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Nov 21 2012

It’s not Feminism Just Because it Claims to Empower Women

I know of a specific form of quackery aimed solely at women, by women.

Home Births. We aren’t discussing “Natural Birth” which often takes place in a hospital which is also a very quacktastic woo laden field of idiocy masquerading as feminism but at least occurs in a hospital setting so if anything goes wrong help is available. We are talking about home birth which is a more extreme form of that. This is a serious group of people who think your Ob/Gyn is a plot to take away your freedom and that the only option is the ancient methods of birthing as practiced by our ancestors. Which is like suggesting that your dentists is earning money from pulling your teeth and the only way to deny him that is to pull your own teeth out with a door and some string.

Straight up before anyone starts jumping up and down saying “But it’s a woman’s choice”, you have to realise this important thing. Just because you have a stomach doesn’t mean you can make medical decisions about a stomach ulcer. Just because you have a uterus doesn’t make your opinions on childbirth valid. You can have some frankly insane opinions. Home Birth without the support of trained medical professionals (Even Nurse Practitioners operate under the umbrella of a Obstetrician, Paediatrician and an Anaesthesiologist so if things go wrong they can save the baby.) is dangerous. And it shows. You are between three to four times more likely to lose a child in birth with a home delivery.

A lot of people I know defend them. A famous natural birther midwife was Mayer Eisenstein. A lot of antivax love him. The average malpractice suits faced by an Obs/Gynae over their lifetime in the USA is between 2 to 3. Obs/Gynae has a high rate of malpractice suits due to the nature of the event. A lot of it is on the fly and sometimes the child is hurt during the birth. Mayer had 15. Including two cases that I know of where the direct responsibility for mortality and morbidity was his actions. He refused to test for Rh incompatibility which resulted in one dead baby and another suffering from cerebral palsy and mental retardation. This man is treated as a hero. Other midwives proudly tell of “difficult” deliveries they have managed which often ended in the deaths of the child. Mothers who lost kids treat it as an experience akin to fighting a war rather than a serious error in judgement that cost the life of their child.

A lot of people straight up don’t believe me when I say this. I have been accused of misogyny for actually pointing out how mad this is as a practice because I impinge on a woman’s sovereign right to make decisions regarding her genitals. I have even been accused of “rape” because I don’t think these midwives should be allowed to carry on their quackery. It’s a lovely group for classy arguments. But I know you won’t believe me. This is a skeptical place, skeptics demand proof. You want to see the bullshit for yourselves.

Footling Breech Birth has a 10 to 15% mortality rate if done vaginally. Here are people actively defending breech delivery by vagina, mentioning that there are midwives who do it (and therefore encourage it) and actively telling people that they can do it too. In addition breech has a high rate of complication resulting in permanent sequelae for the child.

I can go into the umpteen moronic things these women believe, but I think “Breech Birth is perfectly Safe” is enough for now. Not just breech birth, breech birth done by a bunch of quack midwives with little to no medical equipment at home…

If you want to read more about this. Check out the Skeptical Ob and Skeptoid.

(Fixed bad grammar and Linked to the Skeptical Ob)
(Added link to Skeptoid)

105 comments

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  1. 51
    anat

    To Becky again: I see that most of the studies (33 of 38) in the report you linked compared epidural to opiates. Opiates were off the table as far as I was concerned, no way for me or my child. The conclusions do not differentiate epidural vs opiates and epidural vs nothing. In any case, while the rate of c-section overall remains the same the rate of c-section for fetal distress is increased. And then there are all those recovery side-effects. I doubt I could have nursed my daughter in the delivery room if I had been on an epidural.

  2. 52
    Erin McC

    “Just because you have a stomach doesn’t mean you can make medical decisions about a stomach ulcer. Just because you have a uterus doesn’t make your opinions on childbirth valid.”

    ummmm excuse me but YES, i DO get to make medical decisions about stomach ulcers, if they are MINE. my opinions on childbirth ARE valid, if the child is coming out of MY vagina.

    and this is one huge reason why women are choosing homebirths, because those in the medical profession seem to think that the woman gets no control over her own body. we just went through an election where the potential threat to women’s bodily autonomy was a driving factor in how women voted, and now you want to say we cant make our own medical decisions?

    hospitals and doctors follow protocols that are often not evidence based or in the patients best interest. patients are expected to sign blanket consent statements that lead to such things as pregnant women being given repeated unnecessary pelvic exams by medical students while unconscious. hospitals sometimes even restrict who is “allowed” to have a vaginal birth, and the c-section rate is astronomically high. even just entering a hospital to give birth in a low-risk pregnancy can get you confined to a bed, strapped to a fetal monitor, and hooked up to an IV pole. not to mention the inability for hospital personnel to keep their germ-introducing hands out of a woman’s vagina, vastly increasing the risks of infection.

    its no wonder women are choosing to avoid these things during the most intimate experience of their entire lives. and it is their right to do so, regardless of how many medical professionals disagree.

  3. 53
    Avicenna

    And for those who want to hear the full quote…

    “Just because you have a stomach doesn’t mean you can make medical decisions about a stomach ulcer. Just because you have a uterus doesn’t make your opinions on childbirth valid. You can have some frankly insane opinions.”

    Erin – I suggest reading the comments all your issues are addressed and covered. You aren’t producing a solid argument. You are used to using that argument on people who don’t know anything about women’s healthcare.

    Sigh… I shall go rehash the arguments I have already made.

    1. There is a difference in the depth of the knowledge we have. I spent a lot of time learning how the human body works. I know more than you. Crommunist and Jason on the site here know more than me about computers. PZ Myers knows more than me about biology. There is no shame in not knowing everything but in this case I have spent a lot of time learning anatomy, physiology, biochemistry and indeed the basics of gynaecology. If you say “I have this organ, therefore my knowledge and ability to make medical decisions is the same as yours” then I should have been born knowing how to treat testicle related diseases. We are discussing MEDICAL decisions.

    And to demonstrate this I will tell you this. Home Birth Quackery is the deadliest of all quackery affecting first world nations. Anti-vax, Chiropractic and Homeopathy combined do not have the kind of mortality rate home birth has. You just don’t get to see the mortality rate because home birth organisations are notoriously censorial.

    “and this is one huge reason why women are choosing homebirths, because those in the medical profession seem to think that the woman gets no control over her own body. we just went through an election where the potential threat to women’s bodily autonomy was a driving factor in how women voted, and now you want to say we cant make our own medical decisions?”

    2. You have control over your body. In fact with modern medicine you have MORE control over your body than you ever have had in history. The thing is you believe the midwives when they tell you that medicine is some sort of enslavement. What I said was if your medical decision is stupid, I get to call it stupid. If you say “I Want to Pray Rather than Take Chemotherapy” then I get to say “Goddamnit that’s moronic”.

    “hospitals and doctors follow protocols that are often not evidence based or in the patients best interest. patients are expected to sign blanket consent statements that lead to such things as pregnant women being given repeated unnecessary pelvic exams by medical students while unconscious. ”

    Er… In the UK that’s illegal. It’s also illegal in the USA. It’s been illegal for nearly 30 years or more in the UK. My mum didn’t learn like that and she did her medical school in the 1970s.. I think the issue is in Canada where it is illegal and has been since 2006. Which is like 30 million people. Compared to the UK which has 60 million and the USA which has 300 million and the rest of europe which is around 700 million people… Also India which has a 1.2 billion people in it.

    Are you canadian? If so then “It’s illegal there now”. If not then “your argument is stupid”. That’s like saying you refuse to go to hospital for a compound fracture in the USA because if it’s really bad they will amputate it in India… It’s illegal and unethical and it’s not done anymore.

    “hospitals sometimes even restrict who is “allowed” to have a vaginal birth, and the c-section rate is astronomically high. even just entering a hospital to give birth in a low-risk pregnancy can get you confined to a bed, strapped to a fetal monitor, and hooked up to an IV pole. not to mention the inability for hospital personnel to keep their germ-introducing hands out of a woman’s vagina, vastly increasing the risks of infection.”

    Yes. Yes they do. Do you know why?

    Because some women CANNOT have a vaginal birth. Not if they want to survive without issue. For example women with high birth weight babies. Women with pre/eclampsia. Women with breech. Women with specific vertex issues. Women presenting poorly. Women with foetuses that are wrapped in cord.

