I laughed until I cried!

A Man’s Guide to HomeBirth on Dr. Momma [Update: it was removed from Dr. Momma, but here it is in full.]

This is hilarious! Simply hilarious. I’ll give you a taste, but you must read the whole thing:

These are the items that men need to assist in a homebirth (not in order of use by the way): a black-light, princess wand (any type of wand toy will do,) fun-house mirror, catchers mitt/fishing net/soccer gloves, pocket watch, thesaurus, gum, woman who has witnessed a live birth, six pack of beer (or favorite alcohol), shovel, bucket, 1 dozen eggs, shredded mozzarella cheese, shower shoes, swimming shorts, push-up/pull-up bars or a wheelbarrow, old table covers (plastic holiday ones are best,) 1 big steak (or other red meat,) and 1 big cliche. Most of these items are for preparing for the birth, while a few are for the actual birthing….

So when I came down the stairs and was informed that she was in labor at 9am-ish, I felt ready this time since I just slept for 10 friggin hours. Alas, after hanging around downstairs for about ten minutes, my eyes rolled into the back of my head and I went and took a nap. On a side note, this is where the doula’s biggest strength lies – they are highly trained to withstand the Hypno-Fog. It was after that nap during the Hypno-Fog stage that I discovered that women who are about to go into labor cast this area-of-effect spell that can drop a man to the floor in a matter of minutes….

A flawed study published in “a second-tier journal”

That was the conclusion of Dr. Nicholas Fogelson about the much-publicized recent meta-analysis on home-birth, in a comment on Science & Sensibility’s post about it. [Honestly, I didn’t know that the AJOG was so poorly respected. Makes me rethink what studies I’d look at, if it was published there.] In the S&S post, Amy Romano questions whether the meta-analysis was even appropriate, in light of the huge de Jonge study of over 300,000 planned home births in the Netherlands. She writes,

Lack of statistical power could not possibly be the rationale for conducting a meta-analysis on the safety of home birth. [The de Jonge study] contributed 94% of the data on planned home birth in the meta-analysis (321,307 of 342,056 planned home births). That study found virtually identical rates of neonatal death in both the planned home and planned hospital births, with relatively narrow confidence intervals.

The blog “Birth Sense” has two posts on this study: a prologue of sorts and then a discussion of the 12 studies included in the meta-analysis. And despite Dr. Fogelson’s comment that AJOG is a “low-impact” journal, many news sources apparently didn’t get that memo, and had no problem trying to make a huge impact with the sensational headlines that “home birth is three times as deadly as hospital birth.”

I have read numerous blog posts and news articles about this study and will include links to them below, but I want to comment on some things. First, since the study isn’t going to be released for a few more months, I haven’t read it (I know it’s available by request, and I presume for a price or if you have a subscription), so I’m not sure what I can add to what those who have read it have said. In some ways, what I’ve read has raised more questions than answers. The main question is, what were the inclusion criteria? From some sources, I’ve discovered that the original study had to have been published in English (a common enough restriction — gotta make sure the doctors don’t get bogged down in any bad translations from reading foreign language studies!), and also to studies that reported outcomes of mothers and babies in both home and hospital births (apparently the reason why the Johnson & Daviss 2005 article on CPM births, published in the BMJ was not included — they didn’t have a hospital “control group”).  But I wonder, did they not have any exclusion criteria for the size? They included one study that had 5 women in each group — a total of 10 women studied! If I may say so, “Good grief, Charlie Brown!”

Additionally, they included the Pang study, which itself was flawed, in that it reported not only planned home-births (with or without a qualified attendant), but it also included unplanned home-births — this despite a title that declares that it looked at planned home births. Nor was the study limited to the “term” period, but included births as premature as 34 weeks. Since I don’t have the meta-analysis in front of me, I can’t say how heavily it influenced the conclusion, but “garbage in, garbage out” — if the data going into the study is wrong, you can’t reach the right conclusion.

In all meta-analyses I’ve read, there has always been a discussion of inclusion and exclusion factors; if there are others besides the ones I’ve mentioned above, I’d like to know — out of curiosity, if nothing else.

Some of the articles I’ve read have touched on problems researchers may have in reconciling different studies, which may all have different designs, or look at different populations, etc. Again, I don’t have the study, so I don’t know if Wax and associates looked at all the different factors and did an appropriate exclusion or analysis of differing studies. Some differences among studies that I can think of that might need some statistical calculation or exclusion of some births (which may or may not have been included in any of the cited studies), include prospective vs. retrospective study design; inclusion of term, preterm or post-term births; cross-over (women planning a home birth who transferred to the hospital, or women planning a home birth who gave birth precipitously outside of the hospital); whether babies with congenital anomalies were excluded; whether the mothers were properly matched in the groups — same general age, income, health, parity, etc.; whether twins or breech or post-term babies were included or excluded (many studies are limited by design to “singleton vertex babies from 37-42 weeks gestation”); cause of death (for example, excluding accidental deaths by smothering or car wreck would be a good idea, I’d think, if possible); whether there was a trained birth attendant; quality of the original study, and undoubtedly many other things I can’t think of.

