If people ran studies with the omission, exaggeration, bias, and bulked up with extraneous research, with the same enthusiasm as creating a paper with proven percentages, ages, participants, races, etc that were real and accurate without cutting corners, omitting pertinent information while not concerned who it offends, or what the results will reveal, science would begin to grow legs which would lead to actual usable material to forge new horizons.
I am glad that Dr Rall as a third year resident is taking an active interest in medical issues such as this. However, I think that he is failing to understand some important distinctions between planned home birth in the USA and planned home birth in other western " well resourced "countries. Full disclosure - I am an OB Hospitalist who frequently is required to admit and deliver " home births gone bad " in a region of the country where planned home birth( including home VBAC ) is very popular - and I also manage and deliver a lot of previous cesarean patients with high VBAC success rates , and work closely with hospital based nurse midwifery groups . I agree that cesarean rates are too high in some places, and I have my own thoughts as to why that is, but more home births is not the solution, at least not in the US . FIrst and most important - a " midwife " in Europe and Canada is by definition a Certified Nurse Midwife who has undergone structured graduate level medical training . In the USA this is not the case- a " midwife" can be a Licensed Midwife, a Professional Midwife, A Certified Professional Midwife, a lay midwife or a Certified Nurse Midwife. Most often patients do not understand the differences. With the exception of the CNM credential , all of these paths to midwifery are apprenticeship based- there is some kind of variable book learning in an informal setting , and a student midwife apprentices herself to a working community midwife and observes and performs births - usually the number is 75 observed and 25 performed - and is then off an running on her own. Since many high risk conditions occur with frequencies of 1-2% this gives the trainee a very narrow experience , and no real training in how to recognize high risk and dangerous conditions in my experience. There is no requirement for college level work ( just a high school diploma ) and the ability and judgement among various individuals is highly variable. This path to practice is actually not recognized in Europe and Canada, who utilize CNM midwifery( bachelor's in Nursing and Graduate level Midwifery degree) training exclusively. Second , and most importantly , the triage mechanism for who is eligible for home birth in the USA is basically patient desire. A large number of high risk women ( prior CS, obese, diabetic, hypertensive, age > 35 , twins ) do not wish to see themselves as high risk and will opt for a community midwife and a planned home birth as a way to avoid having to face the fact that they are indeed, high risk. Very few of these patients are turned away by the apprenticeship- type midwives, who preach patient autonomy over medical judgement. In contrast, the CNM model in other western countries ( and in integrated CNM/physician groups in the US ) will risk stratify patients as suitable or not suitable for midwifery care and decline to enroll high risk patients for planned home birth if they are not truly " low risk" regardless of what they want. Additionally, in Europe, people live close together and close to hospital care, there is collaboration between nurse midwives delivering in homes and physicians that is not allowed in the US due to medical malpractice rules and restrictions . I live in the Western US , and the travel time from home to closest hospital with OB services can be > 100 miles . Clearly , an unforseen emergency in winter with 100 miles to transport does not lend itself to good outcomes. Europe is not structured this way . Having worked with British midwives, I can say that their system is a good one, but not one we have here. So when comparing outcomes data we have to be sure we are comparing apples to apples and not apples to oranges.
Question: if the outcomes of planned home births (by definition these are low risk) is no different from planned hospital births (which includes all the high risk births), doesn't that suggest that the rate of bad outcomes for home births is greater than rate for low risk hospital births?
A related issue: social class may be another confounding factor. In the US, mothers choosing home birth are more likely to have higher socioeconomic status; they can afford to pay out of pocket for services not covered by insurance. Wealthier patients have better outcomes; if home births became more common, they would start to include women with lower incomes and higher risk.
A separate issue: as a family physician delivering babies in a medium size inner city, I notice there are fewer and fewer low/normal risk births. Over half the women of childbearing age are obese, and a higher percentage develop gestational diabetes, PIH, pre-eclampsia, and postpartum hemorrhage. The pool of women eligible for "low risk" deliveries is shrinking.
No indication of issues. Quick delivery, doctor proclaimed “flat”, nurse hit the emergency red button, immediately in came a team, she was whisked out in a stainless steel pan, off to emergency prenatal to revive. Survived with no effects.
My daughter’s birthing room at the hospital was huge and comfortable with a full bath and a bed for her husband. She labored and delivered in that room, and there was space for an entire team if needed. Interference from staff was minimal. Her space was quiet and peaceful. Seems to me this set up is a perfect solution~ comfortable and private, but close to help if needed.
I feel so confused when I read how great the home birth situation is in Canada. I live in New Brunswick and I had six babies in hospital because it’s illegal to have an attended at-home birth.
And it’s very difficult to get a birth certificate after an at-home birth.
Lost me first paragraph! Your a MD and you gave birth to your kids at home, no problems! I think you are a little more expert than 99.5 % of the people who might chose that route. Dumb Article!