    The C-section rate is not astronomically high. 75% of western births occur by vaginal delivery. In fact since you indicated that you may be canadian judging on your very specific fear that’s unique to Canada… I checked it. The rate in canada is 18%. Roughly 80% of all hospital births are VB.

    Foetal monitors cut early neonatal mortality and morbidity by 50%. (http://download.journals.elsevierhealth.com/pdfs/journals/0002-9378/PIIS0002937811004807.pdf) Makes sense, they help protect foetuses that are having circulatory distress.

    The risk of infection is lower in a hospital than in home births. Vastly so, Especially if you are GBS positive. And you just demonstrated the massive gap in your knowledge. Tell me… What’s in the IV bag? It’s for women who require epidurals. It keeps them hydrated and helps deliver pitocin for those who require it. It also is an emergency precaution. If you need medical assistance the line is already in place and put in when you were calm and stable. Not when everyone was rushing around in a panic.

    “its no wonder women are choosing to avoid these things during the most intimate experience of their entire lives. and it is their right to do so, regardless of how many medical professionals disagree.”

    http://www.bmj.com/content/341/bmj.c5639

    This is the dutch model… The risk of death in a home delivery for low risk babies is higher than the risk of death of high risk babies in a hospital.

    http://www2.cfpc.ca/local/user/files/%7BF8052A68-D510-401A-B323-0D9DA912C58C%7D/planned%20place%20birthj.1523-536X.2010.00458.x.pdf

    This is another one. This is actually from pro-home birthers. They either made a mistake or cooked their calculation here.

    The mortality given for home births is fine, but they use the wrong denominator for their hospital births. AKA only tertiary care hospitals which is where the most difficult pregancies are dealt with. It’s bound to have the highest mortality rate. This is due to the fact that you cannot determine the quality of a doctor by mortality rate (In some cases really good doctors may have high mortality rates because they take very difficult cases). The tertiary care hospitals in NZ are usually for serious cases. Which is why the mortality rates look the same.

    You are trying to compare between home birth and “hospital birth” are you not? Not home birth and “Dangerous Cases”.

    The figures calculated are astounding. You have a 0.11% mortality rate for home birth. And a 0.03% rate for a hospital one if you work it out. Even in New Zealand the numbers hold true. The PMR in hospitals is at least a third of the PMR in home birth.

    This holds true in nearly every paper ever written on the topic. The colorado midwives posted a Perinatal Mortality Rate of above 15 per 1000 live births. The hospital mortality (bearing in mind they deal with much much more difficult cases) is more than a third lower.

    USA, Holland and New Zealand. The stats hold in every first world nation where this sort of quackery exists.

    You are straight up 3 times more likely to die or lose the baby in a home birth. Out of every 3 babies that die at home 2 would have lived in a hospital. This HARMS women. Physically.

  4. 54
    Becky

    ” I doubt I could have nursed my daughter in the delivery room if I had been on an epidural.”

    The vast majority of women can nurse while still recovering from an epidural. I had no problems after my cesarean while my epidural was in place, it was no more difficult than after my four unmedicated deliveries.

    If you don’t want the side effects of the epidural, then choosing not to get one is fine. Definitely. But epidurals are simply not as risky as often presented, they don’t significantly increase the risk of cesarean. Moreover they have been improved considerably over the decades to minimize side effects and maximize effectiveness.

  5. 55
    Crunchy Renee

    THANK YOU
    THANK YOU
    THANK YOU
    I have been waiting for someone, anyone in this community to go after this dangerous form of quackery. It is so important that it is exposed for what it is- dangerous misinformation. Thanks again.

    I have 12- count em , TWELVE- friends that lost babies due to HB MW quackery. Before I met the first one, I didn’t even know is was a thing. HBers really want to turn back the clock to 1850, and their stats prove it. Those 12 don’t even count the others with kids with severe CP that will never walk or talk due to HB (www.wearable.com) or the moms that were hurt. One poor mom I know required full reconstructive surgery and lost her uterus because of MW negligence. If thats not bad enough, just imagine an untrained MW cutting your perimun twice with no pain meds, then not being able to stitch it either…..

    And yeah, all women have the right to HB, just as I have the right to call it insane. I personally don’t think there is anything worth risking the life of my baby, especially not for the minor benefits of staying at home. but its your body so it is your choice.

    But its not about that! Its about information, and the Hb movement is sorely lacking when it comes to accurate info. they brag about how they are so educated, but they have no clue about even the most basic anatomical facts. Like Ina May and her “sphincter law”, which is truly ignorant. There are some true believers, but I worry about the mainstream moms that get sucked in thinking they are doing something safe and superior.

    anyway, thanks again!

  6. 56
    Amy G

    I also thank you for this post. It is amazing how physicians and their care are portrayed by some people. as you touched on, it is very very difficult for women to access information like this when pro – HB avenues delete and ban people who try to use real statistics and logic. There’s even a new Facebook group called “Banned from Birth Pages”, which I’m sure will flourish once it’s discovered. I will never understand why women are in such denial about this, when the *real* statistics all point the same way. Just like with anti-vaccine sentiment. It’s no coincidence that these groups are largely intertwined. Perhaps we really need to focus on making sure that women get better information in school, both in science and in reasoning. As far as it being a “feminist” issue; please. Feminists fought for years to be deemed worthy of pain relief and medical advance in child birth. Most “interventions”, like epidurals for instance, came about because women demanded them, and they deserve them. My baby and I deserve better care than we would have received in 1800.

  7. 57
    OttawaAlison

    I am so happy you’ve stepped up and discussed this. Yes, you’re male but at this moment in the skeptic community is majority male and women issues are mostly not being discussed.

    What I would love to see examined by the skeptical community:

    1. Epidurals – myths and facts
    2. Breastfeeding and formula feeding.
    3. The rise in csections and what has triggered the increase (and is the increase as terrible as they say).
    4. Home birth – the other studies, the truth about the Netherlands and New Zealand.
    5. Freestanding birth centres in countries with decently educated midwives.
    6. Drugs during birth – sometimes you just need some morphine.
    7. What makes a doctor go to a csection.

    There really needs to be more places discussing it. I haven’t read all the comments but if people are calling you a misogynist or paternalistic – a lot of the gurus in the natural birth / parenting world are men.

  8. 58
    Erin McC

    i am not canadian, i am american, and yes, the cs rate IS astronomically high. in the us, the rate for 2010 (latest year released by the cdc) was 32.7%. can anyone with a straight face say that the human species has evolved to the point where nearly 1/3 of our births literally cant be done vaginally? thats ridiculous. in some states the rate climbs as high as 39.7%. either way, its over twice the rate suggested by the WHO as safe for mothers and babies.

    im not sure whether you are claiming blanket consent statements or pelvic exams on unconscious women are illegal. regardless, i can say they both have happened in the us within the last 5 years.

    “And you just demonstrated the massive gap in your knowledge. Tell me… What’s in the IV bag?”

    please, dont stoop to trying to denigrate someones knowledge to try to win your argument. because i am pretty sure, as a woman with a vagina, a uterus, and 3 kids born in the us medical environment, i have significantly more knowledge as a birth consumer than you do =) i have had more pelvic exams, planned more hospital and home births, and been condescended to by more obs.

    as for the iv bag, that depends on what its being used for. for women entering the hospital for birth, its likely just a saline bag for hydration with possibly dextrose, especially if they are restricting her food intake. if shes there for induction or has a slow labor, pitocin may be in there. if she has pre-eclampsia or is in pre-term labor, magnesium sulfate.

    the study you cite for efm does show a lower mortality rate with efm, however efm is also known to increase the rate of cesarean section, which in turn has a higher mortality rate for the mother than does vaginal birth. the study also states that you have to subject 1226 women to efm to save one baby. how many more cesareans and maternal deaths is that? that study also has some flaws, such as not including stillbirths, vbacs, or any pregnancy remotely considered not low risk.

    home and hospital birth can be safe and comfortable, but not for everyone. thats why its up to the mother. its unfortunate that medical personnel dont understand how their own practices are driving women away. if standard procedures were more women- and baby-centric and less about convenience and protection from lawsuit for the medical professionals, i am positive you would see a lot more women willing to birth in the hospital.

  9. 59
    Avicenna

    In which case the practice has been banned in the USA for longer than I have been alive and longer than my mother has been practicing medicine. So it’s a fear akin to me fearing incineration by the catholics everytime I go near a church.

