And just to hit these points home. Yes, I know these studies and articles are old but availability of obstetric care has declined, not improved since they were all published.
www.ncbi.nlm.nih.gov/pmc/articles/PMC1404977/ Hospital discharge data from 33 rural hospital service areas in Washington State were categorized by the extent to which patients left their local communities for obstetrical services. Women from communities with relatively few obstetrical providers in proportion to number of births were less likely to deliver in their local community hospital than women in rural communities with greater numbers of physicians practicing obstetrics in proportion to number of births. Women from these high-outflow communities had a greater proportion of complicated deliveries, higher rates of prematurity, and higher costs of neonatal care than women from communities where most patients delivered in the local hospital.
***** Receipt of reproductive health services by sexually active women, aged 15–44 years, within the past year, was less likely for women living in nonmetropolitan areas (13); rural women relied on female sterilization (35%) to a greater extent than women living in central metropolitan (24%) or fringe metropolitan (25%) areas (14). A 2006 survey of women aged 18–44 years in Colorado found that women in small towns or rural areas indicated that they plan for contraceptive use less and were more likely to have had an unintended pregnancy than women in more urban areas (15). www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Health-Care-for-Underserved-Women/Health-Disparities-in-Rural-Women
**** More than 8 percent of OB/GYNs who responded to a 2006 survey by ACOG said they had stopped practicing obstetrics during the previous three years, and the organization says more than one-third of OB/GYNs have cut back on high-risk obstetrics care. (For comparative purposes, ACOG’s 2004 survey—which covered 1999–2003—showed that about 14 percent of OB/GYNs had stopped practicing obstetrics.)
In areas where the liability crisis is most pronounced, “there are now populated areas with no OB/GYNs actively practicing the specialty,” says Dr. Ralph W. Hale, ACOG’s executive vice president.
In Tennessee, for example, 42 of the state’s 95 counties now have no residing OB/GYN in patient care, according to the most recent data from the American Medical Association (AMA) in Chicago and the Nashville-based Tennessee Medical Association (TMA). A TMA survey in 2006 found that 70 percent of Tennessee’s physicians believe the state has a shortage of high-risk specialists, and the AMA recently designated it as a crisis state.
Because of the lack of available doctors, pregnant women in some areas must travel long distances—60 miles or more in some instances—to find a physician willing to provide obstetric care, some experts say. The same is true for women trying to find OB/GYNs willing to perform complicated gynecologic surgery.
“It’s a very serious problem,” says health-policy expert Helen Darling, president of the Washington, D.C.-based National Business Group on Health (NBGH), which represents health care interests of more than 200 large employers. “The fear of being sued is driving OBs and other specialists out of practice,” she says, and that in turn can lead to higher costs for employer-sponsored health plans.
Remember. You KNOW what's going to happen in here. DO NOT ENGAGE when it starts. Do not empower through questions or arguments. Be like the phalanx in The 300.
I can't deal with her sanctimonious bullshit on a Monday with minimal coffee. just. can't.
Remember. You KNOW what's going to happen in here. DO NOT ENGAGE when it starts. Do not empower through questions or arguments. Be like the phalanx in The 300.
I'm honestly flabbergasted that the majority of women having home births are using a CPN. I mean, not to generalize, but don't most pregnant women pour over car seat reviews and interview periatricians and "research" the safety of vaccinations? Or is that just women on the bump? How do you not know or understand the education and experience of the person delivering your baby?!? Just....wow.
My only options in the stare of Ohio for a homebirth are CPMs and lay midwives (from local Amish area). In fact, I no longer even have the option of using a CNM in the hospital. The one I used with my older boys was eventually run out of the practice by the OBs who were mad that she was taking all their business. There are no midwives left in my region at all.
But who's to say women using CPMs don't understand the training and education of their midwives? I know I researched mine thoroughly. I interviewed three different CPMs before deciding on mine and asked tons of questions including where they received their education, how long they have been practicing, what equipment they carry, what their transfer rate is, have they ever lost mothers/babies and why, do they do continuing education, etc. I feel very confident in my MWs abilities. I'm more confident in the abilities of my CPM than the CNM I used with the first two.
Post by pinkdutchtulips on May 2, 2016 9:56:37 GMT -5
My sister had 2 home births by choice under the watchful of a CNM. She had minimal prenatal care. She's ridiculously lucky that nothing catastrophic happened during her deliveries. Even w their backyard abutting the hospital, when it comes to birth, complications can arise and seconds matter, not munutes.
It should not shock anyone that she and my bil are part of the anti vax crowd and MILITANT about it :/
I think she is saying women will have home births no matter what so by outlawing medical professionals from attending home birth you are giving them only dangerous options. When if you permitted CNMs with established OB partnerships you would have safer situations.
The abortion comparison being that woman have abortions no matter what even if they are dangerous. So we pass laws to make them safe and legal. Women will have home births no matter what, even if they are dangerous so we should pass laws which make them as safe as can be.
Yeah, I think I explained above why both trains of thought are patently stupid but I'll repeat it again. Only dangerous options is a lie. There are plenty of safe, affordable and accessible options for childbirth. Women aren't choosing dangerous options because they aren't safe ones.