Makary is a surgeon. He does not have medical staff privileges in Ob Gyn. It is unprofessional conduct for a physician to stary outside their area of expertise which is referred to as "epistemic trespassing". Physicians should confine their opinions to those areas in which we are credentialed.
Part of the issue here is that the medical world treats birth like a surgery or other hospital procedure. I had two hospital births and they were both fine, but the hospital experience does not match the emotional and almost spiritual process of having a child. I often felt like I was on other people's time. The hospital wants you out of the there ASAP. For my first birth, my water broke and I was having contractions like crazy, but I was only a fingertip dilated. They said I either had to start Pitocin or go home. I begrudgingly went home to wait it out. You feel constrained by all the rules and structure of a hospital. You feel like you are sick because it is a hospital. It's not a great place to go through a bodily process that requires the woman to work through pain and find a groove. It is annoying to have doctors ridicule women for looking outside the system when the system has little patience, is expensive, and often unsympathetic to the wild world of giving birth. Birthing centers near hospitals are probably the best middle ground options that address some of what I mention above.
Lots of strong opinions here to be sure ...backed almost entirely by anecdotal experience as opposed to the scientific method advocated by the author. Of course, anecdotes do influence our our practice of medicine and always have, but we should at least be cognizant of that.
There is no mention however of The possibility that there are world views where absolute risk and relative risk are not the way we see our lives and our responsibilities.
MY EXPERIENCE DELIVERING BABIES IN THE HOME, From my book, 'Never Get Sick on the 1st of July' Larry J Miller MD
In the sixties, thousands of women who could not, or would not, come to Cook County to have their babies were delivered in their homes by an organization called the Chicago Maternity Center. Personnel included midwives, nurses, doctors, and medical students. They provided help for over 100,000 women in their history and complication rates were lower than in many area hospitals.
There were many reasons why women did not deliver at the hospital, including tradition and ignorance. Others simply could not leave their families unattended to go to the hospital and for others a lack of transportation made it impossible.
Before the advent of the Chicago Maternity Center, the infant mortality rate for this group was unacceptably high as were maternal deaths from hemorrhage and infections. Since these women were unable or unwilling to come to the hospital, Chicago Maternity Center personnel went to their homes and assisted in deliveries.
After my rotation on the labor line, I volunteered my services to the Chicago Maternity Center one day a week. We could only volunteer during our rotation on certain services where there was an excess of interns, so that when we were away from the hospital, our floor could be covered. We were assigned in pairs for our own safety and, in case of complications, one could attend to the mother while the other cared for the infant or went for help.
The only requirement for patients was to have received prenatal care from a visiting nurse, and access to a telephone somewhere in the neighborhood. Each patient was to have available clean, warm blankets for the baby, a large pot of boiling water, and a stack of newspapers. The boiling water was to clean our instruments, wash our hands and the patient, and the newspapers were used as sterile drapes. Printers ink is bactericidal and renders the newspapers perfectly sterile.
My partner for the day was Tom Norton, a huge man who had played on the Nebraska football team. We rode in his small Volkswagen Beetle to our call in the ghetto. Even with John by my side, I was apprehensive as we drove through the dilapidated streets to our destination. Although I had never heard of any health care workers being attacked, it was a fact that white folks were not welcome in these neighborhoods, especially after dark. We were advised to disregard stop signs and red lights and continue driving.
We arrived at a duplex which, in its day, had been a magnificent home. We parked along the curb in front, among a few other old cars. Folks were sitting on their porches talking and staring at us. Others were standing in groups along the street, drinking beer and chatting. A few children were chasing each other up and down the sidewalk. We must have been a curious sight as we carried our large OB bag up the stairs to the second-floor apartment. The patient's 11-year-old son was waiting and opened the door.
"C'mon in docs," he said.
The apartment was dimly lit with scattered, broken down furniture, piles of dirty clothes in the corner, and bags of garbage along one wall. The patient was lying in a small bedroom, covered with a sheet. I introduced myself and John and asked her how long she'd been in labor. Everything was in order. There was a stack of newspapers beside the bed and a pot of boiling water was on the stove. Blankets were at the bedside for the baby. I opened the OB pack and laid it at the foot of the bed. After putting on a pair of sterile gloves, I examined the patient and, sure enough, she was about 8 centimeters dilated (full dilation is about 10). She was fully effaced, meaning the cervix had completely thinned out, and the baby was at a plus-one station. It would only be a short time before she delivered.
John and I made small talk with the patient between labor pains and chatted with the kids. The mother kept screaming for them to get out of the room and wait in the kitchen. But they kept coming back in to see what was going on. She was tough and only moaned slightly with the pain. She'd been through labor many times before but was appreciative that we were there to help her. As the baby's head began to crown, I placed the newspapers under her perineum and she bent her knees up like a frog. I asked her to place her hips on the inverted basin in our pack to elevate her hips off the soft mattress. I washed the perineum with a soap solution and soon the baby was born. She did not require an episiotomy since she had not had one for the previous babies, and as soon as the baby was born, he began to cry vigorously. I clamped the umbilical cord and placed the baby in her arms. The mother quickly wrapped him in a towel.
