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Wednesday
Feb272008

Long Note to Students/Apprentices & Homebirth Advocates

In the comments section, you will see that the person in question is NOT an apprentice or student, but a lay person. The assumption was definitely mine as she made it sound as if she knew what she was talking about, spoke about how many midwives attended births, said things that only a midwife or apprentice would typically know. But, my assumption was wrong! Sorry for the incorrect finger-pointing.

So, I'll need to change the post around to say what I still want to say, but from a different slant.

Thanks, non-student, midwifery advocate for clarifying.

I will say, however, that anyone "defending" homebirth sure as crap should know what they are saying before putting their foot in the entire homebirth community. It really does make us look bad.

---------------

If you are going to argue on other websites or with midwifery/medical folks, please get your facts straight so you don't look foolish or make the whole of the homebirth community appear ignorant!!

A homebirth advocate (HBA) made a comment in another blog that leaves me shaking my head in utter confusion and not a little bit of concern. She cavalierly say that midwives at home can do everything short of hysterectomy for a woman who is hemorrhaging.

deep breath

Let's begin, shall we?

A discussion of a hemorrhage in the hospital was being had. The woman bled immediately postpartum and it was obviously frighting and extremely serious. It took 4 people and many steps to stop the bleeding. The steps were not outlined at this early point in the conversation.

A HBA poked her head in and said:

This makes me curious. OB nurse, can you specify what it was that stopped the hemmorhage? What steps were taken? In my state there (to my knowledge) isn't anything a home birth midwife couldn't do to stop a hemmorhage that a hospital does, short of a hysterectomy. Could you elaborate?

To say the midwife can't do anything less than a hospital does BUT a hysterectomy speaks volumes about what a midwife cannot do. Hemorrhaging women sometimes need hysterectomies! FAST!

For crying in a bucket, women wanting to birth at home should know every detail of what happens in whatever setting so they can give TRUE informed consent!

The discussion unfolds like this; my questions/comments are in black:

The OB Nurse asks and the HBA replies:

1) Do they have 4 trained people there?

There are 4 or more people present at births my midwifery practice attends. While it's standard, I doubt it's a requirement. I bet 2 is closer to the requirement.

HBA, if you are going to support homebirth and consider yourself active in midwifery legislation, it really would behoove you to know what the law mandates as well as what the standard of care is. There is no "betting" in midwifery. You either know or you keep your mouth shut or you say you don't know and go find out the answer.

2) Can they give all these Meds? Pitocin, cytotec, methergine, hemabate.

Of Course.

I would really like to know where you live that the midwives all carry cytotec and hemabate.

This is the "Adverse Warning" from the Hemabate Website. Would YOU want to use this medication outside of a hospital? I've asked before, but haven't gotten an answer - do any homebirth midwives carry hemabate? What are the standards of care of usage if you do have to use it? How symptomatic is the mom? How much blood does she need to have lost? Do you try cytotec first?

BEGIN WARNING:

The adverse effects of Hemabate Sterile Solution are generally transient and reversible when therapy ends. The most frequent adverse reactions observed are related to its contractile effect on smooth muscle.

In patients studied, approximately two-thirds experienced vomiting and diarrhea, approximately one-third had nausea, one-eighth had a temperature increase greater than 2° F, and one-fourteenth experienced flushing.

The pretreatment or concurrent administration of antiemetic and antidiarrheal drugs decreases considerably the very high incidence of gastrointestinal effects common with all prostaglandins used for abortion. Their use should be considered an integral part of the management of patients undergoing abortion with Hemabate.

Of those patients experiencing a temperature elevation, approximately one-sixteenth had a clinical diagnosis of endometritis. The remaining temperature elevations returned to normal within several hours after the last injection.