And the abortion comparison is a false one for the same exact reasons. Women choose dangerous abortions because there are few safe, accesible, affordable options, in many cases none at all. In the case of childbirth, some women simply do not like the options offered them, and choose a more dangerous route.
Because some women are willfully choosing a decidedly less safe option I am not on board with the idea that they wouldn't do it if they didn't have to. Plenty of them will still choose more dangerous way simply because they want the illusion of choice and self control.
Since when is hospital childbirth considered affordable?
If women should be able to have safe, affordable, abortions they should be able to have safe, affordable births.
Yeah, I think I explained above why both trains of thought are patently stupid but I'll repeat it again. Only dangerous options is a lie. There are plenty of safe, affordable and accessible options for childbirth. Women aren't choosing dangerous options because they aren't safe ones.
And the abortion comparison is a false one for the same exact reasons. Women choose dangerous abortions because there are few safe, accesible, affordable options, in many cases none at all. In the case of childbirth, some women simply do not like the options offered them, and choose a more dangerous route.
Because some women are willfully choosing a decidedly less safe option I am not on board with the idea that they wouldn't do it if they didn't have to. Plenty of them will still choose more dangerous way simply because they want the illusion of choice and self control.
Since when is hospital childbirth considered affordable?
If women should be able to have safe, affordable, abortions they should be able to have safe, affordable births.
Oh, IDK, probably since medicaid in virtually every state covers pregnancy with a much higher income limit than other forms of medicaid qualification.
Post by mrsdewinter on May 3, 2016 14:22:53 GMT -5
Medicaid pays for nearly half of all births in the U.S., so it's not a small percentage.
Home births cost thousands of dollars and often insurance will not cover it. And home birth significantly increases the chances of neonatal death and brain damage. So I'm not sure it falls under either safe or affordable. We need to make health care more affordable and accessible, but the answer isn't more home births.
Medicaid pays for nearly half of all births in the U.S., so it's not a small percentage.
Home births cost thousands of dollars and often insurance will not cover it. And home birth significantly increases the chances of neonatal death and brain damage. So I'm not sure it falls under either safe or affordable. We need to make health care more affordable and accessible, but the answer isn't more home births.
thanks you for the stat on medicaid. I didn't know it was that high.
I'm honestly flabbergasted that the majority of women having home births are using a CPN. I mean, not to generalize, but don't most pregnant women pour over car seat reviews and interview periatricians and "research" the safety of vaccinations? Or is that just women on the bump? How do you not know or understand the education and experience of the person delivering your baby?!? Just....wow.
(Pardon me if this is stated later on in the thread). In states like mine, CNMs are not legally allowed to attend homebirths. So if you're heart set on a homebirth, a CPN is the only option.
Medicaid pays for nearly half of all births in the U.S., so it's not a small percentage.
Home births cost thousands of dollars and often insurance will not cover it. And home birth significantly increases the chances of neonatal death and brain damage. So I'm not sure it falls under either safe or affordable. We need to make health care more affordable and accessible, but the answer isn't more home births.
Maybe it's because I hated laboring in a hospital but if I could have I would have loved to have given birth at the birth center in my hometown. Every appt plus labor and delivery was 3k. They have privileges at local hospitals if you don't meet the safety criteria for delivering at their center. The board of the center is,made up of MDs. I realize this is not technically a home birth but it's a non hospital birth attended by CNMs and nps. It's much more what I would have wanted for myself. And I don't see what is so dangerous or horrible about it. It's a million times cheaper than a hospital birth and it's safe because if you become high risk you get kicked out to a hospital.
There are possibilities between homebirth with lay midwife and hospital birth. It can be safe and it can save money.
My sister had 2 home births by choice under the watchful of a CNM. She had minimal prenatal care. She's ridiculously lucky that nothing catastrophic happened during her deliveries. Even w their backyard abutting the hospital, when it comes to birth, complications can arise and seconds matter, not munutes.
It should not shock anyone that she and my bil are part of the anti vax crowd and MILITANT about it :/
I often see the "birth can go awry in a quick second" sentiment in these discussions. While these situations can and do happen, and having been part of birth and neonatal loss groups, personally knowing mothers who have experienced these situations, this is often overstated and exaggerated. A mom can go from a normal, uneventful labor to abnormal heart tones after spending time on pitocin or misoprostol. Both pose risks of uterine hyperstimulation and uterine tetany. A mom can have her membranes ruptured, one of the most common interventions, that can lead to increased risks of infection if VEs are performed, or malpositioning if baby wasn't in the optimal position for birth. While interventions can create conditions that lead to emergencies, it's not common to for these situations to arise without the presence of, say, oxytocic drugs or inducing and augmenting with a low Bishop's score. Two of the most common reasons for ECS are prolonged bradycardia, often in the presence of oxytocic stimulants, and tachycardia, often the result of intrauterine infection. And in both situations heart tracings are observed over a period of time before making the decision to deliver within the 30 minute guideline.
Consider this:
CONCLUSION:
Fewer than 40% intrapartum deliveries by caesarean section for fetal distress were achieved within 30 minutes of the decision, despite that being the unit standard. There was, however, no evidence to indicate that overall an interval up to 120 minutes was detrimental to the neonateunless the delivery was a 'crash' caesarean section. These data thus do not provide evidence to sustain the recommendation of a standard of 30 minutes for intrapartum delivery by caesarean section.