A few minutes later I delivered the placenta and massaged the uterus. John gave her Methergine tablets to control the bleeding, then we began to wash our instruments and pack them away. I filled out the birth certificate and did the paperwork. By now the mother was resting comfortably, she was no longer actively bleeding, and the baby was sleeping contentedly. It had been a completely uneventful delivery -- the best kind. We talked to the mother about breast feeding and birth control and encouraged her. She was a sweet lady who thanked us profusely for our help.
It was almost dark as we left the apartment with our used maternity pack wrapped in green sheets, but we could see something was wrong with John's Volkswagen. It seemed to be sitting very low to the ground. It soon became apparent that all four wheels had been removed and it was resting on its axles. Most of the same people who had been sitting around the porches and talking along the sidewalks when we arrived were still there. Certainly, they had seen what had happened. I was frightened, but John was furious. He spoke in a loud voice, almost as if giving a political speech.
"We came here to help one of your sisters deliver her baby. We did it out of the goodness of our heart because we wanted to help you. Now, look at the thanks we get. You stole our tires and we can't get home! We don't get paid anything for coming here. We don't get paid anything at Cook County Hospital. Why don't you pick on somebody else?!"
I stood in the doorway as his words echoed up and down the block. I said to myself, "We're going to get killed." I thought about running back upstairs and hiding under my patient's bed.
Groups of people on various porches began talking among themselves, a few others scurried in and out of doorways. A minute later I heard an enormous sound behind me coming from the third-floor apartment. THUMPETY, THUMP, THUMP, THUMP, THUMPETY, THUMP, THUMP, THUMP.
I turned to see what was happening and four teenagers, each rolling a wheel, scooted past me out the door. The first one said, "We're sorry, Doc! We didn't know it was your car!"
With the speed and efficiency of midnight auto suppliers, they jacked up the car and bolted on the wheels, the whole process taking less than five minutes. I still felt uncomfortable and stood in the doorway, watching all the activity, while John stood in front of the car with his hands resting on his hips. When they finished, John thanked them, then said, "Miller, let's get out of here."
The boys were laughing and the small crowd of people continued to gawk as if this was just another episode of life in the ghetto. But I knew this was not business as usual. We were lucky to have our wheels back and to leave unscathed for our next delivery. I only hoped this gesture of kindness, in delivering a baby in the home, would have a positive effect on the neighborhood and their impression of the crazy interns at Cook County.
Ha, it sounds like an episode of "Call the Midwife"! That's a great series. Medical professionals simply helping fellow humans without any of the associated trappings of organized medicine, mediolegal pressures, or hospital regs. Thanks for sharing.
The situation in the US is different than Europe. Most home births here are assisted by lay midwives. Their certification exam reveals they are not safe practitioners — if you think giving homeopathics for hemorrhage is a concern.
In Colorado, the statistics for lay midwives were required by law. When increased to 16 deaths per 1,000, the legislature’s response was to stop collecting the data.
In the US, a better choice is a birthing center located next to a hospital. OB emergencies are not always predictable, and when they happen, you want a team of professionals that can respond in minutes. Neonatal death!is not the only problem outcome.
I live in the northeast, and it's fairly easy to find a CNM here. I've don't know anyone who has used a lay midwife, but maybe it's different in other parts of the country? Unfortunately, our free-standing birth centers are very few (I think we have one left in the state), and the one that I birthed my children at two decades ago has closed. Many hospitals that service rural areas are also closing their labor and delivery units. Nine have closed in the past decade in my very rural state of Maine. Some expecting mothers have a 3 hr drive to get to a hospital with a labor and delivery unit. They were simply not profitable, although I would argue they were essential to the health of the communities they served. I would love to see more birth centers, and labor and delivery units, but the landscape is as it is, for now. Home birth with a CNM may be an informed decision some women feel is best for them and their families. They are certainly being sent the message that because they are not profitable, the hospitals deem their needs to be non-critical.
That one, almost off-hand, comment on home birth in Dr. Makary's superb book really stuck out to me as well. I guess doctors just get immune to how disgusting hospitals actually are. I was lucky enough to have my babies at a free-standing birth center with an amazing midwife and a doula. There was lots of room to move around, relaxing lighting, a huge birthing tub, and no one nagging about maybe getting an epidural. If I didn't have that option, I would have 100% gone with home births. If my first birth had been in a hospital, I'm sure I would have ended up with a C-section. They simply would have been like, this is taking too long and she doesn't have the urge to push, time for the cesarean. Having visited family members in hospitals after they gave birth/were born made me fully appreciate how fortunate I was.