Adverse effects observed during the use of Hemabate for abortion and for hemorrhage, not all of which are clearly drug related, in decreasing order of frequency include:

Vomiting
Diarrhea
Nausea
Flushing or hot flashes
Chills or shivering
Coughing
Headaches
Endometritis
Hiccough
Dysmenorrhea - like pain
Paresthesia
Backache
Muscular pain
Breast tenderness
Eye pain
Drowsiness
Dystonia
AsthmaInjection site pain
Tinnitus
Vertigo
Vaso-vagal syndrome
Dryness of mouth
Hyperventilation
Respiratory distress
Hematemesis
Taste alterations
Urinary tract infection
Septic shock
Torticollis
Lethargy
Hypertension
Tachycardia
Pulmonary edema
Endometritis from IUCD
Nervousness
Nosebleed
Sleep disorders
Dyspnea
Tightness in chest
Wheezing
Posterior cervical perforation
Weakness
Diaphoresis
Dizziness
Blurred vision
Epigastric pain
Excessive thirst
Twitching eyelids
Gagging, retching
Dry throat
Sensation of choking
Thyroid storm
Syncope
Palpitations
Rash
Upper respiratory infection
Leg cramps
Perforated uterus
Anxiety
Chest pain
Retained placental fragment
Shortness of breath
Fullness of throat
Uterine sacculation
Faintness, light- headedness
Uterine rupture

3)Are some of the folks able to start another IV line well? Be really proficient at it?
Even apprentices have passed Phlebotomy and IV training. Obviously proficiency is subjective.

It just makes me angry that you would say "obviously proficiency is subjective." OBVIOUSLY to the rest of us, profiency is NOT subjective! And I also encourage you to find out if all the apprentices have had IV training - ours certainly have not.

Being taught how to do an IV and practicing on giggling friends and fellow students is NOTHING like inserting an IV to save a woman's life. Blood vessels are nearly non-existent when a massive hemorrhage is happening. Do homebirth midwives know how to do a "Cut Down?" I know I don't and unless a midwife has done medical care in the war or worked in high risk places, she won't know how to do one either. But, there are people who know how to do them in the hospital.
4) Can they place a ballon (sic) tamponade at home?

I don't know what this is, so I have no idea if they can or can't.

No, they/we cannot. If you don't know what something is, ask or look it up! There are about 80,000 websites that explain balloon tamponade when used for postpartum hemorrhage.

Look here

and

here. This site has an amazingly detailed description of what to do for a postpartum hemorrhage in the hospital. It is untrue that homebirth midwives are able to do what can be done in the hospital. If we used addition and subtraction, I am willing to bet homebirth midwives can do a fraction of what can be done in the hospital.

Read this article for a great description of using a sterile condom as a tamponade inside the uterus. (No, we can't do this either in a homebirth setting!)

5) Do they have blood that is typed and screened for the mother who has lost most of her circulation?

No, they do not carry blood products. They would place IV and transport for this. (and after any of the above treatments, unless the blood loss was mild)

Yes we do. RhoGam/Anti-D is a blood product. BE CLEAR in what you say. If you think I am being picky, you bet I am. We are being JUDGED by what we are saying. People read things like what has been posted and roll their eyes at how uneducated homebirth midwives are. We cannot afford to make foolish, careless remarks.

In another post, OB Nurse says:

What did we do for our PPH?

Started 2 large bore IV's

Gave oxytocin, cytotec, hemabate

Fundal Massage

Foley Catheter

Took her Vital Signs, monitored blood loss, and at no time did the OB stop massaging her fundus.

Also, we *could have* given her blood, which we *almost* had to do, as well as an emergency hysterectomy almost immediately if it came down to it.

I want to say right off that I was making assumptions in suggesting that the woman would have died at home. Sorry. I don't know what would have happened, because I don't know how many skilled birth attendants are normally around. In my area, one midwife attends home births without any other assistance. I do know that it took 4 of us to get her IV's started, run around getting the meds, the foley, one to massage her fundus, one to monitor her vital signs, weigh the pads, phone the blood bank, etc.

Thanks for the reply ob nurse. I wasn’t being snarky either, just curious. All the above can be easily done at home in case of a PPH. None of this requires specialized equipment, only the hands and skill of the providers. (?!?!?! Oh, really? Do the midwives you work for carry 14 gauge IV catheters? I am also distressed at the word "easily," as if these things are a hair toss backwards in difficulty level.) The difference is time to blood products and hysterectomy, which thankfully your patient didn’t need. It bears mention that my city has a couple OB squads which respond to homebirths if called. Still doesn't get a hysterectomy any faster though.

Another important site gives yet another detailed outline of what steps need to be done in a hospital hemorrhage.