"There were 755 emergency caesareans carried out in the study period. Of these, 122 were grade 1, 211 were grade 2, and 422 were grade 3 procedures. The mean decision-to-delivery interval for grade 1 caesareans was 23 minutes (SD 11) with 82.0% of babies being born within 30 minutes of the operation being requested and 99.2% being born within 75 minutes. For grade 2 caesareans, the mean decision-to-delivery interval was 32 minutes (SD 13) with 45.0% of babies being born within 30 minutes of the operation being requested and 98.1% being born within 75 minutes."
More on decision-to-delivery guidelines. (UK study)
I often wonder what sort of emergencies people are referring to when they paint crash c-sections as something other than a rare occurrence. You mention catastrophic emergencies, and on ACOG's site it states:
"Some emergencies are truly sudden and catastrophic, such as a ruptured aneurysm, massive pulmonary embolus, or complete abruptio placentae in a trauma setting."
Uterine rupture, placental abruption, cord prolapse, amniotic fluid embolism, fetal-maternal hemorrhage, and other complications that could be the result of fetal or placental/cord abnormality. And for postpartum emergencies, PPH and uterine inversion. The risks of uterine rupture increases with the use of uterine stimulants. Outside this method of management, how likely is a crash c-section without specific risk factors? Some of these catastrophic emergencies can and do occur outside labor and delivery. I was irrationally anxious about amniotic fluid embolism when I learned of a mother in a distant circle I was in years ago who developed it late in her pregnancy. It's extremely rare, as are these other emergencies where a mere few minutes is life or death. I'm not trying to be a dick, but you say seconds matter, but if the standard time to delivery is 30 minutes, how does this sentiment work?
My midwife with my third baby had a client who was having a normal, uneventful spontaneous labor, around 5 cm, with intact membranes. She noticed abnormal heart tones, variable decelarations, and after further monitoring called the nearby L&D to notify them of transfer. She thought it was a cord compression, though uncommon with intact membranes. After brief monitoring in L&D triage she was immediately taken for a stat c-section. Baby had an abnormally short cord that was stretched during contractions causing the decels. Outside the catastrophic situations, embolisms, aneursym, abruption, rupture, hemmorhage, etc., if there is quick access to a hospital in OOH settings, and providers are competent and know what they're doing, there is enough time to transfer. Even in these incredibly rare obstetric emergencies, they can happen at any point in pregnancy or in early labor before moms can't be admitted anyway.
I'm curious to know the statistics for crash c-sections, not the c-sections that fit within the standard decision-to-delivery time. In cases of fetal distress, if mom is on pitocin, PE2 or misoprostol, she's being observed, and they're watching for signs of distress, so they can respond accordingly. The situations I'm familiar with where heart rate drops dangerously low out of nowhere and doesn't recover, heart tones that don' fit the pattern of decelerations associated with uterine stimulants, involved fetal or cord defects. Some can argue that just the smallest risk, no matter how rare, is too much risk. But if many of these catastrophic emergencies are not exclusive to L&D, they can occur at any point (I was at risk for cord prolapse and uterine rupture due to severe polyhydramnios during my third pregnancy, which increases the risks of PTL), then what?
Many have addressed access to providers being a real problem. OOHBs were more common than usual in some of the military spouse circles I frequented years ago, and that was often due to many families being stationed in areas, rural areas, that did not have access to providers, or hospitals with a L&D. And those that did, didn't have anesthesiologists, or around the clock access to one. At the time, I was fortunate to live areas where I had options, and I had great health insurance. I could choose whatever provider I wanted in my network, and I had dual care when I planned my homebirths. However, my health insurance with my fifth baby was/is awful. I wanted (and eventually planned a homebirth with a CNM), but there was a shit-ton of crap and red tape I had to deal with when it came to choosing providers. I have a major hospital 1.2 miles from my home, but the hospital that accepts my insurance is a 25 minute drive. That would not have worked for me, nevermind that I didn't want a hospital birth, but aside from that, it didn't make sense logistically. I have extremely fast births, as in, I didn't really have a labor with my fourth. My midwife wrote "<5 minutes" in the length of labor section on his birth certificate application. Part of the reason why homebirth is the right choice for me. And, like I/we expected, my fifth baby was born less than 10 minutes after finding out I was in labor. Had my midwife not checked me and told me I was 8 cm with her head at +2 station, I wouldn't have known anything was actually happening. There would have been no time to do much of anything let alone drive 25 minutes to the hospital. The majority of providers, good providers, in my area do not accept my insurance. I can't imagine what it's like for those who live in more rural areas with shitty insurance.
As an aside, I wonder whether the study takes into account preexisting conditions or abnormalities, some undiagnosed, into fetal demise statistics. An old friend lost her son during a homebirth, and she and her midwife were vilified for it... until it was discovered he had an undiagnosed heart defect that was the cause of death. Another woman in a support group I was in lost her son during a homebirth as well, due to a severe case of undiagnosed CDH. She had dual care. And no doubt, there are cases of incompetency in OOHBs. I know those fairly well, too. They are tragic and heartbreaking, and why I am a proponent of stricter laws and regulations when it comes to midwifery care (and I've used CPMs). I just think overall, with trying to create more options, better access to care, and collaborative efforts, this is the way to go. A midwifery model and regulations similar to Canada and UK is what I'd like to see.