    Modern C-Sections have existed with high survival rates for a 150 years. Prior ot this small women and big babies were a bad combination. HOWEVER 150 years ago there was a fall in life expectancy due to the industrial revolution. In western society we lived in slums. Disease was rife. Now big babies are more likely to survive in such situations. So you have a surgery that causes increased survival rates for larger children and decreased mortality for women who give birth to larger children so they can keep doing that. So you see a net shrinkage in size of women’s hips due to more of their genes surviving and a net increase in initial size of baby. Added to which in western society we eat a lot better which means bigger babies. It shows. The Average Bt. Wt. In the USA is 3.4 Kg. In India? 2.8 Kg. A difference of 600 gm (looks small but the indian baby is 80% of the size of the american one).

    20% is a massive change. Your vagina and pelvis hasn’t increased by 20%. In India 14% of the population has a C-Section. In healthy women roughly 10% of the births end in C-section just due to unavoidable stuff. That’s from the Home birth stats for California where healthy homebirth approved women have had to go in for a c-section due to unavoidable issues. 4% indicates the diabetics, the high bt. wts., the teenage pregnancies (still growing, smaller pelvis) and things like Hypertensives. I can easily see that rate doubling with a 20% increase in the mass of babies. Not to mention the associated obesity related issues in mothers such as diabetes and hypertension. Remember it’s a bell curve. The average range in the USA is 2.7 Kg to 4 Kg. 4 Kg is rather large. And if you remember the Indian average is 2.8 Kg. 100 g above the lowest acceptable end for american babies. India’s low border of acceptable would be considered a low birth weight in the USA. 4 Kg is unheard of in India in the majority population. During the 1940s the Infant mortality in the USA was the same as modern India. It probably had the same birth weight and the same issues back then. In under a 100 years it’s achieved a 600 gm increase in average weight of babies. I am sure there has been no evolutionary pressure to increase the pelvic size of the mother because at no point in human history have we ever lived in the modern era of artificial excess. So our pelvis has remained the same, our babies have grown larger.

    If we stopped doing c-sections this would correct itself over time but you know as well as I do that evolution is driven by the death of those who “don’t work”. Hence we use C-sections…

    The study on EFM includes stillbirths. Perinatal mortality is any death of a 28 week foetus to a 7 day old child. Women who are high risk tend to have C-sections. Hence the mortality rate. The women who tend to have them tend to have other problems as well. There are confounding factors as to why the mortality of C-section is higher. If you did let these women try and deliver vaginally they would have higher mortality rates than C-section. The Risk is 0.2 per 1000 births by C-section. This includes heroic measures to save children from dying mothers which make up a lot of maternal deaths in the USA. The fact remains that you really have no grasp as to why the EFM is used. If you don’t check the baby still gets hurt. It changes the outcome in favour of the baby. The problem still is there it’s just that you don’t know it’s there in a home birth.

    My posession of a car doesn’t make me an expert in it. Neither does you being on the recieving end of a hospital birth. Your actual statement is “I know more than you because I delivered a baby”, all your book learning is useless!

    And why do you think that IV is necessary? For funsies?

    Home birth can NEVER be as safe as a hospital birth. Do an experiment. Next time you are in the bath lean over and dunk your head under the water. See how long you can hold your breath. In effect a non-progressing pregnancy in a home birth is strangling the child. Can you hold your breath long enough for an ambulance to get in?

    The midwife cannot do anything in that situation but hope to god the baby doesn’t come out blue. The obs has access to tools and skills that can help the baby.

    The standard procedure is incredibly woman and baby centric. Do you know what a NICU is. It’s the most delicate piece of human ingenuity in medicine designed to stop dying babies from dying. Do you have one at home? Then I am sorry. You aren’t baby centric. The scans, the multiple visits the pre-natal care all there so that you can get the best healthcare. You want it to do what midwives do which is lie through their teeth and pretend that danger and suffering makes you a better woman.

    Oh and 144 million dollars was the payout for a case of shoulder dystocia occuring from a vaginal birth. You can operate a hospital for a year on that kind of money. Doctors lost their jobs and their licenses.

    You want to know something? There are CPMs who have presided on cases where the baby has died from things such as GBS where they claimed that garlic cloves placed in the vagina will stop the transmission of GBS. Because the CPMs don’t have malpractice insurance they cannot be sued by a lawyer because there is no profit. Complaining to the police didn’t do anything to her. Even to the midwives association who gave her a punitive punishment.

  10. 60
    anat

    Avicenna: I agree there are some of the increase in c-sections is likely due to medical-relevant factors such as the rise in maternal age, the rise in obesity and gestational diabetes. But look at this:

    Rates of obstetric intervention among low-risk women giving birth in private and public hospitals in NSW: a population-based descriptive study

    Among low-risk women rates of obstetric intervention were highest in private hospitals and lowest in public hospitals. Low-risk primiparous women giving birth in a private hospital compared to a public hospital had higher rates of induction (31% vs 23%); instrumental birth (29% vs 18%); caesarean section (27% vs 18%), epidural (53% vs 32%) and episiotomy (28% vs 12%) and lower normal vaginal birth rates (44% vs 64%). Low-risk multiparous women had higher rates of instrumental birth (7% vs 3%), caesarean section (27% vs 16%), epidural (35% vs 12%) and episiotomy (8% vs 2%) and lower normal vaginal birth rates (66% vs 81%). As interventions were introduced during labour, the rate of interventions in birth increased. Over the past decade these interventions have increased by 5% for women in public hospitals and by over 10% for women in private hospitals. Among low-risk primiparous women giving birth in private hospitals 15 per 100 women had a vaginal birth with no obstetric intervention compared to 35 per 100 women giving birth in a public hospital.

    Why is the rate of intervention so much higher in private vs public care? Note that the difference holds when looking only at low-risk pregnancies. Do women going to private hospitals demand more interventions? Are there other pressures on doctors in private hospitals to act more aggressively? Are doctors in public hospitals under budgetary pressure to be more conservative? Do doctors in public hospitals have better legal protection from litigation? Whatever the reason, the fact that the differences are so big within the same society after accounting for common risk factors suggests there is more than purely medical calculus going on.

  11. 61
    Avicenna

    Elective C-sections are also a thing. Some women want them for non-medical reasons. And those are performed privately.

  12. 62
    No Light

    Avicenna – do you have a link to any info on the illegality of practicing pelvic examinations on anaesthetised patients?

    I just ask, because it definitely does happen in NHS teaching hospitals, and in some US ones too. Both NHS facilities I’ve worked at did it. On the client side, a distraught fellow patient was talked to by a scarlet-faced consultant after she awoke from. abdominal surgery to find that her Mirena IUS had expelled after the strings were snagged by a speculum-wielding student.

    The NHS doctor known by the ‘nym “John Crippen”, who blogged for the Guardian, talked about it on his now-defunct blog back in 2008.

    Here’s an anecdotal report from.

  13. 63
    No Light

    Hit send too soon, sorry!

    Here’s an anecdotal report from a US doctor : http://carnalnation.com/content/45486/887/messy-ethics-pelvic-exams

  14. 64
    Avicenna

    The problem with anecdotal evidence is precisely that. You only hear about them like this. The only place where I have confirmed that this happens is Canada. In every other country it is illegal. Even in the UK.

    I poked around and found the original article that begged the controversy. The issue is Consent. The feminists were treating medical consent like sex consent. The problem with medical consent is once you give it and start a procedure you really cannot just stop half way through. It wasn’t to do with this issue it was to do with people changing their minds halfway through a procedure due to the experience of the procedure. I think the problem is a lot of medical procedures are like roller coasters. You really cannot stop halfway through without the patient accepting liability which people loathe to do. Liability is important. A society without liability has doctors who are cavalier. A society with too much liability treats defensively. In many cases patients start a procedure, refuse the procedure halfway through but on completion thank you for ignoring their request. How do you differentiate between “That’s the Pain Talking”.

    Some patients don’t realise what they are in for. Sometimes I have patients when I demonstrate to the lower years who come in for a hydrocoele or a hernia and then realise they are going to be examined in front of 30 to 90 students and palpated by more than 1. (Both are nudity requiring examinations since they both are indicated by testicular swellings).

    One of the earliest papers I wrote was about the “Anatomy Story”.

    Every medical student is told stories of anatomy dissections. Of cadavers used as pranks and a cavalier attitude taken towards them…

    You know what? I found only one such tale to be true. A human head got “thrown” out of a window landing in front of scared bystanders.