Including answering this baffling question:

May I ask why the Foley?

One of the easiest ways to try and end uterine atony is by emptying the bladder! A full bladder can interfere with a uterus' attempts at clamping down. Plus, any manipulations done to the uterus for PPH care can damage the bladder if it is distended with urine. Also, a Foley is used to measure input and output - crucial in a number of ways including getting an idea of the body's system's inner workings; if urine output doesn't equal input, then something is wrong and needs to be explored immediately.

Do the midwives in your area carry Foley's? Most midwives I know do not (myself included). We/They/I carry straight caths.

“I want to say right off that I was making assumptions in suggesting that the woman would have died at home. Sorry. I don't know what would have happened, because I don't know how many skilled birth attendants are normally around. In my area, one midwife attends home births without any other assistance.”

I think that is something that varys with location. As I mentioned above, 4 providers are the standard number to attend homebirths in my area. But I don’t think that is a rule.

Doing births for over 2 decades, I haven't ever heard of taking 4 providers to a birth unless you were bringing along students/spectators/journalists/etc. Oh, except when we had twins - we had 3 LMs, 1 CNM and a highly trained apprentice, so I can see piling on the care providers in unusual circumstances, but to have 4 trained midwives/apprentices is amazingly odd, even in a city as large as the one I am in that has over a dozen Licensed Midwives working.

“What does happen in the home if mother is bleeding to death and the baby requires resus as well? That is my question. Genuinely curious, not trying to be snarky at all...”

In my area the same steps would be taken, only with fewer people as one or more would be attending to the baby.

We do say that we bring one attendant for the mom and one for the baby where I am. Not every midwife might choose to have another set of hands, but around here, it is the standard of care.

So, knowing what I know about PPH, why would I still be a midwife in a homebirth setting? Because women do weigh the risks and benefits. They, in many cases, understand the reasons for postpartum hemorrhage (distended uterus, previous history of bleeding, long labor, large baby, etc.) including the catch-all that sometimes there IS no reason that can be discovered either earlier or later. And still, they choose a homebirth because they feel the interventions that happen in hospitals might also be precipitating factors, including using oxytocin (that tires out the uterus once the baby is born), manipulation of the uterus including an aggressive third stage management and having adrenalin coursing through her system because of the fear or anger that occurs while in the hospital.

I am a homebirth midwife who also weighs the risks to my life and that of the mothers' and babies'. When a woman begins to step towards a hemorrhage late in pregnancy or during labor, transferring to the hospital is a better idea than staying at home and waiting it out. Blessedly, I've made the right decisions (for the most part) so far. Once, I should have transported sooner, but the end result was positive after the clients were very angry and disbelieving that the woman (who'd had a large HBAC) needed to be hospitalized and given blood. It took almost a year for them to accept that she was hemorrhaging and did need to be transported. I knew I'd made the right decision. This mom went on to have a fantastic hospital VBAC a couple of years later.

My main reason for writing this post is to really speak to students, apprentices and HBAs. I want them/you to really understand what you are getting into as a homebirth care provider and someone who's speaking with authority about homebirths. If YOU don't know, how iare your clients or friends going to make informed decisions? And, with this discussion being played out on the Internet, it really is important to get the facts right and to be able to argue intelligently and sanely. Giving misinformation and boasting makes ALL homebirth advocates look like asses. And we all aren't asses.

All HBAs should become hyper-vigilant in their self-education. Don't know something you read about here? Then learn about it, for goodness' sake! Don't just ask someone else to tell you what it is - get moving and learn about it yourself.

deep breath

And so, I shall finish my post about "Midwifery Education" in the next day or so and post it. Right along these lines, blurry sometimes - the knowledge, information and skills of a homebirth midwife; I'm examining myself most intently.

Reader Comments (24)

Ahhh, very interesting. This is why I am a doula. So I don't need to know the medical stuff. :) BUT, I agree, I would want a homebirth midwife to KNOW her stuff! Thanks.

February 27, 2008 | Unregistered CommenterSheridan

Thanks for posting this. It is scary that there are many care providers out there who don't know how much they don't know.