One of the confounding factors that some of the articles I’ve read, is that some of the studies examined only the early neonatal period (up to 7 days), while others examined the full neonatal period (up to 28 days). Which reminds me of another factor I should have included in the paragraph above — perinatal deaths including stillbirths, and also possibly intrapartum deaths. Several of the writers have noted that the largest study, the Dutch study, was not included in the actual analysis of the most loudly trumpeted conclusion, namely, that home birth carries a 3x death risk for babies when compared to hospital birth. The largest study which had almost 95% of all of the births in all of the studies, and showed no difference for neonatal death, was excluded for the purposes of  neonatal death. It seems that it is because that study only went up to 7 days. Was there not some sort of statistical analysis that could be done to extrapolate deaths that may have occurred from days 8-28, so that this study could have been included? Or, an analysis that could have excluded deaths from 8-28 days in the other studies? As I said, I have more questions than answers. I’d love to read the study for myself (and the Birth Sense link has links to all 12 of the included studies — some of them are abstracts but some of them are the full studies, so I may start by reading those), but I wonder if any of the questions I have would be answered if I did read it.

Now for the links that I read, in addition to those I cited above (some of them include other links to other articles, as well) — obviously, most of them are going to be favorable to the “this meta-analysis is junk” viewpoint, but not all of them are:

Now for some links to other home-birth related stuff that is not about this flawed study:

  • The Unnecesarean’s blog post on a new study in this month’s issue of Obstetrics & Gynecology that says it’s important to distinguish between planned and unplanned home births [and I’m just in the mood right now, due to lack of sleep, to say cheekily, “and next, they’ll tell us that water is wet, and the sun is hot!” :-)]; but seriously, it’s because many times “unplanned” home births are to women with known risk factors that may cause problems with either themselves or their babies
  • the NHS write-up of the de Jonge (Dutch) home-birth study
  • High Tech vs. Nature’s Way,” an article from Minneapolis-St. Paul
  • The College of Physicians and Surgeons of British Columbia “Resource Manual” on planned home births

Ahhh, now I can close out some tabs on my browser.

Oh, and Dr. Amy, I’m pretty sure you’ve been waiting for me to write this up since I know you read me (not to mention you probably have “home birth” on your Google Alerts, and probably regularly add other keywords to make sure you don’t miss any internet discussions), so if/when you comment, just remember that you have to stay on topic. No cut-and-paste jobs like you usually do, m’kay? Oh, and before you bluster that the studies which showed that home birth is safe only in the countries of the study (like the Netherlands and Canada), because of how their midwives are integrated into the health system, I want you to answer a question: if that is true, why don’t you try to integrate midwives into the health system in America, rather than trying to elbow them out? That would solve that problem. 🙂

International Day of the Midwife

Celebrate midwives and midwifery! If you like this video, pass it on.

ISO: Home Birth and/or Midwifery pictures and videos

I’m making several promotional/educational videos about midwives, midwifery, and home birth for our Mississippi Friends of Midwives group, and would like to have more pictures and/or videos that I can use. Here are the two that I’ve gotten done so far.

This second video is clips from my younger son’s newborn exam (we had no video nor pictures from my first home-birth). I edited it for length as well as due to background noise (my mother and sisters talking), so this isn’t the entire exam.

I may even be able to make a lengthier DVD production if I can get enough material. If you have any pictures or video that I can use of midwife-attended births (preferably a home-birth, but I wouldn’t exclude a hospital birth), or even pictures/video of an OB-attended hospital birth to use as a contrast to home birth, or you can video yourself talking about why you chose a home birth, if you’re a midwife why you became a midwife, etc. — if you would like to be included, you can email me the pictures and/or links at kathy_petersen_283 at yahoo dot com [note the spelling of my name!], and in the email please write some sort of statement giving me permission to use the pictures/videos for MS Friends of Midwives.

Thanks!

Permission to Mother

Years ago, I first became acquainted with Dr. Denise Punger by an article that she had written that was posted somewhere on the internet. That she was a pro-natural/home-birth MD was refreshing as well as memorable. I remembered her story about Jayne, who was the first woman she had attended in labor who had a doula, although I didn’t know anything else about Dr. Punger. Fast-forward a few years, and I rediscovered her, along with her blog which was given the same name as her book, Permission to Mother. Now, I have read the book and must say it was thoroughly enjoyable.

It is written from the perspective of a woman and a mother who happens to be a doctor, rather than from the perspective of a doctor who happens to be a woman and a mother. And that makes a big difference. It is her personal story, part autobiography (birth experiences and breastfeeding years up to homeschooling, or unschooling), part “why I chose what I did” (including extended breastfeeding, bringing her child(ren) to work with her, and homeschooling or unschooling), and another part her perspectives on certain medical issues (like the triple screen done during pregnancy, or resolving breastfeeding problems).