Medicaid pays for nearly half of all births in the U.S., so it's not a small percentage.
Home births cost thousands of dollars and often insurance will not cover it. And home birth significantly increases the chances of neonatal death and brain damage. So I'm not sure it falls under either safe or affordable. We need to make health care more affordable and accessible, but the answer isn't more home births.
Maybe it's because I hated laboring in a hospital but if I could have I would have loved to have given birth at the birth center in my hometown. Every appt plus labor and delivery was 3k. They have privileges at local hospitals if you don't meet the safety criteria for delivering at their center. The board of the center is,made up of MDs. I realize this is not technically a home birth but it's a non hospital birth attended by CNMs and nps. It's much more what I would have wanted for myself. And I don't see what is so dangerous or horrible about it. It's a million times cheaper than a hospital birth and it's safe because if you become high risk you get kicked out to a hospital.
There are possibilities between homebirth with lay midwife and hospital birth. It can be safe and it can save money.
Right, and what you are describing sounds like a good option for women who are truly low risk. That's kind of the whole point of the original article--we need more options like that if OOH birth is going to be as safe as possible. Instead we have a state by state patchwork of lay and illegal midwives with poor education standards, no integration into the larger healthcare system and no national standards of care.
But anyone delivering OOH should be informed that they don't have access to all of the emergency resources of a hospital and while rare, sudden emergencies can arise where that lack of resources can have serious consequences, including death. And for that reason, and because many women are risked out, we shouldn't be looking to OOH birth to solve the high costs of care in the U.S.
Maybe it's because I hated laboring in a hospital but if I could have I would have loved to have given birth at the birth center in my hometown. Every appt plus labor and delivery was 3k. They have privileges at local hospitals if you don't meet the safety criteria for delivering at their center. The board of the center is,made up of MDs. I realize this is not technically a home birth but it's a non hospital birth attended by CNMs and nps. It's much more what I would have wanted for myself. And I don't see what is so dangerous or horrible about it. It's a million times cheaper than a hospital birth and it's safe because if you become high risk you get kicked out to a hospital.
There are possibilities between homebirth with lay midwife and hospital birth. It can be safe and it can save money.
Right, and what you are describing sounds like a good option for women who are truly low risk. That's kind of the whole point of the original article--we need more options like that if OOH birth is going to be as safe as possible. Instead we have a state by state patchwork of lay and illegal midwives with poor education standards, no integration into the larger healthcare system and no national standards of care.
But anyone delivering OOH should be informed that they don't have access to all of the emergency resources of a hospital and while rare, sudden emergencies can arise where that lack of resources can have serious consequences, including death. And for that reason, and because many women are risked out, we shouldn't be looking to OOH birth to solve the high costs of care in the U.S.
my argument was not that it should solve the issue of expensive care in the US. My argument (in response to ios) is that because it can be safe and because it is more affordable there's no reason it shouldn't be made available- just like abortion.
Medicaid pays for nearly half of all births in the U.S., so it's not a small percentage.
Home births cost thousands of dollars and often insurance will not cover it. And home birth significantly increases the chances of neonatal death and brain damage. So I'm not sure it falls under either safe or affordable. We need to make health care more affordable and accessible, but the answer isn't more home births.
Pretty much all of this.
Also, there are special laws set up around medical bills, how they affect your credit, how one can contact you to pay them, what they can do when you don't pay them. I would assume the majority of homebirth midwives expect to be paid upfront, so what do you do when you can't do that?
In addition, with pregnancy medicaid, you can get a decision very quickly or at minimum, paperwork showing you have applied and are likely eligibile. And many doctors will go ahead and see you with that paperwork even before your medicaid claim is fully approved.
Maybe it's because I hated laboring in a hospital but if I could have I would have loved to have given birth at the birth center in my hometown. Every appt plus labor and delivery was 3k. They have privileges at local hospitals if you don't meet the safety criteria for delivering at their center. The board of the center is,made up of MDs. I realize this is not technically a home birth but it's a non hospital birth attended by CNMs and nps. It's much more what I would have wanted for myself. And I don't see what is so dangerous or horrible about it. It's a million times cheaper than a hospital birth and it's safe because if you become high risk you get kicked out to a hospital.
There are possibilities between homebirth with lay midwife and hospital birth. It can be safe and it can save money.
Right, and what you are describing sounds like a good option for women who are truly low risk. That's kind of the whole point of the original article--we need more options like that if OOH birth is going to be as safe as possible. Instead we have a state by state patchwork of lay and illegal midwives with poor education standards, no integration into the larger healthcare system and no national standards of care.
But anyone delivering OOH should be informed that they don't have access to all of the emergency resources of a hospital and while rare, sudden emergencies can arise where that lack of resources can have serious consequences, including death. And for that reason, and because many women are risked out, we shouldn't be looking to OOH birth to solve the high costs of care in the U.S.