February 27, 2008 | Unregistered CommenterAnonymous

Between this post and your lambasting that other apprentice, I'm starting to wonder why we should homebirth at all...

February 27, 2008 | Unregistered CommenterAnonymous

Thank you so much for your thoughts. My own naive perceptions of out of hospital midwives have been challenged by the things I have witnessed in midwifery school and at births. I appreciate the critique of bold students saying foolish things and worry that this mindset is purely hubris (which we all know leads to our downfalls). We are being scrutinized right now, and possibly rightly so! Let us as SMs and LMs and CPMs rise to the challenge and educate ourselves in order to arm ourselves against the barrage. Thank you for your words!

February 27, 2008 | Unregistered CommenterAmanda

Anon: Well, I think that people need to think about the issues, that's for sure. Knowing the WHOLE story allows women to choose appropriately.

I've even re-considered my own consent forms after writing some of these posts... am sure I will add some more detailed information.

I think the main reasons I am writing these "tirades" is to challenge students/apprentices to *know* more, to absorb everything about their profession, not just the froo froo stuff. Does that make sense?

February 27, 2008 | Unregistered CommenterNavelgazing Midwife

NGM, it makes perfect sense to me. I wonder if you would post your revised consent form here?

Anonymous (2) why should we homebirth at all? Should? We? No, no one *should*. Some still might though. Because some, after taking the long view are willing to take some risk to enjoy the benefits of the whole home birth midwifery 'package'. This is why informed choice is important. After reading something as jarring as this, a mother would do well to look for answers to questions like these: What do we know about PPH and maternal mortality from PPH at home births? Do I feel the risk is personally acceptable to me? Are we (midwife and myself) being conscientious in continually evaluating my individual risk factors? How prepared are my midwife and her helpers to deal with a rare but life threatening complication like this? Am I comfortable with their level of preparedness? How can I ensure that, in the event of a transfer, hospital staff have as much of the necessary information about me as possible? etc. Then she would do her homework, make her decision either way, hope/pray for the best, and feel at peace...

February 27, 2008 | Unregistered CommenterJudit

NGM,

Once again, you are a voice of reason. It is comments like the ones you addressed in your post that perpetrate the idea that HBAs and NBAs, and the midwives who help them, are uneducated idiots ready to squat in a field to give birth, completely ignorant of the risks, and flippant about emergencies that may arise.

As for the people questioning home birthing despite the risks: nearly everything we do carries a risk. We tend to weigh the pros and cons, look at the relative risk versus the safety, and then we make a decision.

Do you stop driving for fear of getting hit by a drunk driver? What about the rare (but real) risks carried with things like dental surgery? What about the risks of general anesthesia? If you really needed the operation, you would have it, right? But you'd want to know the risks involved.

That's the point here: REAL informed consent, with a REAL assessment of the risks involved. No sugar coating, no "emergencies don't happen," no "EVERY woman can give birth naturally no matter WHAT." The issue is that it seems like women are being lied to not only by OBs, but uneducated midwives as well--but in their minds, they are not lying, because, well, they don't know any better.

Mis-education is scary. You can bet your butt I'd rather have a midwife who knows the risks and knows that they are real than one who trusts "mother earth" and the alignment of the stars for my birth.

There has to be a middle ground here--of course we can trust birth and our bodies, but that can only take us so far. It is unfortunate, but it happens all the time--pregnancies and deliveries go awry--and there is no terrible reason, only nature. Because as pregnancy and birth are natural, so are complications with both. And that's what makes us grateful for modern medicine.

February 27, 2008 | Unregistered CommenterMommy Dearest

Barb, I am really disappointed in this post. I have 'known' you from other lists and places for over 5 years now, and I have always found your writing thought provoking and enjoyed reading you. But you really missed the mark on this one.

I am Mt2wbb (Mom to 2 water born babies) on the blog you reference. I want to point out to you that I am not, and never have been a midwifery apprentice. I do not attend births in any capacity. I have never had a home birth and probably never will. I am a consumer of licensed midwifery however.

I do not know what made you jump to the conclusion that I was a student midwife, as I have never inferred this on the blog you mention. If you care to tell me what might have given you that impression, I'll be happy to hear it.

You said "For crying in a bucket, home birth advocates should know every detail of what happens in whatever setting so they can give TRUE informed consent!"

