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Risk factors and homebirth - a general discussion for supporters of HB. - Page 2

post #21 of 35
The more i think about it , the more it comes to no.
Are the CNMs proposing that they are part of this regulation? No
Are the Naturopaths? No Are the MDs? No.
The regulation is on midwives who are not nurses.
as a mother , because of "fads" in regulation was a componet of why I did have a UC with my last child. I would not ask a midwife to break a rule for me.

Right now we have as rule a strict freedman's curve- of 1cm/hr primip and 1.5cm/hr multip , even though there are plenty of studies showing that women take longer to birth now .and most likely no one has really looked at freedman's bellcurve--- what is more likely to be a problem are labors that fall outside 2 deviations of normal, either way.

As for comparing the rules in Oregon to the Rules in the Netherlands, that is not in legislation the midwives make their own rules, midwives in the hospitals and midwives out of the hospital, doctors are directed by midwives.
And some of them although not addressed may still in all be something a midwife would pass on.
And to be frank i have worked with several CNMs and a couple NDs in out of hospital births, they have all gone well beyond what I would ever think of doing at home, i can recall the instances where they stepped outside my comfort zone. Or even MD back-ups , when misoprostol was first being used for induction, there were docs who would place the misoprostol observe in the office a few hours and then send mom home to have a home birth with midwives, we gave feed back that this was not normal labor and warned clients to not allow doc to do this in office... The CNMs and the NDs all have used and still use misoprostol as an induction at home.
post #22 of 35

This article, which was linked from One World Birth, asks a long list of questions about birth at home and what is appropriate. These are the questions we should be asking about the safety and appropriateness of birth OOH.


"A coroner has found a baby's death after a home birth went wrong could have been prevented if the labour and delivery had been carried out in a hospital.

Coroner Kim Parkinson said the hypoxic brain injury suffered by Joseph Thurgood-Gates happened during labour before the birth.

Ms Parkinson said a contributing factor to the baby's death was his mother Kate Thurgood's failure to attend at the hospital when contractions began.

The coroner said this had "resulted in inadequate monitoring of the course of the labour, removed the opportunity to identify any complications arising and prevented early intervention".

Ms Parkinson said midwife Fiona Hallinan had indirectly contributed to the baby's death by failing to tell the mother of the risks of home birth which had "sustained the misguided views of the mother, contributed to her disregarding the advice provided by obstetric medical clinicians and facilitated in her a level of confidence that she may safely proceed to home birth".

The coroner said Ms Thurgood was determined to have a home birth after researching the topic on the internet and found the risks were negligible.

Had she known there was a risk to her baby she would have had a caesarean at 40 weeks.

Ms Parkinson said Ms Thurgood’s use of the internet to research home birth was ‘‘sadly an example of the danger of untrained users utilising raw data or statistical information to support a premise as to risk, without knowledge and understanding of the complex myriad of factors relevant to the risk’’.

‘‘To disregard the obstetrician’s advice on the basis of a mantra founded in the uncertainty of statistical data obtained from the internet is a dangerous course to follow,’’ the coroner said.


Ms Parkinson pointed out the inquest into Joseph's death had not been an inquiry into the appropriateness of home birth because the circumstances of the case were such that "home birth was never a safe or appropriate option".

But the coroner said it became apparent during the inquest that the community had lost an appreciation that childbirth had inherent and unpredictable risk and the debate was currently largely directed towards denial of the risk, particularly in the context of home birth.

There appeared to be little current discussion that managing the risk or identifying complications may be more difficult during home births when the technology used in a hospital obstetric unit is not available.


The coroner said there also appeared to an absence of legislative standards and practical supervision and regulation of private midwifery practice and home birthing in particular.

The midwifery guidelines under the Australian College of Midwives were unclear and uncertain as to the circumstances in which care should be transferred to a medical clinician and at what point the midwife should withdraw from providing care.

Ms Thurgood and her partner, Dwayne Gates, had had three children all born by caesarean section before Kate discovered she was pregnant again in March 2010.

On December 13, 2010, when Kate, 41, was 42 weeks pregnant, she attended Monash Medical Centre with what she described as a heavy bleed.

She was seen by obstetrician Peter Neal and scans revealed both baby and placenta were fine except the baby was in the breech position.

Dr Neal suggested Kate have a caesarean, which she declined.


She went into labour the next day about 4pm and her midwife Fiona Hallinan arrived about two hours later.

Kate's labour intensified quickly so Ms Hallinan contacted a second midwife, Jan Ireland, to attend and assist.

The fetal heart rate was found to have dropped to 80 beats per minute at 9.15pm but it wasn't until 9.35pm Ms Hallinan said Ms Thurgood had to go to hospital.

Joseph was born at 10.16pm but was floppy, not breathing and had no heart beat.