    The reason? Someone slipped while carrying it near a window and accidentally flung it out. A lot of medical things people believe in (Even doctors) if they are hearsay and gossip may not be true. The anatomy story is a staple of medical literature.

    SO we have a problem. Is it Anatomy Story or Saville. Gossip or Real. That’s the thing, no one is willing to come forwards to tell us that. Again this keeps being linked to childbirth in hospitals because women don’t feel like they are treated well, but somehow prefer having their pelvic exams visualised by a midwife with the same tools as the doctor. The only difference is the education (And possibly the gender) of the assistant (Midwives are almost universally female).

    As I said. The only place I have confirmed where this has happened is Canada. UK and USA have laws against it. You would be surprised how much you can get away with if you ask to see a cervix rather than doing this.

    However? I do know that in a lot of places your first pelvic exam is just you being told how to do it and just sent on your merry way to fumble about. In the UK many places hire “Stunt Vaginas” to learn (People who are paid to have pelvic exams done on them).

    In a similar vein? I have heard the medical rumour of a bunch of medical students hiring willing sex workers to practice the skills on (It either ends just there or them saving a life by discovering a growth).

    Separating rumour from fact in medicine is hard because practices and ideas on this sort of thing differ. I know indians who have refused anasthesia to have bone marrow biopsies and who sit patiently while 30 or 40 students shine lights into their eyes to look at cataracts. I know people who refuse to see me because I am a man…

    So officially, I am sure it may have occured in other places. But it may just be hearsay and gossip that has created the widespread notion that this occurs.

  15. 65
    No Light

    I counseled at two NHS hospitals. Staff only. On numerous occasions I had to deal. with distressed students (male and female) who’d been shuffled into pre-op, and been told to practice with speculums on unconscious patients, and thought it was ethically suspect. This occurred in two separate PCTs.

    Again, if you have a link to the relevant legislation outlining the illegality of such practices across the UK, that would be great.

    I did not mention pregnancy at all, so I’m confused as to where your arrogant lecture about cervix checking during active labour came from. Not sure where the “OMG hysterical feminists” snippet came from either. What I do suspect, is that you’ve googled Crippen, and found some old “birth rape” post referencing him on a different blog, and not the original post. The url would be handy, so I can check if we’re talking about the same thing. He deleted three or four years ago, and is still missed. He was like a British Orac.

    Right, now onto your patronising “Idiot patients don’t know what they’re in for” rant. The woman with the dislodged IUS was there for the maintenance of a blocked shunt (ventricular placement, draining abdominally). So no, nothing to do with her vagina. I’m not aware of the invention of a vaginal shunt to. drain CSF. It would be awfully impractical, don’t you think? Like I said, the consultant explained what had happened to her.

    Oh, and having a hydrocele inspected by a gaggle of students is precisely fuck all like having them inside your vagina. Wouldn’t you be surprised if you woke up sore after maxfax surgery, to be told that you’d been used as a stunt arse for a proctology demonstration?

    FWIW, I’m totally with you on the absolute necessity to disallow anyone not medically trained to practise as a midwife, to strip the woo from birth and remind women that the dream they’ve been sold of a perfect ~birth experience~ matters less than a live birth with a healthy mother and baby. There are so many options available privately and on the NHS, that don’t place undue risk on the woman or baby. There are world-class delivery units attached to fully-staffed hospitals, that offer a home-like scenario, water birth, or drug free, or whatever. They’re safe, clean, and don’t put anyone at risk.

    You really shouldn’t jump to so many conclusions, you’ll wear yourself out. Don’t let arrogance be your downfall. You have a valuable message, but your delivery method is akin to shouting “There is no god, you fucking imbeciles!” at the visibly religious. It just confirms their bias against atheists in that case, and doctors in this one.

  16. 66
    Avicenna

    It’s in the Consent Guidance rules from the GMC. No procedure unless pertaining to life saving may be done without consent unless there is explicit indication.

    The GMC’s “basic phrase is” “Good Medical Practice, which requires doctors to be satisfied that they have consent from a patient, or other valid authority, before undertaking any examination or investigation, providing treatment, or involving patients in teaching and research.”

    http://www.gmc-uk.org/static/documents/content/Consent_-_English_0911.pdf

    The GMC good practice guidelines are 100% clear on this. No patient can be used for teaching purposes without giving a clear yes and knowing what it entails.

    The OP on Crippen is not available and it’s not even cached. I looked around and from what the various blogs are complaining about is “Consent changing.”. And they discussed another case which was “Patient goes in for X, doesn’t like the new doctor’s clumsiness which causes pain and tries to stop procedure” which is why I am rather confused. As I said. It’s illegal. Like “Registration Issue Illegal”. Breaking consent is only acceptable if you save a life and even then you have to be able to defend your logic in court. I think the ONLY time I have heard of consent being broken succesfully being defended was the court ordered blood transfusions to children who are Jehovah’s Witnesses because the adults and priests who usually accompany them do not have their best interests at heart. I think Dr. Crippen may have done two or more things to irritate people.

    A gaggle is putting it lightly. 90 Students is not a gaggle. Many medical schools don’t have 90 students in a single semester.

    What I am pointing out is that the event you are mentioning is clearly defined as wrong by the basic GMC rules. You need consent for all procedures. You need consent even while taking a history in a teaching hospital and you have a student in the same room. If that’s the level of consent you require for teaching history then teaching pelvic exam would require at the very least explicit verbal consent.

    As I said. Liverpool, Manchester, Birmingham and Keele are in my area. I never heard of such a tale until I came to India and indeed in context of a practice that’s common. Searching online every single argument pertaining to this seems to be centred around Canada and almost every single one mentions that the USA and UK both ban the practice. It’s not explicitly banned in the UK but the guidelines say “it’s banned” from what I can see.

  17. 67
    Avicenna

    Redact – I have to not use the Colorado figures anymore. In order to acquire the Colorado figures you have to pay CORA money (Which I won’t damnit!) and then they send it to you. Since it is not public figures it cannot be accurately verified by third party since CORA may be 100% correct but you cannot check the figures yourselves.

    This still means the two papers on safety from NZ and Netherlands hold true.

  18. 68
    No Light

    Avicenna – pushing excess diamorphine to make a dying patient dead more comfortable isn’t GMC-approved best practice, neither is pre-signing an HSA1, but both happen on a daily basis.

    If hospitals operated to the book, they’d grind to a halt. There are tweaks, blind-eyes turned, and daily dodges to ensure that a balance is kept between patient care on one hand, and bureaucracy on the other. Same goes for GP and clinic practice.

    The easiest example I can think of is the dispensing of medicines to inpatients.

    In theory there are drugs taken every 4/6/8/12 hours, or as needed. There are drugs that must be taken with food, NSAIDs not administered orally to patients who have to stay prone, drugs that must be taken on an exact schedule to maintain a therapeutic dosage in the bloodstream, drugs that can’t be taken at the same time as particular classes of drugs, and so on.

    In reality there’s a morning drug trolley (usually between 7 and 10am), an afternoon one (noon till 15:00) and bedtime (19:00 – whenever the fuck there’s time. You get your pills then or not at all, and if they were doled out in accordance with the factors I mentioned above, the drug trolley would need to be in motion 24/7.

    Hospital life is incompatible with total adherence to rules.

  19. 69
    unnullifier

    Erin McC wrote:

    “… its unfortunate that medical personnel dont understand how their own practices are driving women away. …”

    I’m not going to delve into the rest of the discussion because it’s over my head, but I wanted to address this statement specifically. My wife’s first son was 48 hours of labor followed by an emergency c-section. She was told by the doctor at the time that the size of her son and her hip bones were such that either his bones or hers would have been broken in a vaginal birth. Many years later, with her second child we went to an Ob/Gyn practice that had many doctors including a midwife. Due to her previous experience, my wife was determined to have a c-section again and avoid the pain, fear, and risk of broken bones that she faced with her first pregnancy. The doctors were generally pleasant, however the midwife upon hearing that my wife planned to have a c-section, cut her off from explaining why by literally waving her hand at us and saying “Okay, whatever.” So we had the opposite experience that you generalize over all those in the medical profession.

    Later I found the attitudes of other midwives and those who are advocates of home-births to be dismissive and insulting to those who choose to have hospital-births, c-sections, or even those who having a c-section due to a high risk birth! Even with this experience, I wouldn’t say that all midwives or home-birth advocates have bad manners towards those who don’t go the way they think is best. However I don’t think that poor bedside manner is something that solely afflicts medical professionals.