We were able to come home with our baby hours after giving birth, and the follow-up, in-home care from the midwife that we received in the weeks after was amazing. I should give a shout out, though, to our pediatrician, who suggested he make a house call for our first well baby check. He said we were on his way to the office and that newborns should be at home with their family, not in a doctor's office or hospital. So, I do hope that in future editions of his book Dr. Makary adds a bit more nuance to his home birth comment. The issue is not with home birth in and of itself, but with a system that profits from over-medicalizing every birth, even the straightforward ones.
I would like to see discussion of social media’s effect on the decision to have a home birth. I haven’t had my coffee yet, and there’s too much to say to contain in one comment. I will say, I definitely felt the pressure to be more “natural” and “against those corporate uncaring doctors” by foregoing epidurals and having a birth in a blowup pool in your living room.
I am an obstetrician and I have delivered about 10000 babies. There are some generalizations in this article that could be a bit more nuanced. I agree that there has been the over medicalization of pregnancy and child birth. Electronic fetal monitoring was going to lower cesarean sections, reduce CP, etc. It has done none of that. There are some instances when it has been life saving for the baby, but mostly I see people "over reading" fetal heart rate strips and rushing to surgery. The fear of being sued is a huge reason, too. Newborns should not be given vaccines on day one is another example. I think it is important to look at the hospital you plan to deliver your baby. Our hospital has a cesarean rate well below 20%, I cant remember the last time I did an episiotomy....(I think they are barbaric), used forceps, etc. I have worked with midwives my entire career both civilian and military and they are an integral and invaluable part of care. Home births are great until they are not. I am at a tertiary care hospital and we accept patients who are trying home births by lay midwives and I have seen dome catastrophes. The answer does lie somewhere in between. Ready access to a hospital for emergencies is key along with people knowing their limitations regarding child birth. PS-I think ACOG has lost their collective mind in the last 10 years. They are so pro-abortion it is ridiculous. I went into OB/GYN to promote healthy moms and babies. I don't think that abortions should be illegal but what happened to safe, rare and legal?
Appreciate your thoughts!!! Very rare to see an OB who gets how rubbish fetal monitoring is. I had labored at home for 48 hours before going to the hospital. I went because the pain was starting to get to that point where I wasn't sure I would be able to handle it. The CNM on call is like... you're 5cm. We don't admit till you're 6cm. You just have to wait in triage till you're 6cm (side note- I was still 5 cm 6 hours later. Took nitrous for 2h, feel asleep and woke up 10cm and ready to push). So I was like- I'm not sitting here in triage where my doula isn't allowed to be here with me to help with pain management. I'm going home. Suddenly they "notice" decelerations on the EFM. My birth plan said no EFM (precisely because I didn't care for the "reading of tea leaves" that it is)... but the intake EFM seemed impossible to avoid. So they admitted me. Kept pressuring me throughout to get EFM. It's all so surreal looking back.
Thank you, Dr Melnitz. I, too, have delivered thousands of babies, over 2,000 personally, and many more as attending for CNMs in a hospital setting. My experience and perspective on the medicalization of childbirth is very similar to yours. For me this is your key statement "Home births are great until they are not." Even in the hospital, sudden onset of hemorrhage, maternal and/or fetal compromise mean every minute is vital. Over the nearly 40 years I practiced in inner city hospitals in poor southern cities, I was amazed to see just how unhealthy our patients became and how much more frequent maternal complications and (yes, death) have become. Unfortunately, when our patients would insist on home delivery, it was most often the ones who were not "low risk". I wonder how the population in Denmark, as discussed in this article, compares to the US.
Wise, seasoned certified nurse midwives (like one of the ones who delivered my baby) in an attached birthing center would seem to be the key.
I also think that many women have been influenced by social media to have an expectation of the birth process that may be unattainable and this leads to disappointment and guilt over what is perceived to be a "failure". A healthy Mama and baby are always the best result, in my humble opinion.
As for ACOG, my friends and I agree they have lost their minds. Birthing persons, racism, supersubspecialization. Safe, rare and legal should be the goal in this OBGYNs opinion.
When I was pregnant, everything in online pregnancy groups or online was all about the “birth plan” and insisting that the providers adhere to the birth plan. It made doctors and hospitals sound absolutely awful! But, my mom died during my birth, and so my birth plan said- healthy and mom and baby. Whatever it takes to get there. I had a wonderful OB who tenderly guided me through two pregnancies, and she delivered both of my children. There is so much emphasis placed on “wishes” and “plans,” and that is great, but birth is anything but predictable sometimes.
If people ran studies with the omission, exaggeration, bias, and bulked up with extraneous research, with the same enthusiasm as creating a paper with proven percentages, ages, participants, races, etc that were real and accurate without cutting corners, omitting pertinent information while not concerned who it offends, or what the results will reveal, science would begin to grow legs which would lead to actual usable material to forge new horizons.