Kent Kuswanto, who delivered Joseph, gave evidence that Ms Ireland had been blocking the staff's access to the cardiotocography (CTG) machine to monitor the fetal heartbeat.

"The reason given for this obstruction was for Kate to have as little intervention as possible," Dr Kuswanto said.

At one stage Ms Ireland asked, "Why does she need that?", the obstetrician said.

Joseph died on December 21 when his life support system was turned off.

Ms Thurgood and Ms Hallinan were not in court today.

Ms Ireland declined to comment."

post #23 of 35
I still would be hard to say how much the OZ midwives were to blame, it sounds as if the midwife referred her to the hospital numerous times. That it took 20 minutes to leave, hard to say what all occured, including the possiility of convincing the mom they needed to go.
I dont know if they are having the same malpractice issues in OZ that they have here but it can undercut everyone's credibility when c-sectiions are done frivoulously , and for self-serving reasons.
post #24 of 35

I think (MHO) that the midwives were quite a bit at fault. In other parts of the coroner's inquest report the midwives were asked why they didn't take a firm stand and transport the laboring woman. Their response was that they didn't want to upset the woman and feared she might decide to "freebirth".

I have had women tell me that if I didn't take on their high risk pregnancy and attend them at the birth, then that is what they would do also. That is their choice, but I won't be manipulated into attending a birth that has identifiable risk factors or known complications. I won't enable someone to make those choices. If she feels that strongly that she doesn't want a hospital birth, then she can take full responsibility for it. I am responsible for my professional decision making.


OTOH, the coroner's inquest did place blame on the internet sources and the influence they had on this woman's decision making. This column delves a bit more deeply into why those sources also bear responsibility in the baby's death.

post #25 of 35
Just because we are reading it in the papers doesnt mean they are accurate in their accounts. And yes it did look like they were cautious with her in how they approached information. She was in the hospital the day before she gave birth... Do you think nothing was said to her there? They have a bit of a different system in that midwives do attend, even when a woman will refuse everything. We are not there and not part of any peer review, the news can be reasonable and true or could be sensationalizing we dont know. I do know that some women can be very set on what they want to do . In reading over the accounts it did seem that there was a time after the midwife recommended to go to give birth at the hospital during prenatals ,that maybe she didnt even see the midwife.
You know that a heart rate of 80 can be a normal dip, during pushing, and that it would take a second and third listen as well as assessment as to how soon the baby would be born... And who knows if after when she was documenting that she really did delay or if it was just an approximate time when they walked out the door.

On the other hand , internet information can be really challenging and I could take your point on that.
Vbac alone would be my personal variation from normal 1 thing, is my limit and any additional stuff would just mean transfer, there is no way to even simply caclulate all the risks involved - everything could have been ok but there is an risk a higher than average risk that the baby would die or that mom would have a ruptured uterus or that both would be compromised ,
We have vbac x 3 with a risk of placental abnormalities - including previa, which the bleeding makes me feel like maybe a marginal placenta
We have breech baby. Higher risk of infant death, with an unproven pelvis... What was the reasons of her csections? Cpd???
We have post dates
Uncooperative mom---- i put this because it is a risk all the way around
post #26 of 35

I didn't read any links, only what was presented in post 22, so I appologise if my questions have been answered elsewhere, but I wonder what information the mother was presented with before her 3 c-sections?  And if she had shown up at hospital, would a VBAC attempt have been considered, or was the hospital environment hostile towards that idea?  My point is that while the midwife's choices and the mother's choices were probably the primary factors in the baby's death, the hospital policies and culture, and previous doctors' actions also could have contributed in very meaningful ways.  For example, did the OB practice she was seeing discuss the risks with her in a meaningful way, or just lecture and expect her to agree?  Were her c-sections all necessary, or was she just told after the first one that once a c-section, always a c-section with no discussion of options?  Was her reluctance to go to hospital partly the result of previous bad hospital experiences?  

post #27 of 35

If any one needs these statements, the ACNM, AAP, and ACOG statements relating to having a safe home birth. In all cases, these organizations pretty much say the same things. This is from Safer Midwifery for MI about how to have a safe home birth.


Only low risk women should be having home birth.

They should use a well educated, licensed health care professional: CNM, CM or physician attending the birth.


Their reasoning is thus: Licensed HCP have a more consistent and high quality education.

They are integrated into the larger maternity system, making transfer, if needed, easier to accomplish and communication is more consistent.


SMM feels that although the woman should ask questions of the midwife or HCP she chooses, sussing out qualifications and education, and how those things will affect her and baby's care in the event of complications, is quite complicated. Why add a layer of complication to the whole process? When attorneys and legislators need to be educated about the different sorts of midwives, their education, skills, and capabilities, how can we expect women to learn all that in such a short period of time.