I agree with you. But I'm not sure I expect the same from a lay person. Do you? Yes, I can say some stupid things. And there will always be something I don’t know. But the blog is a BLOG and nothing more, I think I might be excused from saying something stupid in the comments section of a blog.

Look, I could go on and address each point of your tirade, but I don't think it's useful since the whole thing is based on your misunderstanding. I do think you owe me an apology for jumping to an unfounded conclusion.

I suggest you re-write your post, with the understanding that I am a lay person. I can take criticism from you Barb, but not when it's unjustified. If you desire further discourse with me about the situation in the state I live in, the one just north of you, I am open to it.

February 27, 2008 | Unregistered CommenterAnonymous

I hope you'll consider leaving the post up, after correcting it to reflect that mt2wbb is not professionally involved in birth. I know there *are* midwifery students who hold the same basic beliefs she expressed, and this should be a very educational post for them.

I myself am not involved in birth in any way except as a mother and a sometime commenter, and I very much appreciated this discussion of PPH. Even those of us on the "other side" should know the things which midwives can and can't do in a home setting, so that we may be accurate in our criticisms.

February 27, 2008 | Unregistered CommenterEmma B.

Mt2wbb, you being a lay person *does* make a difference.

No offense or "snark" intended here at all, but maybe the fact that you have such little and incorrect information, after two water births, even as a lay person, speaks volumes about just how much misinformation there is out there, even amongst midwives.

For instance, the fact that you were led to believe that a home birth MW can do everything a hospital can in case of a PPH says to me that you were grossly misinformed. Even the fact that you do not know which medications they are able to give, whether or not they carry blood products, etc, says volumes not about you, but about the MWs that cared for you. You should have been informed of all of these things, in case of an emergency situation.

As such, NGM's post still speaks to educate, albeit from a different perspective.

February 27, 2008 | Unregistered CommenterMommy Dearest

This is really interesting. I am so thankful my midwives 'knew their stuff' when I haemorrhaged at home!

February 27, 2008 | Unregistered CommenterHannah

I liked your post. I really don't know much about homebirth midwifes since I have never come in contact with them. However, we have had 2 homebirth transfers as of late. So it would be good to know what capabilities they have at home.

February 28, 2008 | Unregistered Commenterchris

Isn't one of the cornerstones of defending the midwifery model being able to say "Midwives know the signs of serious problems and are able to spot them in time to refer the mom to the hospital or OB in time." ?
If you take that away by having ignorant/untrained midwives making such egregious errors as this student does doesn't that damage the credibility of the argument? Is that so hard to see??

Would Dr. Wonderful have such an excellent relationship with Barb if she wasn't as educated about the not normal and willing to LEARN as she i and as good at dealing with HER area of expertise as she is?

Wouldn't ALL women be better served if both sides respected each other for what they are good at and acknowledged where each others strengths lie and admit their own weaknesses?

February 28, 2008 | Unregistered CommenterAnonymous

From previous comments the poster in question has made on Dr. Amy's site, she lives in a state which has midwifery laws similar to Oregon's, although I don't know if she specifically lives in Oregon.

According to the http://arcweb.sos.state.or.us/rules/OARs_300/OAR_332/332_025.html" REL="nofollow">Oregon DEM rules, the only authorized anti-hemorrhagics DEMs may carry are oxytocin, methergine, misoprostol, and ergotrate. I'm not sure if CNMs would be able to administer Hemabate in a home setting, but it seems as though DEMs can't, at least in Oregon.

February 28, 2008 | Unregistered CommenterEmma B.

Mommy Dearest,
I resent your comment that I have been ‘led to believe’ anything. Let me ask you this, is everything you believe something you have been led to? Can you identify who led you to it?

Have you read the conversation as it happened on the original blog? NGM did a fairly good job at keeping the parts she brought over intact, except that the questions she attributes to ob nurse actually were asked by someone else. And other people were involved in the conversation as well. In fact, I was replying to someone other than ob nurse in half of what NGM attributes to me.

ob nurse stated that the patient she had treated for hem would have died at home.

