hospital birth with a CNM.

"they make no distinctions among babies who were delivered by CPMs, family members, taxi drivers or anyone else who may or may not have been adequately trained for the task at hand."

You haven't even looked at the statistics, have you? If you had, you would know that there is a separate category for deliveries attended by non-midwives.

You are a member of the Wisconsin Guild of Midwives, but you don't even know the safety statistics on homebirth in your own state. You claim that those statistics are irrelevant, yet you clearly have not even looked at them. You claim that homebirth is safe, but you have no data to support your claim, and you never intended to offer any data to support your claim.

You have also neglected to address an equally important issue. The Midwives Alliance of North America has been collecting statistics on CPM from 2001-2007, but they are withholding that information from the public. They have offered it to midwifery organizations who can show that they will use it for the "advancement of midwifery". Yet even midwives must sign a legal non-disclosure agreement promising not to reveal any data to anyone else. It does not take a rocket scientist to suspect that MANA's own data shows that homebirth with a CPM is not safe.

The Wisconsin statistics show that homebirth with a direct entry midwives TRIPLES the rate of neonatal death. MANA is currently withholding the safety statistics it has gathered over the past 7 years. You have literally no data on which to base your claim that homebirth is safe, and now you are backpedaling on YOUR claim that we should look at Wisconsin if we want to know if homebirth is safe. This is the fundamental problem with homebirth advocacy. It is based on mistruths, half truths and outright deceptions. The women of the US deserve better.

Thank you for a balanced look at our birthing choices. I have had 3 very different births... my first an emergency cesarean at 34 weeks, my second a typical medicallized hospital VBAC with an epidural and a 3rd hospital VBAC unmedicated using Hypnobabies... very empowering. Now that I know I can be comfortable without medication using Hypnobabies (I did have a pain-free birth with my 3rd, using Hypnobabies), with our next baby I will have a homebirth with a midwife. I am at that point where I trust my body and birth.
It is important that moms birth where they feel safe, so for some moms that is a hospital and for some moms that is home. But we should have the choice!
Sheridan enjoybirth.wordpress.com

I think it is imperative to note that providers of maternity care have differing fundamental approaches to pregnancy and birth. Midwives, whether they be certified nurse-midwives or certified professional midwives, believe pregnancy and birth are normal and look to guide a woman through her childbearing process. Midwives study the normalcy of these processes and are trained to spot any developing complications. For decades, certified nurse-midwives have been shown to be as safe as their obstetric counterparts. A midwife's approach to health and appreciate of the normal processes of pregnancy and birth sets her apart from her obstetrician colleagues. Visit www.midwife.org to learn more about midwives or find a midwife near you!

What an informative article! I live in South Dakota, and Certified Professional Midwives are currently prosecuted in our state for assisting in out-of-hospital births. Surprise, surprise, we have one of the highest infant mortality rates in the nation. This will hopefully change, as the grassroots pressure increases to have our legislators pass legislation allowing a wider range of options outside the hospital.

Thank you SO MUCH for speaking up for those of us who do not believe birth is a catastrophy waiting to happen! Obviously, obstetrical care is a wonderful gift to those who need it. Anyone who is ill (pre-eclampsia, diabetes, etc.) will be referred to a physician anyway, so its not as if midwives are the primary care givers in higher risk births. Cesareans can be life saving but they are not free of risk. More women die following a c-section than following a vaginal birth. To do surgery when there is not a clear medical benefit is bad practice. Home birth midwives have no worse statistics and almost always have better outcomes in the same population (healthy normal pregnancies) than OBs. Look to the 21 or so countries who have better peri-natal outcomes than the US - the difference? Midwives!

Thank you for bringing up this important topic.
As a growing number of childbearing couples are beginning to realize that how we give birth impacts a mother and baby for life, more and more of them are researching their options thoroughly before selecting a care provider and deciding where to have their baby. As a young woman in my twenties who is looking for ward to haveing kids someday, having safe options is very important to me. The more I look at the research, the more convinced I am that if I am healthy when I get pregnant, the best place for me to give birth will be at hom ewith a professional midwife.

Thank you for delving into this most-important subject.
Birth matters, because it affects both the mother and baby for the rest of their lives.
We, as a culture need to take it more seriously, and look at the science. Who (midwives or doctors) is achieving the best outcomes - mortality AND morbidity? And then we need to encourage women to act on science, not just traditions.