I am glad that Dr Rall as a third year resident is taking an active interest in medical issues such as this. However, I think that he is failing to understand some important distinctions between planned home birth in the USA and planned home birth in other western " well resourced "countries. Full disclosure - I am an OB Hospitalist who frequently is required to admit and deliver " home births gone bad " in a region of the country where planned home birth( including home VBAC ) is very popular - and I also manage and deliver a lot of previous cesarean patients with high VBAC success rates , and work closely with hospital based nurse midwifery groups . I agree that cesarean rates are too high in some places, and I have my own thoughts as to why that is, but more home births is not the solution, at least not in the US . FIrst and most important - a " midwife " in Europe and Canada is by definition a Certified Nurse Midwife who has undergone structured graduate level medical training . In the USA this is not the case- a " midwife" can be a Licensed Midwife, a Professional Midwife, A Certified Professional Midwife, a lay midwife or a Certified Nurse Midwife. Most often patients do not understand the differences. With the exception of the CNM credential , all of these paths to midwifery are apprenticeship based- there is some kind of variable book learning in an informal setting , and a student midwife apprentices herself to a working community midwife and observes and performs births - usually the number is 75 observed and 25 performed - and is then off an running on her own. Since many high risk conditions occur with frequencies of 1-2% this gives the trainee a very narrow experience , and no real training in how to recognize high risk and dangerous conditions in my experience. There is no requirement for college level work ( just a high school diploma ) and the ability and judgement among various individuals is highly variable. This path to practice is actually not recognized in Europe and Canada, who utilize CNM midwifery( bachelor's in Nursing and Graduate level Midwifery degree) training exclusively. Second , and most importantly , the triage mechanism for who is eligible for home birth in the USA is basically patient desire. A large number of high risk women ( prior CS, obese, diabetic, hypertensive, age > 35 , twins ) do not wish to see themselves as high risk and will opt for a community midwife and a planned home birth as a way to avoid having to face the fact that they are indeed, high risk. Very few of these patients are turned away by the apprenticeship- type midwives, who preach patient autonomy over medical judgement. In contrast, the CNM model in other western countries ( and in integrated CNM/physician groups in the US ) will risk stratify patients as suitable or not suitable for midwifery care and decline to enroll high risk patients for planned home birth if they are not truly " low risk" regardless of what they want. Additionally, in Europe, people live close together and close to hospital care, there is collaboration between nurse midwives delivering in homes and physicians that is not allowed in the US due to medical malpractice rules and restrictions . I live in the Western US , and the travel time from home to closest hospital with OB services can be > 100 miles . Clearly , an unforseen emergency in winter with 100 miles to transport does not lend itself to good outcomes. Europe is not structured this way . Having worked with British midwives, I can say that their system is a good one, but not one we have here. So when comparing outcomes data we have to be sure we are comparing apples to apples and not apples to oranges.
Question: if the outcomes of planned home births (by definition these are low risk) is no different from planned hospital births (which includes all the high risk births), doesn't that suggest that the rate of bad outcomes for home births is greater than rate for low risk hospital births?
A related issue: social class may be another confounding factor. In the US, mothers choosing home birth are more likely to have higher socioeconomic status; they can afford to pay out of pocket for services not covered by insurance. Wealthier patients have better outcomes; if home births became more common, they would start to include women with lower incomes and higher risk.
A separate issue: as a family physician delivering babies in a medium size inner city, I notice there are fewer and fewer low/normal risk births. Over half the women of childbearing age are obese, and a higher percentage develop gestational diabetes, PIH, pre-eclampsia, and postpartum hemorrhage. The pool of women eligible for "low risk" deliveries is shrinking.
No indication of issues. Quick delivery, doctor proclaimed “flat”, nurse hit the emergency red button, immediately in came a team, she was whisked out in a stainless steel pan, off to emergency prenatal to revive. Survived with no effects.
My daughter’s birthing room at the hospital was huge and comfortable with a full bath and a bed for her husband. She labored and delivered in that room, and there was space for an entire team if needed. Interference from staff was minimal. Her space was quiet and peaceful. Seems to me this set up is a perfect solution~ comfortable and private, but close to help if needed.
Sounds like the way it should be!
I feel so confused when I read how great the home birth situation is in Canada. I live in New Brunswick and I had six babies in hospital because it’s illegal to have an attended at-home birth.
And it’s very difficult to get a birth certificate after an at-home birth.
Lost me first paragraph! Your a MD and you gave birth to your kids at home, no problems! I think you are a little more expert than 99.5 % of the people who might chose that route. Dumb Article!
Makary is a surgeon. He does not have medical staff privileges in Ob Gyn. It is unprofessional conduct for a physician to stary outside their area of expertise which is referred to as "epistemic trespassing". Physicians should confine their opinions to those areas in which we are credentialed.
Michael Patmas, MD, FACP
Multiparous women under thirty five, without prior C/Section, represents what percentage of births?