Like c-section? That's what you're referring to by emergency resources? Many of these sudden emergencies can happen whether or not a woman is in labor. What do you propose then? The vast majority of unplanned c-sections are performed within a standard delivery time, which is not seconds or even a few minutes. So how dire is it if the standard time to incision is 30 minutes or more? For many who do the necessary research and come to the decision to plan a OOHB with a competent, skilled provider, this is taken into consideration. How close they are to a major hospital and the midwife's relationship with local hospitals/providers, which presently isn't great for a lot of midwives, whether CNM or CPM.
In many OOHBs, in the event of a life-and-death situation, or serious complication, the nearest hospital is notified of an emergency transport (vs. transfer for non-emergent situations) where the OR is prepped and ready for the patient. Obviously this is involves clients/patients who have access to a hospital with an OR and anesthesiologist around the clock. With patients who don't there's more risk involved.
And if we're talking about these incredibly rare obstetric emergencies that warrant stat c-sections, what about the recent change in guidelines for classifying stages of labor? If moms aren't supposed to be admitted until 6 cm, what's now considered active labor, basically spending most of her labor at home, is not that risky? Can't something go awry in a matter of seconds at home? It's less risky to labor at home for however many hours, but not birth there? Couldn't a laboring mom develop a serious complication like amniotic fluid embolism or complete placental abruption while laboring at home before going to the hospital?
The hospital I would have delivered at with my last baby doesn't admit until 5 cm. I was 5 cm for six days before my membranes ruptured. I wasn't in labor, and had no idea I was in labor, until 10 minutes before her birth. This is the norm for me. Shit can hit the fan at any point in pregnancy and stage of labor, whether at home, out shopping, running errands or at the hospital. There's lack of resources no matter where you happen to be if you're hit with a sudden complication.
I'm still curious what sudden obstetric emergencies (that warrants a stat c-section) many refer to when they talk about these risks in context of requiring immediate action. I'm not talking about fetal distress in the presence of pitocin, misoprostol or other oxytocic drugs or maternal infection that presents with a fever and elevated heart rate. These are complications that present with symptoms or patterns over a period of time before the decision to deliver.
In any case, yes, I considered the possible (SD) and extremely rare obstetric emergencies (aneurysm, embolism, peripartum cardiomyopathy, HELLP, complete abruption and rupture without risk factors) when I planned my homebirths. I was hyper-aware of these super serious complications, but I also knew they could happen whether or not I was in labor, and in my situation, if something as these as these complications were to happen in labor, I wouldn't make it to a hospital anyway.
Medicaid covers home births in the state of Virginia. I am sure it does in other states as well, although I know it varies.
I have Medicaid. Before the switch to managed care Medi-cal covered CNM in homebirths and birth centers. I actually toured a FSB super close to me and was super excited to find out they accept Medi-cal. Come to find out, they, and a lot of other providers, only take straight/standard Medi-cal, not managed care Medi-cal plans, which is contracted with insurance agencies. Just a few months before the pregnancy the county I live in made managed care the standard. There is no option for standard Medi-cal, which limited my options because most providers don't accept managed care Medi-cal. (I've lost count how many times my kids' ped has been changed because I discover they no longer accept my insurance plan). It was a pain in the ass the deal with and caused me a lot of stress and anxiety until I found my CNM.
My CNM has a special program for Medi-cal recipients that offers homebirth services at a discounted rate. Her normal rate, where I live in Nor Cal, is $5500. I paid $2000 in installments.
Right, and what you are describing sounds like a good option for women who are truly low risk. That's kind of the whole point of the original article--we need more options like that if OOH birth is going to be as safe as possible. Instead we have a state by state patchwork of lay and illegal midwives with poor education standards, no integration into the larger healthcare system and no national standards of care.
But anyone delivering OOH should be informed that they don't have access to all of the emergency resources of a hospital and while rare, sudden emergencies can arise where that lack of resources can have serious consequences, including death. And for that reason, and because many women are risked out, we shouldn't be looking to OOH birth to solve the high costs of care in the U.S.
Like c-section? That's what you're referring to by emergency resources? Many of these sudden emergencies can happen whether or not a woman is in labor. What do you propose then? The vast majority of unplanned c-sections are performed within a standard delivery time, which is not seconds or even a few minutes. So how dire is it if the standard time to incision is 30 minutes or more? For many who do the necessary research and come to the decision to plan a OOHB with a competent, skilled provider, this is taken into consideration. How close they are to a major hospital and the midwife's relationship with local hospitals/providers, which presently isn't great for a lot of midwives, whether CNM or CPM.
In many OOHBs, in the event of a life-and-death situation, or serious complication, the nearest hospital is notified of an emergency transport (vs. transfer for non-emergent situations) where the OR is prepped and ready for the patient. Obviously this is involves clients/patients who have access to a hospital with an OR and anesthesiologist around the clock. With patients who don't there's more risk involved.
And if we're talking about these incredibly rare obstetric emergencies that warrant stat c-sections, what about the recent change in guidelines for classifying stages of labor? If moms aren't supposed to be admitted until 6 cm, what's now considered active labor, basically spending most of her labor at home, is not that risky? Can't something go awry in a matter of seconds at home? It's less risky to labor at home for however many hours, but not birth there? Couldn't a laboring mom develop a serious complication like amniotic fluid embolism or complete placental abruption while laboring at home before going to the hospital?