You will notice that I asked a genuine question of ob nurse (what steps were taken?) I was careful to add a caveat, (as far as I know). A third party asked questions of me, and I answered to the best of my knowledge, while waiting to hear back from ob nurse about my question to her. This is where you see me “betting” about requirements in my state, And saying I didn’t know what a balloon tamponade is. NGM makes it seem as though I was teaching. I wasn’t. I was asking a question.

The facts are, the midwifery practice I birthed with has 4 people attending each birth. 2 midwives and 2 (sometimes more) apprentices, all of whom can start IVs. I examined with curiosity the pit and misoprostil (and something else which I didn’t recognize) which was laid out at my latest birth. Now I *was* in active labor at the time, so you’ll excuse me if I got something wrong. Perhaps the tablet was something else starting with the same letters, and not knowing of anything else but misoprostil I assumed that’s what it was. Midwives do NOT carry blood (and why the hell would they give Rhogam for a hem?) Since we were discussing hem I think it should be obvious what I intended by saying “blood products”.

Now NGM is right, I shouldn’t have used the word “easily”, stopping a hem isn’t easily done in or out of a hospital. But I think my point stands, that the steps taken by ob nurse and her team were not dependant on location for success. The same hem out of hospital could also have been managed in the same way. (Although possibly using fewer/different meds) The difference lies in how quickly *further* treatment can be reached.
mt2wbb

February 28, 2008 | Unregistered CommenterAnonymous

As a homebirth advocate (not in a clinical role), I think it is very important that we not try to convince people (including ourselves) that birth at home has almost everything birth at a hospital has, except the bad stuff we want to avoid. Birthing at home has very real risks, a PPH is one.

NGM, I enjoy the critical eye you turn to our community and I believe that it raises the bar. We musn't be pseudo-scientists or spout half truths. In the long and short run, it harms our cause.

February 28, 2008 | Unregistered CommenterLarissa

I guess I don't quite get the point of this post. Yes, folks should know what they're talking about no matter what they are advocating for, but I don't know that castigating folks who aren't fully informed is helpful to anyone. How many times in the blog world or chat board world are there hospital birthing women talking about the necessity of hospital birth without knowing fully what they are talking about? I've read a lot of "my baby would have died if the doctor didn't do the c-section after the cytotec made his heart rate go down" type of stories, after all.
This post seems sort of mean-spirited, and Dr. Amy-like. She is fond of posts that are basically "look what this idiot is saying" type rants, but it's not usually your style.
How about writing a post on what types of things midwives are able to do at home, vs the hospital management of a pph, and how to go about interviewing your midwife so you know what they can offer you - and importantly, how to know what a homebirth midwife cannot do, and when she'd be calling you an ambulance. Even point out that not everyone is well educated on these points, and some homebirth practices may not be able to offer *any* medical-type treatments for PPH. Encourage apprentices and homebirth assistants and students to know what is available and what is not, and how practical it is to administer certain things in their settings. Make sure prospective clients know that they should probably be concerned if their homebirth provider can't give them a run down on their personal PPH protocol (of course different folks will be comfortable with differing levels of available medical treatments at home, but EVERY client should understand just what it is they are being offerend in the way of care.) Your post would be just as informative without picking apart the lay person's comments, and not come across so antagonistic.
For the record, regardless of side effects, I don't think hemabate would be usable in a home setting because it needs to be refrigerated, which seems like it would be difficult in the homebirth practice setting. In the hospital setting when I am worried about a high chance of bleeding (usually when I've had a client with prolonged pitocin use during labor, known anemia, prolonged second stage, history of bleeding, or combinations of the above) I have the nurse get hemabate from the refrigerator just before delivery and have it in the room, and then we return it to the refrigerator if we don't need it (and, following the law of the more prepared you are, the less you need, we almost never need it except in those cases we never saw coming and then we are running for the refrigerator in the middle of a bad situation and it's so nice to have the extra hands around that we have in the hospital.)

February 28, 2008 | Unregistered Commenterdoctorjen

"I think it is very important that we not try to convince people (including ourselves) that birth at home has almost everything birth at a hospital has, except the bad stuff we want to avoid. Birthing at home has very real risks, a PPH is one.

NGM, I enjoy the critical eye you turn to our community and I believe that it raises the bar. We musn't be pseudo-scientists or spout half truths. In the long and short run, it harms our cause."