The subtitle to the book is “Going Beyond the Standard of Care to Nurture Our Children.” What is the “standard of care”? In a nutshell, “what everybody else is doing.” You remember those times when you were a child or teenager and you did something that was dumb, or you knew you shouldn’t, or you knew your mom wouldn’t approve, and you got caught, and your mom or dad asked you The Dreaded Question — “Why on earth did you do that???” and you shuffled your feet and said defensively, “But everybody else was doing it, too!!” Well, that’s basically the same thing, only nobody’s going to ask the doctor sarcastically, “And if everybody else jumped off a bridge, would you do it too?!?” Instead, it’s a legal safeguard to protect the doctor or hospital — as long as they’re doing what “everybody else” is doing, then they’ve got a defense. And, as long as “everybody else” is doing what is right or best, then we can all be happy. But sometimes that’s not what happens. For example, take my sister who was advised by her doctor to wean her son when she was put on an antibiotic. Sure, that’s what doctors are trained to do (“we don’t know if it’s excreted into breastmilk, so to be on the safe side…”), so that’s what “everybody else” was doing: when in doubt, advise to wean. However, the antibiotic that she was on is also given to infants much younger than her baby was at the time! The amount of drug that might have ended up in her breastmilk was almost certainly less than what the baby would have received had he been prescribed the antibiotic himself. By this example, you can see that “what everybody else is doing” is not always what is right — sometimes, it’s just what is easiest or most defensible.

Starting from her days as a “candy-striper” volunteering at her local hospital, through med school, residency, and beginning her own practice, Denise tells stories of pivotal and memorable experiences that helped to shape her as both a mother and a doctor. From the preface to the book:

People who didn’t know me before I had my three children often assumed that all my births were homebirths, and that it always was easy for me to trust my body to birth and nourish my children the way I do now…

The first birth was not satisfying. It was undermining and left me unfulfilled… I was grateful that my obstetrician had patience with me that night, but for two years afterward I dwelled on what a demoralizing expeirence that birth was.

My second birth, two years later, was also a planned hospital birth. Still, that birth restored to me the trust that my body knows how to labor. It allowed me to regain confidence in myself. It helped that this time I had a doula that had had nine homebirths herself.

Most of my patients find it hard to believe that the field of obstetrics doesn’t teach much about real-life pregnancy and birth, and that pediatrics teaches next to nothing about breastfeeding beyond the first few days of life. Now, I share my own experience.

Some of the chapters and stories in this book were originally written as articles for a doula publication, and are brief (just a page or two), which is very good for the busy mother who wants to squeeze in just a little solo reading while the kids are all happy, or who only has a few minutes to read before falling asleep at night. However, other chapters are lengthier, particularly the stories of her children’s births, or other pivotal stories which need more depth to explore.

Many of the choices that Denise Punger has made are not “the norm” of society — extended breastfeeding, “family bed,” home birth, cloth diapering, baby-wearing, unschooling, etc. Hearing her positive experiences can be helpful to people who are considering these for themselves, moral support for those who are already doing them (and perhaps may be facing family or societal pressure to stop), or a learning experience for those who have never heard of such.

As I said at the beginning of this blog post — thoroughly enjoyable.

Twin Home Birth Story

Click here to read Robin Elise Weiss’s story of the home-birth of her 5th and 6th children — identical twin girls. A lovely story!

Tangled in the Safety Net

One of the blogs most recently added to my blogroll is “Birth Sense,” previously, “The Midwife Next Door,” and I’m glad I’ve found it. In a recent post, she details a birth story, illustrating that the “safety net” of a hospital may not always function like it should.

In most hospitals today, you will see a central monitoring station with nurses clustered around it, eyes fixated on the monitor screen.  Rather than spending this time in one-to-one assessment of their patient, observing the whole picture of how things are going, they focus on one element of the labor–the fetal heart rate.  Where is the physician?  At the office, or elsewhere, while the nurse is expected to monitor and identify problems with the labor and notify the physician if problems arise.

This is one common misunderstanding regarding home vs. hospital birth.  Many women feel safer in the hospital because they have emergency services immediately available.  But if you have an emergency and your physician is not at your bedside, who is going to perform emergency surgery?  The nurse? The anesthesiologist?  No, you will have to wait until your physician is summoned and arrives at the hospital, assesses you, and makes the decision to perform a c-section…..

I paged the chief again.  I called my supervisor again.  No other doctors were  on the floor, or I would have begged one of them to help.  No one was answering my calls.  I finally called Brianna’s physician again and told her that I had notified the OB chief  and the nursing supervisor that she was refusing to come in.  Very angry now, she hung up on me.  A few minutes later she walked into Brianna’s labor room.  I still had not heard back from the OB chief, and the nursing supervisor was also trying to reach him….

Click here to read the rest of the story.