  20. 70
    Who's the boss

    The problem with the insanity of this post and with childbirth in general is that providers and anti-women’s choice advocates have the insane idea that other people/medical personnel have authority over our bodies. I am the ONLY person capable of making medical decisions for my body unless I am unconscious. THE AUTHORITY IN BIRTH IS THE BIRTHING WOMAN AND NO ONE ELSE.

    This article is full on half truths and untruths. The evidence supports home birth, the evidence supports vaginal breech birth for carefully selected candidates, midwives are extensively educated and trained.

    This is article was written by someone who has a paid agenda to dis-empower women in birth as to keep birth within the domain of medicine and allow them to play their power games with human lives.

    The effects of birth last a lifetime. Birth rape is real. Disempowering abusive births traumatize mothers and destroys families. Mothers matter. Birth is not only about the baby. It is equally about the woman who chose to become pregnant to become a mother.

    Feminism is empowering women, not telling them the are too stupid to make educated decision for them or their families. If women are too stupid to choose their birth circumstances how could we possibly be trusted to care for a child.

    And guess who makes medical decisions for those children? THE PARENTS!!! No doctor can make a medical decision for you, unless they assault you. They can only give you advice or a recommendation. You have to make the medical decision yourself.

  21. 71
    No Light

    candidates, midwives are extensively educated and trained

    Not everywhere. In the US there’s bullshit like ‘Direct Entry Midwifery’ (DEMS) and the CPMs. They’re essentially the barber-surgeons of the modern age,

    They could have nifty purple and white poles!

    Feminism is empowering women, not telling them the are too stupid to make educated decision for them or their families. If women are too stupid to choose their birth circumstances how could we possibly be trusted to care for a child.

    Stupid? No. Sucked in by lies, distortions, and guilt-tripping propaganda at one of the most vulnerable times in their lives? Definitely.

    And guess who makes medical decisions for those children? THE PARENTS!!!

    Depends. Laws vary. In the UK it’s the patient who gets final say, as long as they can prove they understand the consequences of refusing/accepting treatment.

    Five year old wants to hold off on surgery to her bowel that would help with nerve problems caused by spina bifida? Then it won’t be done.
    If your nine year old doesn’t want that heart transplant? Nobody can force her.

    Ten year old doesn’t want chemo for the third time, just palliative care and to die in his own bed? That’s his choice.

    Fourteen year old needs contraception or an abortion, or wants to continue a pregnancy? You have no legal say in the matter.

    They’re all based on actual cases. #1 had surgery at 11, #2 ultimately changed her mind after two years, and got a heart, and #3 spent his final weeks with backpack o2 and fentanyl patches w/ backup diamorphine, doing all the “kid stuff” that he never got to do during years of hospital treatment. He died at home, in his sleep, happy and comfortable.

  22. 72
    Avicenna

    No Light… I am not sure about the 5 year old… I know that doctors can over rule minors if they can demonstrate that they don’t understand the issue. But yes mostly correct. The patient has final say. If a 5 year old walked into your A&E you would have to treat them if they didn’t want to call the parents.

    @Who’s the Boss – I suggest you go read the papers I have provided. I even took stats from a home birth magazine and even they come out with a triple mortality in New Zealand.

    That’s even without the individuals who think breech is a safe procedure. These are so called “Reputable Well Trained Midwives” and it’s a paper they produced.

    If you have evidence then I would like to see it, but all the papers and therefore the stats are on my side. Homebirth is bad for your babies. It’s not feminism. It’s woo pretending to be feminism.

  23. 73
    No Light

    Avicenna – WRT the five year old, the procedure was one to allow her bowels to be manually assisted via a port above the hip. I can’t for the bloody life of me remember the name though!

    Amway, it’s an intensely difficult process to get used to, and the child needs to be completely able/willing to engage in daily ministrations, otherwise the risk of failure is high.

    She was told about the procedure and aims, and asked “Do you want this operation, or do you want to stay in nappies for now?” The majority choose to go ahead, she didn’t. She had yearly reviews and the option to change her mind at any time. It’s not a time critical procedure, so nothing was being lost.

    Ultimately it was the upcoming move to comprehensive school that made her choose to undergo the procedure. Although it was successful, the initial learning curve is time-consuming add painful, and she found it emotionally difficult. Her mother remarked that had she undergone it earlier, in her “Fear of hospitals and resentment of treatment” phase, she would not have been able to successfully navigate through the recovery to gain the skillset needed.

    Five is young, but not all kids are created equal. A five year old who’s had constant hospital treatment since birth is typically more mature than one in perfect health.

    My niece underwent impatient cancer care for eighteen months up to the age of three. At four she was spookily at ease with adults, understood and could explain (basically but correctly) remission, PICC lines, how chemo worked, and why it made her feel unwell. She sadly understood death only too well, as she’d lost several fellow and ex-patients, and still does so occasionally. Fortunately her mental health workers are amazing, they’re trained in paediatric cancer care, and four the last four years they’ve really helped her to be a child again, and to deal with loss productively.

    So I prefer legislation that allows child patients dignity and involvement with treatment plans, rather than considering them parental property until they’re either 18 or not on their parents’ insurance.

    WRT emergency situations it’s treating physicians and custodial caregivers who decide, as the patient is almost certainly not in a fit state to do so. They are entitled, provided they’re assessed as competent, to actively be involved in treatment choices for the sequelae of emergency events.

  24. 74
    hemlock

    No Light – “In reality there’s a morning drug trolley (usually between 7 and 10am), an afternoon one (noon till 15:00)”

    Look, you’re a counsellor. Don’t pontificate erroneously on what nurses do, thank you – it’s just a big red herring thrown into the discussion. We don’t do three hour drug rounds and it would be the opposite, the place would grind to a halt if we didn’t do stuff like replace IV fluids when they run out. You know that’s prescribed as well? Probably not. And if you come across something you suspect is unethical like finding out unconscious patients are being examined without consent, you have a responsibility to do something about it. But then I find that odd, because the only evidence given is second hand accounts, even in the link given. Most places stopped anything like it 30-40 years ago. The thing is hospitals aren’t perfect, some practices could be made better but it definitely has things that the home situation lacks like blood banks, emergency departments and neonatal units and you never know when you’ll need them.

    And don’t mistake involving children in their own care, with regard to their development level and the timing of procedures with actually giving consent. The standard in NZ, which would be similar to the UK is up until 16, a parent or guardian must consent to treatment (with the exception of contraception which can be accessed earlier without parental consent). If this is needed to be over-ruled for any reason this gets a court hearing, such as when a parent refuses something like a blood tranfusion for religious reasons, putting the child at risk or if the medical staff and parents cannot reach a resolution about care. If the parents and medical staff agreed the 5 year old needed the procedure urgently, and they didn’t want it, they don’t really get the choice. It nice if you can get them on board, but ultimately it’s not thier decision. The parent is the proxy decision maker for the child.

    Anyway, this has little to do with the politics of childbirth. Anyone got any evidence of those (unnamed) unnecessary procedures that I suspect are regarded so because they are meant to prevent problems and if baby and mum are OK, then that means they weren’t needed, that hospitals are out there to ruin women’s experience by starving them or something or that women don’t get to make choices and exercise autonomy with birth. That those choices might be limited by circumstance or complications doesn’t mean doctors are the problem, but that they rather are part of solution. The answer isn’t to throw out everything they say, but to realise that if you are being advised that a situation is a risk by someone with the training and experience to know that, that it is risk and consider what you might be throwing away by opting for something far less safe than hospital birth.

  25. 75
    Becky

    “The problem with the insanity of this post and with childbirth in general is that providers and anti-women’s choice advocates have the insane idea that other people/medical personnel have authority over our bodies. I am the ONLY person capable of making medical decisions for my body unless I am unconscious. THE AUTHORITY IN BIRTH IS THE BIRTHING WOMAN AND NO ONE ELSE.”

    Absolutely women have the decision making power and must consent to treatment during labor and birth just like any other patient. Has someone argued against that? If so, I have missed it.

    That doesn’t change the fact that they also have a right to be presented with accurate evidence on the risks and benefits involved, and that standard maternity care protocols should be based on evidence which maximizes the safety for mother and child. It doesn’t change the fact that health care providers must be thoroughly trained and licensed or registered and should practice under evidence based standards of care. It doesn’t change the fact that “feeling” that something is safe doesn’t make it safe, and that experts do have more knowledge about their subject of expertise than lay people, and that it is difficult to “educate yourself” by simply reading books or online articles, without a thorough background in the underlying principles of the field.