The hospital I would have delivered at with my last baby doesn't admit until 5 cm. I was 5 cm for six days before my membranes ruptured. I wasn't in labor, and had no idea I was in labor, until 10 minutes before her birth. This is the norm for me. Shit can hit the fan at any point in pregnancy and stage of labor, whether at home, out shopping, running errands or at the hospital. There's lack of resources no matter where you happen to be if you're hit with a sudden complication.
I'm still curious what sudden obstetric emergencies (that warrants a stat c-section) many refer to when they talk about these risks in context of requiring immediate action. I'm not talking about fetal distress in the presence of pitocin, misoprostol or other oxytocic drugs or maternal infection that presents with a fever and elevated heart rate. These are complications that present with symptoms or patterns over a period of time before the decision to deliver.
In any case, yes, I considered the possible (SD) and extremely rare obstetric emergencies (aneurysm, embolism, peripartum cardiomyopathy, HELLP, complete abruption and rupture without risk factors) when I planned my homebirths. I was hyper-aware of these super serious complications, but I also knew they could happen whether or not I was in labor, and in my situation, if something as these as these complications were to happen in labor, I wouldn't make it to a hospital anyway.
The situations where seconds matter and you can not predict them are things like severe shoulder dystocia and postpartum hemorrhage. Sometimes babies with gorgeous FHTs have issues in the last two minutes of delivery. These are not extremely rare situations. You need a lot of hands and people who know what they are doing when you are coding a baby or watching a mother lose blood faster than you can put it back in. So while I don't care about the rest of the stuff in this thread, it's not even close to the truth to act like there aren't any outcomes tied to how quickly you can access medically trained personnel.
Like c-section? That's what you're referring to by emergency resources? Many of these sudden emergencies can happen whether or not a woman is in labor. What do you propose then? The vast majority of unplanned c-sections are performed within a standard delivery time, which is not seconds or even a few minutes. So how dire is it if the standard time to incision is 30 minutes or more? For many who do the necessary research and come to the decision to plan a OOHB with a competent, skilled provider, this is taken into consideration. How close they are to a major hospital and the midwife's relationship with local hospitals/providers, which presently isn't great for a lot of midwives, whether CNM or CPM.
In many OOHBs, in the event of a life-and-death situation, or serious complication, the nearest hospital is notified of an emergency transport (vs. transfer for non-emergent situations) where the OR is prepped and ready for the patient. Obviously this is involves clients/patients who have access to a hospital with an OR and anesthesiologist around the clock. With patients who don't there's more risk involved.
And if we're talking about these incredibly rare obstetric emergencies that warrant stat c-sections, what about the recent change in guidelines for classifying stages of labor? If moms aren't supposed to be admitted until 6 cm, what's now considered active labor, basically spending most of her labor at home, is not that risky? Can't something go awry in a matter of seconds at home? It's less risky to labor at home for however many hours, but not birth there? Couldn't a laboring mom develop a serious complication like amniotic fluid embolism or complete placental abruption while laboring at home before going to the hospital?
The hospital I would have delivered at with my last baby doesn't admit until 5 cm. I was 5 cm for six days before my membranes ruptured. I wasn't in labor, and had no idea I was in labor, until 10 minutes before her birth. This is the norm for me. Shit can hit the fan at any point in pregnancy and stage of labor, whether at home, out shopping, running errands or at the hospital. There's lack of resources no matter where you happen to be if you're hit with a sudden complication.
I'm still curious what sudden obstetric emergencies (that warrants a stat c-section) many refer to when they talk about these risks in context of requiring immediate action. I'm not talking about fetal distress in the presence of pitocin, misoprostol or other oxytocic drugs or maternal infection that presents with a fever and elevated heart rate. These are complications that present with symptoms or patterns over a period of time before the decision to deliver.
In any case, yes, I considered the possible (SD) and extremely rare obstetric emergencies (aneurysm, embolism, peripartum cardiomyopathy, HELLP, complete abruption and rupture without risk factors) when I planned my homebirths. I was hyper-aware of these super serious complications, but I also knew they could happen whether or not I was in labor, and in my situation, if something as these as these complications were to happen in labor, I wouldn't make it to a hospital anyway.
The situations where seconds matter and you can not predict them are things like severe shoulder dystocia and postpartum hemorrhage. Sometimes babies with gorgeous FHTs have issues in the last two minutes of delivery. These are not extremely rare situations. You need a lot of hands and people who know what they are doing when you are coding a baby or watching a mother lose blood faster than you can put it back in. So while I don't care about the rest of the stuff in this thread, it's not even close to the truth to act like there aren't any outcomes tied to how quickly you can access medically trained personnel.
And properly trained CNMs have the tools and skills to manage these situations. The Zavanelli maneuver in severe cases of SD is often performed as a last resort, and even it has risks. A trained CNM can address the complications in much the same way they're addressed in a hospital setting, through a course of steps and management protocols. SD was a complication I weighed and considered when I first started researching my OOH options, and if I presented with severe SD and my midwife already tried the Gaskin, McRoberts, subrapubic pressure and all-fours with internal manipulation, then it would warrant a call to the hospital for emergency transport for third line maneuvers. My midwife with my third baby had sticky shoulders with her fourth and true SD with her fifth, which was quickly and effectively managed. She understood my questions on how she manages these complications. I wasn't particularly worried, but it was important to have as much information on how she manages SD.