What’s your point?
Abut 30%.
Part of the issue here is that the medical world treats birth like a surgery or other hospital procedure. I had two hospital births and they were both fine, but the hospital experience does not match the emotional and almost spiritual process of having a child. I often felt like I was on other people's time. The hospital wants you out of the there ASAP. For my first birth, my water broke and I was having contractions like crazy, but I was only a fingertip dilated. They said I either had to start Pitocin or go home. I begrudgingly went home to wait it out. You feel constrained by all the rules and structure of a hospital. You feel like you are sick because it is a hospital. It's not a great place to go through a bodily process that requires the woman to work through pain and find a groove. It is annoying to have doctors ridicule women for looking outside the system when the system has little patience, is expensive, and often unsympathetic to the wild world of giving birth. Birthing centers near hospitals are probably the best middle ground options that address some of what I mention above.
Lots of strong opinions here to be sure ...backed almost entirely by anecdotal experience as opposed to the scientific method advocated by the author. Of course, anecdotes do influence our our practice of medicine and always have, but we should at least be cognizant of that.
There is no mention however of The possibility that there are world views where absolute risk and relative risk are not the way we see our lives and our responsibilities.
http://ereserve.library.utah.edu/Annual/SW/6623/Frost/sw6623vanish.pdf Appreciate this OB/GYN and medical anthropologist’s perspective here. Data are inevitably a product of social milieu.
MY EXPERIENCE DELIVERING BABIES IN THE HOME, From my book, 'Never Get Sick on the 1st of July' Larry J Miller MD
In the sixties, thousands of women who could not, or would not, come to Cook County to have their babies were delivered in their homes by an organization called the Chicago Maternity Center. Personnel included midwives, nurses, doctors, and medical students. They provided help for over 100,000 women in their history and complication rates were lower than in many area hospitals.
There were many reasons why women did not deliver at the hospital, including tradition and ignorance. Others simply could not leave their families unattended to go to the hospital and for others a lack of transportation made it impossible.
Before the advent of the Chicago Maternity Center, the infant mortality rate for this group was unacceptably high as were maternal deaths from hemorrhage and infections. Since these women were unable or unwilling to come to the hospital, Chicago Maternity Center personnel went to their homes and assisted in deliveries.
After my rotation on the labor line, I volunteered my services to the Chicago Maternity Center one day a week. We could only volunteer during our rotation on certain services where there was an excess of interns, so that when we were away from the hospital, our floor could be covered. We were assigned in pairs for our own safety and, in case of complications, one could attend to the mother while the other cared for the infant or went for help.
The only requirement for patients was to have received prenatal care from a visiting nurse, and access to a telephone somewhere in the neighborhood. Each patient was to have available clean, warm blankets for the baby, a large pot of boiling water, and a stack of newspapers. The boiling water was to clean our instruments, wash our hands and the patient, and the newspapers were used as sterile drapes. Printers ink is bactericidal and renders the newspapers perfectly sterile.
My partner for the day was Tom Norton, a huge man who had played on the Nebraska football team. We rode in his small Volkswagen Beetle to our call in the ghetto. Even with John by my side, I was apprehensive as we drove through the dilapidated streets to our destination. Although I had never heard of any health care workers being attacked, it was a fact that white folks were not welcome in these neighborhoods, especially after dark. We were advised to disregard stop signs and red lights and continue driving.
We arrived at a duplex which, in its day, had been a magnificent home. We parked along the curb in front, among a few other old cars. Folks were sitting on their porches talking and staring at us. Others were standing in groups along the street, drinking beer and chatting. A few children were chasing each other up and down the sidewalk. We must have been a curious sight as we carried our large OB bag up the stairs to the second-floor apartment. The patient's 11-year-old son was waiting and opened the door.
"C'mon in docs," he said.
The apartment was dimly lit with scattered, broken down furniture, piles of dirty clothes in the corner, and bags of garbage along one wall. The patient was lying in a small bedroom, covered with a sheet. I introduced myself and John and asked her how long she'd been in labor. Everything was in order. There was a stack of newspapers beside the bed and a pot of boiling water was on the stove. Blankets were at the bedside for the baby. I opened the OB pack and laid it at the foot of the bed. After putting on a pair of sterile gloves, I examined the patient and, sure enough, she was about 8 centimeters dilated (full dilation is about 10). She was fully effaced, meaning the cervix had completely thinned out, and the baby was at a plus-one station. It would only be a short time before she delivered.
John and I made small talk with the patient between labor pains and chatted with the kids. The mother kept screaming for them to get out of the room and wait in the kitchen. But they kept coming back in to see what was going on. She was tough and only moaned slightly with the pain. She'd been through labor many times before but was appreciative that we were there to help her. As the baby's head began to crown, I placed the newspapers under her perineum and she bent her knees up like a frog. I asked her to place her hips on the inverted basin in our pack to elevate her hips off the soft mattress. I washed the perineum with a soap solution and soon the baby was born. She did not require an episiotomy since she had not had one for the previous babies, and as soon as the baby was born, he began to cry vigorously. I clamped the umbilical cord and placed the baby in her arms. The mother quickly wrapped him in a towel.