  26. 76
    Becky

    “the study you cite for efm does show a lower mortality rate with efm, however efm is also known to increase the rate of cesarean section, which in turn has a higher mortality rate for the mother than does vaginal birth. the study also states that you have to subject 1226 women to efm to save one baby. how many more cesareans and maternal deaths is that? that study also has some flaws, such as not including stillbirths, vbacs, or any pregnancy remotely considered not low risk.”

    How is limiting itself to low risk women a flaw? That was what the study was examining. It is firstly a way to ensure that the two groups are of equal risk for an accurate comparison, and secondly low risk women are the group you want to examine if you are considering *routine* EFM for all patients. High risk patients will have higher risk of fetal distress, in many cases, and so should benefit more. For instance, EFM is the primary way to detect uterine rupture, which occurs in 1 in 200 to 1 in 100 attempted VBACs.

    How many additional cesareans you have depends on the base rate of cesarean in the group. The Cochrane review found that the odds ratio of cesarean was 1.66 in the monitored group. How many additional maternal deaths? In 1226 women, with only about 1/4 or so having a cesarean, you wouldn’t expect to see any. This review notes that the rate of death causally related to cesarean seems to be about 2.5 in 100,000 for primary cesareans. http://www2.cfpc.ca/local/user/files/%7B2CEB26D0-7D69-4FFE-8D01-C7DAF4D59E1E%7D/Maternal%20Death%20C-Section.pdf

    There would be many more babies saved from death and from seizures and the associated brain damage (NNT 661) than mothers killed. The question is, how many cesareans is one babies life worth?

  27. 77
    Becky

    Oh, argh, excuse the grammar mistakes, please!

  28. 78
    dianne

    Late to the party and I haven’t read all the comments, but wanted to make a comment on this statement: “Just because you have a stomach doesn’t mean you can make medical decisions about a stomach ulcer.”

    It’s true that the average patient probably can’t, de novo and without further advice from his or her doctor, make a good decision about how to treat his/her ulcer. That’s why the patient came to you in the first place. But unless you’re going to insist that every patient undergo observed therapy, i.e. you’re going to stand over them and make sure they take their PPIs and, if appropriate, anti-H pylori meds, then communicating to the patient and gaining their agreement with the treatment plan is critical.

    If you say to a patient, “You have an ulcer. Go home and take this,” and refuse to answer his questions about what you’re giving him, what it’s supposed to do, and what the possible side effects are, the most likely outcome is that he’ll throw the prescription away and never get the ulcer treated at all. In which case, you’ve failed as a doctor, not because you didn’t prescribe the right medication (I’m assuming here that you did) but because you failed to convince the patient to take the medication.

    Similarly, if you dismiss a pregnant woman’s concerns about her likely experience in labor as unimportant and not worth addressing, you increase the probability that she’ll go to a nice, chatty midwife who may or may not have any concept about how to actually deal with any emergencies that may come up during birth, but will make her feel comfortable and listened to. And the midwife will be able to use your dismissal of the patient’s concerns as evidence that the “medical establishment” ignores women and that every hospital birth ends up with an unnecessary c-section. And an episiotomy.

    I agree that home birth is woo. It’s also tied to a lot of distinctly non-feminist ideas about gender essentialism and motherhood as the only role for a woman. And eugenics. I’ve occasionally had home birth advocates say that women who need c-sections should die in labor for the good of the species. After they knew that I gave birth by c-section. So I’m very underwhelmed by the “natural childbirth” movement in general. But I can see why it’s attractive.

    Communicating the medical plan with the patient and getting his or her agreement with it-or changing it to make it acceptable to him or her-is a critical skill in medicine and often the hardest one for doctors, many of whom-including me-are introverts and not terribly into long conversations with random people. But dismissing concerns only feeds the woo.

  29. 79
    Becky

    I absolutely agree, Dianne, about how doctors should be communicating to patients. Perhaps I’m lucky in my choice of doctor, but this is my experience as the norm. I wouldn’t stay with a doctor who didn’t treat me as the decision maker and who didn’t take time to thoroughly answer my questions.

    I think what Avicenna is arguing against is the notion strongly promoted by home birth and natural childbirth advocates that the woman can and should “educate” herself by reading natural birth materials, and thus be able to determine for herself when the doctor’s recommendations are evidence based and appropriate or not. I think that asking about the reasons for a recommendation, the alternatives and the risks is important for good decision making, but the natural childbirth movement goes beyond this by encouraging women to reject certain reason for intervention, and to view the natural birth organizations and the woman’s own intuition as more trustworthy than the experts, the doctor and other qualified health care providers. You end up seeing numerous examples of women making risky choices, all while insisting that their health care providers are fear mongering. I’ve seen women with preexisting diabetes, with a history of shoulder dystocia or hemorrhage, etc. all insist that they are “low risk,” contrary to the evidence.

  30. 80
    dianne

    Re c-sections, from the article Becky linked to:
    “Four deaths were
    felt to have been directly caused by cesarean
    delivery. In 3 cases (all primary cesareans),
    death was due to hemorrhage
    from bleeding vessels injured during surgery.
    In 1 case of repeat cesarean delivery,
    death was due to sepsis secondary to
    surgical injury to the bowel during the
    operation. Two deaths were felt to be
    causally related to vaginal delivery: 1 case
    of hemorrhagic death associated with
    uterine inversion and 1 case of rupture of
    an unrecognized berry aneurism during
    labor. In contrast, in 12 cases of death
    related to preeclampsia, 3 because of
    hemorrhage and 1 due to sepsis (a total
    of 17% of deaths), death was felt to have
    been potentially preventable had a cesarean
    delivery or an earlier cesarean delivery
    been performed.”

    So it’s not as simple as c-section is better for the fetus/baby, vaginal delivery better for the mother. Twelve deaths might have been prevented by correct use of c-section. It’s a balance and a decision that both the doctor and the patient have to make between them. The patient needs to have some idea of the risks of having a c-section AND of refusing a c-section, preferably with some information given in advance.

    The hospital I work at is considering hiring people to be “health care coaches” (a term I dislike, but whatever) to spend time with people going over their condition, talking about their treatment options and possible issues down the road, as well as things like nutrition, exercise, keeping guns away from children, seatbelt use, and all the other things that help people live longer but can’t be covered in a 10 minute office visit. Maybe the OB version should cover possible labor complications and help patients start to think about what they might want in various situations? Most of the time, it won’t be necessary, but if things did come up at least the person wouldn’t be left trying to negotiate the risks versus benefits of c-section and augmented labor while the fetus is hypoxic or the patient is bleeding.

  31. 81
    No Light

    Er hemlock, did I touch a nerve or something? I already said that more than three drug rounds a day would be chaos, but the reality is that a) not all drug needs can fit that pattern b) if the patient happens to be off the ward (having a scan, at another hospital for investigations etc) then they’re shit out of luck until the next round and c) if a round is late and the following one is on time ODs happen.

    Also not a counsellor, I’m a BPS accredited clinical psychologist who’s worked in hospitals since 2000.

    t. The standard in NZ, which would be similar to the UK is up until 16, a parent or guardian must consent to treatment (with the exception of contraception which can be accessed earlier without parental consent).

    Nope, you’re flat-out wrong. As I ALREADY said emergent cases are not covered, nor are doctrinal issues (parens patriae overrules religious abstention from treatment) but in the UK a child has the legal right to choose what happens to their body whether their guardian agrees or not.

    The decision handed down follows:


    “As a matter of Law the parental right to determine whether or not their minor child below the age of sixteen will have medical treatment terminates if and when the child achieves sufficient understanding and intelligence to understand fully what is proposed.”

    The term you’re looking for is Gillick Competence, and contraception and pregnancy are covered by the Fraser Guidelines

    Apparently it’s been approved across the Commonwealth, so you may want to check with your ethics board if you are actually a practising HCP in NZ.

    I worked on the ethics board that discussed matters like this and gave guidance to treating physicians. If the child can demonstrate understanding of her condition, and the consequences of refusing/undergoing treatment, then she can consent. So you may get a fifteen year old who can’t, but a seven year old who can.

    Hannah Jones was the child with cardiomyopathy secondary to chemotherapy that declined a heart transplant. She ultimately changed her mind after suffering kidney failure and being told she was unsuitable for dialysis due to her cardiac insufficiency. She got a heart fairly quickly, and is doing well by all accounts.

    http://www.guardian.co.uk/uk/2009/jul/21/hannah-jones-heart-transplant

    I’m going to start a new comment for the next bit.