I had a PPH with my youngest due to uterine atony. My midwife had the equipment and medication to manage it: cytotec, pitocin, methergine, and hemabate. Cytotec and fundal massage worked. I didn't require pitocin through IV infusion, and certainly not the "big guns" that are used to manage more severe blood loss. Had I continued losing after pitocin IV infusion or methergine/hemabate, we'd have transferred the 1.2 miles to the hospital for a transfusion or surgery. I mean, if it takes, say, 10-15 minutes to prep an OR in stat emergencies, based on the decision-to-delivery time frames, and she calls ahead to notify of emergency transport due to 1000> ml blood loss, they would prep in time for our arrival. Even if I were at the hospital at the time of birth, an OR and hematology team still need to be prepped if an infusion or surgery is required. A competent and skilled provider should know how to manage complications, and when they can't be managed, set up an emergency transport.
The risk of severe PPH is less than 5%, and typically have risk factors that contribute to their severity. A mom who presents with severe PPH risk factors would likely be risked out of a homebirth with a CNM, especially without close access to a hospital. In my case, planning a hospital birth wouldn't do me any good if I birth too quickly to have access to these resources.
Post by downtoearth on May 4, 2016 15:34:17 GMT -5
This is also complicated by the fact that it's regulated at the state level. So lots of states thought they could curb homebirths by making CNMs and OBs only delivery in hospitals, but it just meant that homebirths were then attended mostly by direct entry midwives who are not medical professionals. We'd have to change this at the state level, it won't help nationally really. We would each need to talk to local representatives and have them look at the issue of who is licensed through each state to oversee homebirths.
Plus, where are they getting most of the data? Is it b/c only the homebirths with issues are tracked b/c they show up in the hospital that tracks things, I'm curious about that b/c statistically, it might not be tracking everyone since I don't know if direct entry midwives have to report to anyone and how often. Also do they follow HIPPA requirements, I would assume so, but don't know.
The nurse who presented that data to the legislature seems like she knows her stuff, but she also is comparing data from known deaths for out of hospital births in 2012 in OR directly to Canadian and European hospital birth deaths - not directly to OR in-hospital deaths. It's my opinion, but I believe the nurse needed to present more direct data on hospital births in OR and the legislators look at allowing CNMs/OBs to perform out of hospital births rather than having states license direct entry midwives.
ETA2: And the other study, published, that is referenced shows that a national study of births from 2006 to 2009 did have an increase in child deaths, but I can't get the full article, just these results below. Basically, it compares in hospital midwife births with out of hospital midwife births, but looks like it does not compare to in hospital OB births since OBs take higher risk patients and surgeries and therefore have higher loss outcomes due to this. This seems like it would be a valid study to present to lawmakers about regulating direct entry midwives vs. CNMs for homebirths and maybe give guidelines or guidance on when a 41+ week or first born to a mother might be higher risk.
Midwife home births had a significantly higher total neonatal mortality risk than deliveries by hospital midwives (1.26 per 1000 births; relative risk [RR], 3.87 vs 0.32 per 1000; P < .001). Midwife home births of 41 weeks or longer (1.84 per 1000; RR, 6.76 vs 0.27 per 1000; P < .001) and midwife home births of women with a first birth (2.19 per 1000; RR, 6.74 vs 0.33 per 1000; P < .001) had significantly higher risks of total neonatal mortality than deliveries by hospital midwives. In midwife home births, neonatal mortality for first births was twice that of subsequent births (2.19 vs 0.96 per 1000; P < .001). Similar results were observed for early neonatal mortality. The excess total neonatal mortality for midwife home births compared with midwife hospital births was 9.32 per 10,000 births, and the excess early neonatal mortality was 7.89 per 10,000 births.
Post by downtoearth on May 4, 2016 16:03:19 GMT -5
Oh and I'll add again that many OBs/CNMs can't get malpractice insurance for out of hospital births, so the more data that shows that a medical professional standard of care is better out of hospital than a CPM, the more likely insurance will cover them and then you can see CNMs/OBs attend births out of the hospital. I remember reading that Norway has a lot of CNM homebirths, but their CNMs are covered by insurance and such since the outcomes are actually better for all CNM homebirths as compared to low-risk in-hospital OB births there.
Plus, where are they getting most of the data? Is it b/c only the homebirths with issues are tracked b/c they show up in the hospital that tracks things, I'm curious about that b/c statistically, it might not be tracking everyone since I don't know if direct entry midwives have to report to anyone and how often.
Only speaking from my experience, but my CPMs have me fill out a waiver during my first appt saying they can disclose info about my birth to MANA. It is the group that collects data about homebirths for midwives in North America.