A few minutes later I delivered the placenta and massaged the uterus. John gave her Methergine tablets to control the bleeding, then we began to wash our instruments and pack them away. I filled out the birth certificate and did the paperwork. By now the mother was resting comfortably, she was no longer actively bleeding, and the baby was sleeping contentedly. It had been a completely uneventful delivery -- the best kind. We talked to the mother about breast feeding and birth control and encouraged her. She was a sweet lady who thanked us profusely for our help.
It was almost dark as we left the apartment with our used maternity pack wrapped in green sheets, but we could see something was wrong with John's Volkswagen. It seemed to be sitting very low to the ground. It soon became apparent that all four wheels had been removed and it was resting on its axles. Most of the same people who had been sitting around the porches and talking along the sidewalks when we arrived were still there. Certainly, they had seen what had happened. I was frightened, but John was furious. He spoke in a loud voice, almost as if giving a political speech.
"We came here to help one of your sisters deliver her baby. We did it out of the goodness of our heart because we wanted to help you. Now, look at the thanks we get. You stole our tires and we can't get home! We don't get paid anything for coming here. We don't get paid anything at Cook County Hospital. Why don't you pick on somebody else?!"
I stood in the doorway as his words echoed up and down the block. I said to myself, "We're going to get killed." I thought about running back upstairs and hiding under my patient's bed.
Groups of people on various porches began talking among themselves, a few others scurried in and out of doorways. A minute later I heard an enormous sound behind me coming from the third-floor apartment. THUMPETY, THUMP, THUMP, THUMP, THUMPETY, THUMP, THUMP, THUMP.
I turned to see what was happening and four teenagers, each rolling a wheel, scooted past me out the door. The first one said, "We're sorry, Doc! We didn't know it was your car!"
With the speed and efficiency of midnight auto suppliers, they jacked up the car and bolted on the wheels, the whole process taking less than five minutes. I still felt uncomfortable and stood in the doorway, watching all the activity, while John stood in front of the car with his hands resting on his hips. When they finished, John thanked them, then said, "Miller, let's get out of here."
The boys were laughing and the small crowd of people continued to gawk as if this was just another episode of life in the ghetto. But I knew this was not business as usual. We were lucky to have our wheels back and to leave unscathed for our next delivery. I only hoped this gesture of kindness, in delivering a baby in the home, would have a positive effect on the neighborhood and their impression of the crazy interns at Cook County.
Ha, it sounds like an episode of "Call the Midwife"! That's a great series. Medical professionals simply helping fellow humans without any of the associated trappings of organized medicine, mediolegal pressures, or hospital regs. Thanks for sharing.
Thank you for sharing that story. That must have been quite the day, lol.
My, oh my. City of Memphis Chandler Women's Hospital for my first deliveries. Some things you don't forget.
The situation in the US is different than Europe. Most home births here are assisted by lay midwives. Their certification exam reveals they are not safe practitioners — if you think giving homeopathics for hemorrhage is a concern.
In Colorado, the statistics for lay midwives were required by law. When increased to 16 deaths per 1,000, the legislature’s response was to stop collecting the data.
In the US, a better choice is a birthing center located next to a hospital. OB emergencies are not always predictable, and when they happen, you want a team of professionals that can respond in minutes. Neonatal death!is not the only problem outcome.
I live in the northeast, and it's fairly easy to find a CNM here. I've don't know anyone who has used a lay midwife, but maybe it's different in other parts of the country? Unfortunately, our free-standing birth centers are very few (I think we have one left in the state), and the one that I birthed my children at two decades ago has closed. Many hospitals that service rural areas are also closing their labor and delivery units. Nine have closed in the past decade in my very rural state of Maine. Some expecting mothers have a 3 hr drive to get to a hospital with a labor and delivery unit. They were simply not profitable, although I would argue they were essential to the health of the communities they served. I would love to see more birth centers, and labor and delivery units, but the landscape is as it is, for now. Home birth with a CNM may be an informed decision some women feel is best for them and their families. They are certainly being sent the message that because they are not profitable, the hospitals deem their needs to be non-critical.
Excellent post! Thank you, Dr. Rall.
That one, almost off-hand, comment on home birth in Dr. Makary's superb book really stuck out to me as well. I guess doctors just get immune to how disgusting hospitals actually are. I was lucky enough to have my babies at a free-standing birth center with an amazing midwife and a doula. There was lots of room to move around, relaxing lighting, a huge birthing tub, and no one nagging about maybe getting an epidural. If I didn't have that option, I would have 100% gone with home births. If my first birth had been in a hospital, I'm sure I would have ended up with a C-section. They simply would have been like, this is taking too long and she doesn't have the urge to push, time for the cesarean. Having visited family members in hospitals after they gave birth/were born made me fully appreciate how fortunate I was.