    .

  32. 82
    No Light

    @hemlock again- GMC guidance states:

    Good Medical Practice states that doctors must safeguard and protect the health and well-being of children and young people.Well-being includes treating children and young people as individuals and respecting their views, as well as considering their physical and emotional welfare.

    When treating children and young people, doctors must also consider parents and others close to them; but their patient must be the doctor’s first concern.

    Children and young people may be particularly vulnerable and need to be protected from harm; they can often find it difficult accessing services or defending their rights; and they often rely on others for their well-being. They may have particular communication needs and may need help to make decisions.

    Children and young people are individuals with rights that should be respected. This means listening to them and taking into account what they have to say about things that affect them. It also means respecting their decisions and confidentiality.

    Doctors should always act in the best interests of children and young people. This should be the guiding principle in all decisions which may affect them. But identifying their best interests is not always easy. This is particularly the case in relation to treatment that does not have proven health benefits or when competent young people refuse treatment that is clearly in their medical interests. There can also be a conflict between child protection and confidentiality, both of which are vitally important to the welfare of children and young people.

    The GMC even produced GP/clinic/hospital posters and leaflets for children called “KNOW UR RIGHTS” (I know, I know) explaining the concept to them. it was targeted at the 13+ group.

    Full GMC guidance is here:
    http://www.gmc-uk.org/guidance/ethical_guidance/children_guidance_index.asp

    As for why this is being discussed, did you miss (in your haste to snap about drug rounds in the currently chaotic NHS) the part where an HB twoo believes insisted that if medical staff didn’t trust her to give birth wherever she wants, how could they then trust her to consent to said child’s medical decisions until adulthood.

    Anything else? Those links enough for you or do you require actual patient records in order to believe me?

  33. 83
    Who's the boss

    An ulcer in a stomach is abnormal, a pathology.

    A baby in a uterus is normal, not a pathology.

    How can you compare pathology with a normal state of being?

    Giving birth is not a medical decision. It is the result of normal physiology.

  34. 84
    dianne

    A baby in a uterus is normal, not a pathology.

    A “baby” in the uterus can kill a pregnant woman. It may be “normal” but it is not in any way safe.

    Giving birth is not a medical decision. It is the result of normal physiology.

    Normal physiology that fails frequently. Women without access to medical care die, frequently, during childbirth. Pregnancy and birth to be taken seriously, not blown off as “normal” just because they happen to women.

  35. 85
    Rj74

    It is false and misleading to state that homebirth has a 3x higher death rate. There is NO evidence to support that theory. For one, the study that this statement is based on ( the Wax Study) is highly flawed. And even if it was not flawed, the Wax Study showed that the perinatal death rate between home and hospital birth was the same. It also showed that the neonatal death rate was the same when the midwife at homebirth was a certified midwife. Secondly, there are three well-down studies all showing the safety of homebirth. Here they are..

    http://www.cmaj.ca/content/181/6-7/377.full
    http://www.bmj.com/content/343/bmj.d7400
    http://www.bjog.org/details/news/182410/New_figures_from_the_Netherlands_on_the_safety_of_home_births_.html

    The Dutch study that shows that homebirth is safe is a better done, less flawed study than the one that showed that homebirth is dangerous. The Dutch study, which showed higher death rates at home, has admitted limitations. I don’t believe we can come to the conclusion that homebirth is dangerous off of one study done in the Netherlands, especially when the study is openly imperfect AND the Netherlands has another large study that shows no difference in death rates between home and hospital.

    The truth is, there are no real studies that prove homebirth is dangerous. Looking at birth certificates in certain states certainly cannot qualify as proof. I’d like to see the CDC data published and peer reviewed before anyone comes to any conclusions based on it. The reason why this debate is heated, actually, is because the death rates between home and hospital are so similar. If homebirth truly increased the death rate like the SOB claims it does, the debate would be settled. Just look at the Birthplace study, probably the best study we have now on the safety of homebirth and you will see that those claims are not true. The key to a safe homebirth is a low risk mother, experienced midwives and OB backup in the hospital. These are not impossible things to come by. And even though the Birthplace study showed a slight increase in injury to first time mothers choosing homebirth, the other benefits to both baby and mother are enough to support homebirth as a valid option. We know that a TOL of VBAC has a higher risk of death to the baby than a ERCS, yet VBAC is still supported by the ACOG.

  36. 86
    Avicenna

    And can you explain why the other stats are wrong or is it just because you have these?

    The BMJ one points out increased rates of transfer in home births (3 in 16 is nearly 1 in 5 cases. That’s a lot…)

    A little bit less than 20% of home births ending in a trip to the ER… Something smells off.

    Here’s what I think. They aren’t counting anyone who suddenly becomes a high risk at home and gets transferred for their stats. They are counting only births at home and not those transferred to hospitals.

    Because most other stats indicate a tripling of mortality and most other stats indicate that babies do better with NICUs. In addition there are plenty of women whose babies died to extremely simple and preventable things.

  37. 87
    dianne

    For one, the study that this statement is based on ( the Wax Study) is highly flawed.

    Home birth apologists keep calling the Wax study “flawed”, but I’ve yet to see one explain what flaws they see in the study. Care to be the first?

  38. 88
    dianne

    RJ, you did notice that the BECG study showed home birth to be definitively more dangerous than hospital birth in nulliparous women, didn’t you? It’s also interesting, but not definitive, that the risk appears to go up when only women with no complications at the start of labor were included. Possibly this is because women with complications at the start of labor are more likely to be transferred to the hospital earlier rather than later and so have fewer complications in the end. But perhaps it’s random-the numbers aren’t statistically significant, only trending towards more complications in women who are “healthy” at the start of labor when they attempt a home birth.

    It’s also notable that the two populations don’t appear to be similar at baseline. The women in the home birth group were wealthier, more likely to be living with their partners, more likely to be white and fluent in English, and less likely to have complications at the start of labor. Since care given during labor is unlikely to influence complications at the start of labor, this suggests that the hospital group was higher risk at baseline.

    I’m less than completely thrilled with the primary outcome measure as well, which conflates death and encephelopathy with clavicle fracture. I’d like to see an analysis of serious outcome failures only.

    In short, it’s not a perfect study. I’m sure some of the problems I mentioned are necessary compromises to make the study feasible (i.e. the primary outcome including both serious and less serious complications.) It’s not a bad study overall, though, and does suggest that the risk of home birth may be less severe IF the woman in question is completely healthy AND the midwife attending her is a highly competent and trained professional (not a US style DEM) AND she has had an uncomplicated delivery previously AND there is a sound plan for getting her to the hospital quickly if there is a complication. There are still risks, of course. For example, an amniotic fluid embolus is only treatable if you’re already in the hospital-you’ll die getting there if you aren’t already there. But they’re relatively rare complications that won’t be picked up on a study like this.

  39. 89
    Rj74

    dianne-

    Well, there is this.. “Planned Home vs Hospital Birth: A Meta-Analysis Gone Wrong.” I think that will answer your question.

  40. 90
    Rj74

    And yes, dianne, I am aware that there is an increased risk for nulliparous women. But.. what IS the increased death rate? Is it 2-3x times higher for nulliparous homebirth women? I thought the increase was in birth injury alone. Also, I may be wrong, but isn’t it true that most women who choose homebirth are older and are more likely to go post-dates? And if so, wouldn’t that lead to a slightly higher death/injury rate in the homebirth group? I think what is important is that the authors of the Birthplace study concluded that homebirth was a valid option. As I said in my previous post, do we not support VBACs, despite the increased risk to baby? There are benefits to giving birth at home, most notably a lower chance of having a cesarean. Now, that may come with a slightly increased risk for first time mothers, but there is HUGE increase of UR after a woman has had a cesarean, so I do believe that the benefits of being at home are pretty significant. At that is only looking at a lowered cesarean rate.

    I’ll say it again; there is no real evidence that concludes homebirth is dangerous or that women shouldn’t be able to choose it. I wonder, do you support a woman’s choice to have an elective cesarean without a medical need? There are risks to that as well, yet, women are still given the option. Women should be able to make decisions about their own bodies. Period. There are risks to giving birth no matter how it is done. I think we need to stop vilifying birth choices we wouldn’t necessarily make ourselves and realize that women are smart enough to make their own choices. How would you feel if I came to “educate” you about the “dangers” of hospital birth, as if you were not already informed of all the risks of interventions/cesareans already?