I agree.

2/28/2008 12:20 PM

February 28, 2008 | Unregistered Commenterchris

I'm a pre-nursing student and aspiring midwife who has been reading and enjoying your blog for about 2 years; this is the first time I've felt so inclined to comment. Aside from being incredibly interesting, this entry really speaks to my feelings about birth in general. I'm a middle-of-the-road kind of gal. To me, childbirth requires a certain degree of trust alongside a healthy dose of respect. Personally, I'm comfortable with that duality (hence my decision to become a CNM and my openness to attending both home and hospital births). However, my current degree is in psychology and this I am sure of: it’s human nature to see things in black and white. So I can understand how so many people are lulled into the security of choosing one extreme over the other (seeing birth as a completely benign process vs. a medical emergency.) It’s especially easy to make such an assumption with limited knowledge; I would venture to say that all laypeople, such as myself and HBA, struggle under this limitation. Probably many midwifery students and even midwives are not informed to the extent that they can really, truly understand the nature of birth or the essence of the decisions it entails. I should certainly add doctors to that list as well. I agree with the anonymous commenter who pointed out that the safety of midwifery relies on TRULY knowledgeable care providers such as NGM, and Dr. Wonderful, and that knowledge includes recognizing your own limitations (ex. not knowing how to do a “cut down”, or having to work under the regulations of a hospital).

Anyway, I’m reminded of a blog entry you previously wrote about how people desiring a homebirth-like experience should not give birth in the hospital—a “you made your bed, now lie in it” kind of deal. However, if we admit that there ARE benefits to hospital birth not available in the home, why shouldn’t we encourage people to seek the kind of birth they most desire in whatever location they so choose? If someone is uncomfortable with the risks homebirth entails—however minimal they may be—isn’t she still entitled to all the “comforts of home” while in the hospital? It seems like a silly question now that I am reading it—of course she is, and of course I don’t believe you think otherwise.

As a volunteer for Citizens for Midwifery, I am a firm believer that consumers’ wishes are pivotal in inciting change. I’m inclined to think that every woman who goes into the hospital and declines a vaginal exam, requests intermittent monitoring, insists on pushing in the position of her choice, etc. is bringing us one step closer to a mother-friendly hospital environment. Or do you think that choosing an everyday OB and then fighting for these rights is a lost cause?

I really wish I could find the entry to make sure that my memory isn’t distorting your original argument and maybe answer my own question. :)

February 28, 2008 | Unregistered Commenterkatee

*cringes*

As another HBA who recently stated a medical falsehood on her blog out of ignorance, I feel lucky that you simply pointed out my error to me instead of writing a blog entry about me. Ouch.

Sometimes, it's easier to ask someone the answer than find it yourself...especially considering that most of us aren't aware of readily available HB resources outside of MDC and some of the blogs here on Blogger. And BECAUSE the average layperson's knowledge can be limited from these resources, it leads to misinformation.

There is SO MUCH to know out there, and even doctors can get it wrong sometimes. (Not that that's any excuse, though.) How many times have we all heard a doctor spout a blatant lie that he honestly believes is gospel? They're just as flawed as the rest of us, midwives, HBAs and laypersons alike...a scary concept considering that they have our lives in their hands, but that's life for ya.

February 29, 2008 | Unregistered CommenterJill

I got cut short because my son wanted to get on my computer to play a game, but wanted to come back and add that while I usually enjoy your informative posts such as the "11 Myths" one, I have to agree with DoctorJen here...this post was very Dr. Amy-like. I have the utmost respect for you for telling it like it is and being such an excellent advocate for exactly that reason, but this entire post, even after being re-worded, seemed very harsh and uncharacteristic of you.

I daresay that I am leery of writing about homebirth anymore lest I make another mistake and make the community "look bad" (which I'm sure I've already done, but no one [other than the obvious nemeses whose blogs are filled with this kind of stuff] has told me so yet). That's the last thing I'd want to do.

For heaven's sake, there is enough of this kind of attitude in the birth circles already. Let's EDUCATE, not berate! Yes, we all need to know as much as possible, but making someone feel two inches high isn't the best way to start off.