We were able to come home with our baby hours after giving birth, and the follow-up, in-home care from the midwife that we received in the weeks after was amazing. I should give a shout out, though, to our pediatrician, who suggested he make a house call for our first well baby check. He said we were on his way to the office and that newborns should be at home with their family, not in a doctor's office or hospital. So, I do hope that in future editions of his book Dr. Makary adds a bit more nuance to his home birth comment. The issue is not with home birth in and of itself, but with a system that profits from over-medicalizing every birth, even the straightforward ones.
I would like to see discussion of social media’s effect on the decision to have a home birth. I haven’t had my coffee yet, and there’s too much to say to contain in one comment. I will say, I definitely felt the pressure to be more “natural” and “against those corporate uncaring doctors” by foregoing epidurals and having a birth in a blowup pool in your living room.
I am an obstetrician and I have delivered about 10000 babies. There are some generalizations in this article that could be a bit more nuanced. I agree that there has been the over medicalization of pregnancy and child birth. Electronic fetal monitoring was going to lower cesarean sections, reduce CP, etc. It has done none of that. There are some instances when it has been life saving for the baby, but mostly I see people "over reading" fetal heart rate strips and rushing to surgery. The fear of being sued is a huge reason, too. Newborns should not be given vaccines on day one is another example. I think it is important to look at the hospital you plan to deliver your baby. Our hospital has a cesarean rate well below 20%, I cant remember the last time I did an episiotomy....(I think they are barbaric), used forceps, etc. I have worked with midwives my entire career both civilian and military and they are an integral and invaluable part of care. Home births are great until they are not. I am at a tertiary care hospital and we accept patients who are trying home births by lay midwives and I have seen dome catastrophes. The answer does lie somewhere in between. Ready access to a hospital for emergencies is key along with people knowing their limitations regarding child birth. PS-I think ACOG has lost their collective mind in the last 10 years. They are so pro-abortion it is ridiculous. I went into OB/GYN to promote healthy moms and babies. I don't think that abortions should be illegal but what happened to safe, rare and legal?
Appreciate your thoughts!!! Very rare to see an OB who gets how rubbish fetal monitoring is. I had labored at home for 48 hours before going to the hospital. I went because the pain was starting to get to that point where I wasn't sure I would be able to handle it. The CNM on call is like... you're 5cm. We don't admit till you're 6cm. You just have to wait in triage till you're 6cm (side note- I was still 5 cm 6 hours later. Took nitrous for 2h, feel asleep and woke up 10cm and ready to push). So I was like- I'm not sitting here in triage where my doula isn't allowed to be here with me to help with pain management. I'm going home. Suddenly they "notice" decelerations on the EFM. My birth plan said no EFM (precisely because I didn't care for the "reading of tea leaves" that it is)... but the intake EFM seemed impossible to avoid. So they admitted me. Kept pressuring me throughout to get EFM. It's all so surreal looking back.
Thank you for your commentary, Dr Melnitz. How wonderful it would be if more OB/GYNs were like you!
Thank you, Dr Melnitz. I, too, have delivered thousands of babies, over 2,000 personally, and many more as attending for CNMs in a hospital setting. My experience and perspective on the medicalization of childbirth is very similar to yours. For me this is your key statement "Home births are great until they are not." Even in the hospital, sudden onset of hemorrhage, maternal and/or fetal compromise mean every minute is vital. Over the nearly 40 years I practiced in inner city hospitals in poor southern cities, I was amazed to see just how unhealthy our patients became and how much more frequent maternal complications and (yes, death) have become. Unfortunately, when our patients would insist on home delivery, it was most often the ones who were not "low risk". I wonder how the population in Denmark, as discussed in this article, compares to the US.
Wise, seasoned certified nurse midwives (like one of the ones who delivered my baby) in an attached birthing center would seem to be the key.
I also think that many women have been influenced by social media to have an expectation of the birth process that may be unattainable and this leads to disappointment and guilt over what is perceived to be a "failure". A healthy Mama and baby are always the best result, in my humble opinion.
As for ACOG, my friends and I agree they have lost their minds. Birthing persons, racism, supersubspecialization. Safe, rare and legal should be the goal in this OBGYNs opinion.
When I was pregnant, everything in online pregnancy groups or online was all about the “birth plan” and insisting that the providers adhere to the birth plan. It made doctors and hospitals sound absolutely awful! But, my mom died during my birth, and so my birth plan said- healthy and mom and baby. Whatever it takes to get there. I had a wonderful OB who tenderly guided me through two pregnancies, and she delivered both of my children. There is so much emphasis placed on “wishes” and “plans,” and that is great, but birth is anything but predictable sometimes.