  41. 91
    dianne

    @39: Was that supposed to be a link? If so, it didn’t work. Could you post it again? Or give a more specific reference, i.e. with authors?

  42. 92
    Rj74

    Avicenna – the high transfer rate for first time mothers is almost always due to exhaustion/pro-longed labor/ PROM/ desire for pain relief, not emergencies.

  43. 93
    dianne

    But.. what IS the increased death rate? Is it 2-3x times higher for nulliparous homebirth women?

    As far as I can tell, this question can not be answered using this study. Unless I missed it (always possible), they do not give the number of stillbirths and neonatal deaths by place of planned delivery. If I did miss it, I’d appreciate it if you’d point out the data.

    The overall relative risk of an event for nulliparous homebirth women without complications at the start of delivery was 2.80. In short, 2-3X higher.

    As I said in my previous post, do we not support VBACs, despite the increased risk to baby?

    Actually, enthusiasm for VBAC is waning in the obstetric community. It’s still considered an option for women who want it, but it’s really not recommended any more under most circumstances, as far as I can tell. I’m not an OB so treat these statements with caution. Avicenna, what’s your impression?

    No one is suggesting outlawing homebirth. I’m not even sure how that would be possible. Hospitalization for the last three months, just in case? Even if one assumes that the government is willing to throw women under the bus that way (and those who are should remember that Akin was defeated), the insurance lobby would have endless fits (in the US) and they are NOT indifferent to the interests of the insurance lobby. And any woman who wants to risk it, it’s fine with me. Give birth at home, give birth in the hospital, give birth at 10 Downing Street on the PM’s desk, if you can get the PM’s permission to do so. Whatever floats your boat. But don’t go around telling people that your way is safest if it isn’t.

  44. 94
    Rj74

    dianna- http://www2.cfpc.ca/local/user/files/%7B1E683014-14EB-489F-99CE-B5A2185A6FC5%7D/Medscape%20%20Wax%20Critique%20-%20Michal,%20Janssen,%20Vedam,%20Hutton,%20de%20Jonge.pdf

    Right, so the Birthplace *doesn’t* specifically state if there is an increased death rate or by how much. I’m pretty sure, but may be wrong, that there is an increased rate for injury and only for nulliparous women. Where did you get your 2-3x number from, btw? You wrote, ” the overall risk of an ~event~ is 2/3x higher”. What does that mean? Are you referring to a high transfer rate? A high transfer rate is normal for first time mothers and actually shows that there is good system in place for homebirth. A high transfer rate is not a bad thing and as I stated previously, the reason why it’s high for FTM has very little to do with emergencies.

    You said you have no problem with homebirth, you just don’t want anyone to say it’s safest. Well, there will always be people who will believe it’s safer. It’s part of their belief system to think natural is better and you won’t change their mind. However, the majority of people who claim homebirth is safe, claim it is safe ONLY for low risk, healthy mothers with experienced midwives and back-up care. Most, if not all, of the data on homebirth safety supports that notion.

  45. 95
    Becky

    “But.. what IS the increased death rate? Is it 2-3x times higher for nulliparous homebirth women?”

    Yes. For nulliparous women with no complications at the beginning of labor, the adverse outcome rate odds ratio was 2.8 for homebirth when compared to obstetrical unit birth. See table 3. http://www.bmj.com/content/343/bmj.d7400 In addition, for nulliparous women with no complications at the beginning of labor, there was a nonsignificant increase in adverse outcomes at the midwifery led units. According to the published appendix, the difference in mortality for home birth and midwifery unit births increase when only the highest quality data, from trusts reporting on at least 85% of births, was used. The increase in adverse outcomes for nulliparous women in freestanding maternity units was statistically significant in this data. http://www.bmj.com/highwire/filestream/545009/field_highwire_adjunct_files/0 This appendix is worth looking at, for several reasons. It breaks down the composite score into its individual components in Appendeix 8, but doesn’t estimate odds ratios for most of them and doesn’t separate the data into “without complications” or by parity. The document also provides more information on the differences between the women choosing home and obstetrical unit birth.

    The CDC data *has* been published in a peer reviewed paper — the Malloy study which I linked to above. I also posted a couple other links to published papers from the United States showing an increased risk with homebirth. Did you look at those?

    I really think that it is a mistake to be focused on the Netherlands’ results, when the Netherlands has one of the highest perinatal mortality rates in Europe and has come under a lot of flack for this, and is currently considering revamping the maternity care system. If the mortality is the same in hospital and at home in the Netherlands for low risk mothers, that might not mean much for here when their perinatal mortality rate is already higher than ours. For what it’s worth, the perinatal mortality rate in the UK is also higher than ours. The Canadian study is underpowered to detect a difference in mortality, and admits to that.

  46. 96
    Avicenna

    Becky – The reason for the difference is that America has two sets of perinatal mortality statistics. The UK’s is 24 weeks to 7 days. The USA’s is 28 weeks to 7 days for PM1 and PM2 is 20 weeks to 30 days.

    Because PM1 is used, the US perinatal mortality APPEARS lower but if you used the same values the UK’s would be around the same. If you used PM2 the number would double but it wouldn’t mean much. The ideal is 24 weeks to 7 days because we can save 24 week old babies at an appreciable level. 20 weeks is a poor statistic because there is nothing you can do to save a child born at that period because the child’s lungs haven’t formed yet.

  47. 97
    Rj74

    ^What Avicenna wrote. I was about to respond that comparing perinatal death rates between countries is an invalid comparison because of the differences in how perinatal mortality is measured.

    I am not trying to argue that the Birthplace study showed homebirth to be as safe for nulliparous women, I am, however, curious if they are referring to death rates or simply higher rates of problems. I think that’s an important difference to point out. I only bring that up because I have not read anywhere where a specific increased death rate was brought up. But again, perhaps it has and I missed it.

    As far as your links, Becky, would you post them again? The few “studies” based on CDC data in the states are laughable at best. But perhaps you know of some I have not seen yet.

    Lastly, I agree with you that we shouldn’t focus on the Netherlands results. There are TWO studies both contradicting each other.. I am more inclined to go by the homebirth study done in Canada and the Birthplace study. Both of which support homebirth for low risk women.

  48. 98
    Becky

    The WHO estimates of perinatal mortality, using the same methodology and definition, put the US ahead of the UK.

  49. 99
    No Light

    Becky – one issue with perinatal death rates in NL is that they don’t intervene with babies born before 24 weeks. They offer pain relief and palliative care, but no extreme measures.

    Those born at 25wks PLMP will be assessed on an individual basis and sometimes given intensive support, and with 26 weekers there’s a slightly higher chance of intervention.

    Only at 27/28 wks is intensive care almost a certainty.

    So that’s a full 8wks of possible intervention that’s almost guaranteed in the US but only rarely attempted in the Netherlands.

    Although in the UK intervention is offered at 22+ weeks if requested by the parents, it’s not a situation that many in the RCOG are thrilled with, and there are rumblings about trying the Dutch system where the decisions are made by the neonatal team rather than the parents.

    The lasting effects of interventions and risk of severe disabilities, as well as ever-increasing knowledge of how intrusive and painful interventions are for these babies, is starting to influence a rethink on what the absolute limit should be set at.

    Still not a homebirth fan, just expressing one of the reasons for higher perinatal mortality.

    There’s a very interesting Panorama/Four Corners documentary called “The Price of Life” which I think you would find interesting.

    Now to RJ,

    tWell, there will always be people who will believe it’s safer. It’s part of their belief system to think natural is better and you won’t change their mind.

    Oh dear. That’s the whole problem with these flakes. To them “natural” is flowers, rosy-cheeked infants, giving birth under the stars. To those more firmly rooted in reality “natural” is placental abruption, amniotic embolism, HELLP, meconium aspiration, shoulder dystocia, and the most natural thing in the entire world – death.

    Belief =/= reality.

    I believe that there’s no such thing as pandas, that they are humans in suits.

  50. 100
    Stevarious, Public Health Problem

    Home birth apologists keep calling the Wax study “flawed”, but I’ve yet to see one explain what flaws they see in the study. Care to be the first?

    Well obviously the flaw is that they keep putting attempted home births that end in the hospital as ‘home births’! It can’t be a home birth if it ended in the ER!

    [/sarcasm]

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