February 29, 2008 | Unregistered CommenterJill

I really do respect all y'all's thoughts. I appreciate your concern that I might be turning into that shrill other person who-shall-remain-nameless. I especially thank you, Dr. Jen, for taking the time to write; I absolutely respect your thoughts and don't want to lose any I might have from you.

But, I do want to say a couple of things.

I'm frustrated. Really, really frustrated with the way HBA's and midwives are being seen on the Net. It seems that saying things sweetly sometimes is totally ignored; I got loud - hmmm... and heard! I certainly don't intend to become a shrew, but it really is important for me to find a way to get HBAs to awaken from their complacent, comfortable slumber and see we are under attack from all sides. We canNOT any longer say things that can be used as massive ammunition against us. We might just find ourselves pushed aside legally with one mis-step.

I think I am really frustrated with the "Trust Birth Conference" mentality. I hate to say anything remotely like a poo poo head, but how can women make informed choices if those that are supposed to be informing have their heads in the sand?

Someone earlier said she thought I was now afraid of birth... that I created scary situations because I saw them whenever I was in birth. I absolutely disagree! I am no different now than before; I'm just talking about it now. I actually had MORE complications when I didn't talk about things than now, when I do. Not that I believe any of it has to do with the other. I work hard not to be one of the supersticious midwives who, goddess forbid, talk about a complication lest it be created.

I am not "afraid" of large babies. Large babies happen. Sure, large babies can and DO come out! But not all women under 5'5" can handle 10.5 pound babies. (The woman who said she thought I was afraid of large babies spoke about her family's height and babies' weights. Sure! Tall women *can* have much bigger babies - and even hide them inside. The mom at the top of my blog had a baby almost 10 pounds... at 6 feet tall, you can hardly tell how big the baby is.)

Anyway, I, like KneelingWoman, feel some sort of... drive? compulsion? urge? to speak about the side of midwifery so often overlooked. I do apologize if it comes out clumsy and awkward sometimes.

It's hard to leave the other posters out of it, though. Their words are the best stimulus sometimes for my thoughts. Trying to manipulate the context is like writing fiction for me - and I've never been any good at fiction. Give me a great prompt that is real life and I am off and running. I'll try to be more gentle, but I can't promise I will succeed every time.

I hope that helps explain things a bit more.

And, I'm almost done with my follow-up post that will explain things even more.

February 29, 2008 | Unregistered CommenterNavelgazing Midwife

The nonsense posted by mt2wbb on this important subject, whilst deprecated by the more sensible posters here, is sadly representative of the level of understanding of many homebirthers and unfortunately, some homebirthing midwives. This lack of knowledge extends through every aspect of childbearing & birth.

Homebirth can be a great experience for the right woman, with the right midwives, within fifteen minutes of a hospital.

Unfortunately, often the woman is not the right woman, in other words often she's not low-risk and sometimes foolhardy.

The midwife is often not the right midwife. The most experienced and switched-on midwives have seen what can happen in labour and therefore practice in a hospital. The homebirthing midwife is often very inexperienced and therfore has a rosy view of childbirth. Even if she's been homebirthing for many years, inevitably her numbers will be much much lower than a hospital midwife.

It's a potent mixture which often leads to tragedy. Most deaths are swept under the carpet, but the evidence is coming out gradually.

March 24, 2008 | Unregistered CommenterAnonymous

Exactly what carpet are "most" of those tragedies you mention swept under, ANONYMOUS?

Hmmm, where to hide the dead babies.... lemme see... Not the courtroom carpet under charges of manslaughter... Not the carpet at the state Medical Examiners' Board for practicing medicine without a license... The carpet of Child Protective Services while the parents are being investigated for negligence, nope not that one... The carpet at the vital records office that issues certificates of birth and/or death perhaps? Strike'em from the records, they'll screw up our statistics, they'll make the home birth studies look bad!

ANONYMOUS, how exactly do you propose the vast, politically connected, and generously funded natural childbirth conspiracy silences the newspaper headlines... not to mention homebirth debate bloggers?

P.S. NGM, I don't blame you if you don't publish this one--I guess I'm having a morbid humor day...

March 24, 2008 | Unregistered CommenterJudit

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