I know many of the anti-homebirth studies use data from the CDC, which gets their info from the vital statistics forms filled out after every birth. It's the form you fill out to get a birth certificate and take to the Bureau of Vital Statistics. In the hospital this form is filled out fir you by the nurses and they just have you sign it. For a homebirth you have to file it yourself. Anyways, the form asks very generic questions, such as where the birth took place (so you choose hospital, home, etc) and then it asks the outcome of the birth. It doesn't ask if the homebirth was planned or what type of care the mother received prenatally. So to pull statistics from there is slightly misleading in the same way only using stats from homebirth to hospital transfers can be misleading.
Plus, where are they getting most of the data? Is it b/c only the homebirths with issues are tracked b/c they show up in the hospital that tracks things, I'm curious about that b/c statistically, it might not be tracking everyone since I don't know if direct entry midwives have to report to anyone and how often.
Only speaking from my experience, but my CPMs have me fill out a waiver during my first appt saying they can disclose info about my birth to MANA. It is the group that collects data about homebirths for midwives in North America.
I know many of the anti-homebirth studies use data from the CDC, which gets their info from the vital statistics forms filled out after every birth. It's the form you fill out to get a birth certificate and take to the Bureau of Vital Statistics. In the hospital this form is filled out fir you by the nurses and they just have you sign it. For a homebirth you have to file it yourself. Anyways, the form asks very generic questions, such as where the birth took place (so you choose hospital, home, etc) and then it asks the outcome of the birth. It doesn't ask if the homebirth was planned or what type of care the mother received prenatally. So to pull statistics from there is slightly misleading in the same way only using stats from homebirth to hospital transfers can be misleading.
Yeah, it looks that is why they are citing the OR study. OR requires more data to be collected with out of hospital births, so that is why the study focused on that state. I think you are right that many states do not require data to be collected on out of hospital births aside from the birth certificate and/or death certificates.
I'm just chiming in to say that Canada is a very large country and each province regulates midwifery differently. For example, in Nova Scotia, there are like 3 midwives on government payroll all based out of a total of 2 central hospitals. The rest of the province has no (legal) access to any midwives. On the other hand, Newfoundland and New Brunswick don't regulate midwifery (as far as I know). So I'm not sure why the author is lumping all of Canada together. Clearly the statistics were pulled from one provinces regulations.
Medicaid pays for nearly half of all births in the U.S., so it's not a small percentage.
Home births cost thousands of dollars and often insurance will not cover it. And home birth significantly increases the chances of neonatal death and brain damage. So I'm not sure it falls under either safe or affordable. We need to make health care more affordable and accessible, but the answer isn't more home births.
Maybe it's because I hated laboring in a hospital but if I could have I would have loved to have given birth at the birth center in my hometown. Every appt plus labor and delivery was 3k. They have privileges at local hospitals if you don't meet the safety criteria for delivering at their center. The board of the center is,made up of MDs. I realize this is not technically a home birth but it's a non hospital birth attended by CNMs and nps. It's much more what I would have wanted for myself. And I don't see what is so dangerous or horrible about it. It's a million times cheaper than a hospital birth and it's safe because if you become high risk you get kicked out to a hospital.
There are possibilities between homebirth with lay midwife and hospital birth. It can be safe and it can save money.
I am planning to give birth at a hospital based birth center, it is on the hospital grounds, staffed by the same nurses in the hospital, all the midwives are CNMs, and there is a 2 min route to the OR. There are several pages of reasons that you either can't give birth there or momma and baby will be transferred to the hospital after birth.
I think it is a good alternative to a traditional hospital birth. However, it is exceedingly rare as an option, when we did our tour they said it is one of only five hospital based birth centers in the country.
Oh, IDK, probably since medicaid in virtually every state covers pregnancy with a much higher income limit than other forms of medicaid qualification.
well obviously if you're covered by Medicaid but that's a small percentage of the population. Even if you're insured it's not cheap.
If you have high deductible insurance, childbirth even in a hospital can be pretty expensive. We don't hit our deductible until 6500 so it's not cheap to have a baby on our kind of insurance.
I haven't read the thread that closely but I really think women should be able to choose freely between hospital, birthing center, or home. Efforts should be made to make it safer to do at home.
well obviously if you're covered by Medicaid but that's a small percentage of the population. Even if you're insured it's not cheap.
If you have high deductible insurance, childbirth even in a hospital can be pretty expensive. We don't hit our deductible until 6500 so it's not cheap to have a baby on our kind of insurance.
I haven't read the thread that closely but I really think women should be able to choose freely between hospital, birthing center, or home. Efforts should be made to make it safer to do at home.
ITA with all of this. We have a high deductable plan and do not qualify for Medicaid. I met with an OB at the beginning of my last pregnancy to discuss a hospital birth as an option. I decided against it for many reasons, including things like not being allowed to deliver in the tub and stuff like that, but I'd be lying if I didn't say that cost wasn't a factor. I was looking at a $7000 bill for delivery at a hospital with this baby being due at the beginning of the year. Having a homebirth saved us at least $4000. That's a lot of money for a family like ours.
I've had great homebirth experiences. My only option is CPMs and I'm very thankful that mine are extremely skilled and knowledgeable. But I absolutely support measures to make homebirth safer for everyone, so long as those restrictions don't restrict that choice for women. If this country wants to be pro-choice and pro-reproductive freedom, childbirth is part of that.