Hopefully the MERA working group will be able to develop standards for ALL midwives that are consistent with ICM standards. Once every midwife can meet those standards there will no longer be the need for these statements or discussions. However, that is a long way down the road.

Edited by mothercat - 5/14/13 at 5:16am
post #28 of 35


Absolutely! I think that more women would choose to have their VBAC in a hospital if the hospitals were trying to get them to come there for a VBAC. Instead, the OBs and hospitals push women away by not letting them try for what they want in a setting where medical intervention is readily available.

post #29 of 35

This is germane to the discussion of home birth safety. I also posted it in the very long thread about death among home birth babies.


I am adding this as the newest Dutch study showing the safety of home birth, especially for women having a second vaginal birth or beyond.


This link is a summary from Science Codex. The original article is published in the BMJ.



This is the part we need to replicate here:

      "The researchers also stressed that their findings may apply only to regions where midwives are well trained to assist women at home births and where facilities for transfer of care and transportation in case of emergencies are adequate. In 2009, 82% of Dutch women planning to give birth at home were in a hospital within 45 minutes from the time a midwife called an ambulance if the need arose."


We need to have an educational system that educates all midwives to the same standard just as the Dutch system does. Without those standards, we can't expect the same results. I also need to read the entire article to see the neonatal mortality rates, but I believe the only outcome they looked at was maternal mortality.


Autonomy within any profession without responsibility and accountability is simply anarchy.

post #30 of 35

I don't have time to answer all of this, but I wanted to add a few comments.


I do think risk is a spectrum and it's quite unfortunate when state regulations don't allow midwives to regulate themselves. For example, I have a condition that is well handled with safe medication. I've spoken with several midwives in this state and they are all quite comfortable with taking me as a client since the condition is controlled and doesn't actually pose a problem with the pregnancy. But the state won't allow them to take me as a client. It's ridiculous. I think if a midwife feels comfortable treating a client with certain risk factors that should be up to them. If one doesn't, she doesn't have to take that client. 

post #31 of 35

Maybe this is just to big and broad of a discussion for me, or maybe I just don't understand other people. For me, I choose a care provider who I trust and who I believe is knowledgeable. I do my own research and see if our ideas match up.  If they differ, I take another look at things and also think about the care provider's reasoning.  I pay close attention to how I feel.  Do I have any mental or physical concerns?  Is my care provider concerned that this method of keeping track of myself could lead to me missing something important?  How likely is that thing to happen?  What would be the concerns if it did happen?  Are there risks to testing/treatment? 


None of that has to do with laws. I'm glad there are professional schools, tests, boards, certification, etc. for all care providers.  It helps me narrow down the pool of people that I could hire to assist me. But I see a lot of problems when limitations are put on either the provider or the mother. I guess I am on the far end of wanting to be involved in my own care.  I wonder if there is a place for me in this discussion.

post #32 of 35
I am not a midwife and I have only had an OOH attempt turned transport, but I will say that I do feel frustrated at times with the risks I see the homebirth community take. Obviously there are many many individuals within that community and generalizations do no good, but I have seen women championing obviously flat out dangerous situations that, in my opinion, absolutely put baby and mom at risk. I have encountered a midwife who took on births that definitely belonged in hospitals and has had several catastrophes. It is one thing to trust birth. It is another to respect the fact that without intervention, some births will not turn out a love baby or mom.

That said, I am definitely an advocate of OOH birth and feel it is safe, if not safer, than a hospital birth for LOW risk women. For me, that would risk out VBAMC, breech birth, severe anemia, twins, amongst others. I realize this isn't always a popular opinion and absolutely many of the above situations could and do go swimmingly, but as a hypothetical midwife, I wouldn't put myself in that situation. If a client of mine chose to UC instead, that would be her business and not mine.

In my opinion, adequate care for OOH births includes definite assessment of risk and subsequent referral out if necessary, continued monitoring to ensure patient stays low risk (that's a whole other post in itself and definitely a gray area, I will admit), and thorough attentiveness during labor and delivery. I don't have a lot of experience so I am certainly not speaking from a professional standpoint, but only from my limited experience in the HB world.

It's a great topic and I've really enjoyed the answers this far.
post #33 of 35


I agree with this, but the other side of the coin is taking professional responsibility for taking this type of risk - and this could possibly include being sued for acting outside of a professional scope of practice, or being found negligent and perhaps losing one's license. Sure, the professional should be able to take on these risks, but not without consequence if the outcomes are poor. Actually, the professional should expect to take some heat even if all the outcomes are good. Being a member of a profession should mean something. Taking on a higher-risk client should be a VERY DIFFICULT decision. Not one of whimsy.




Yep. And who's the champion when it's the professional who's "comfortable" taking on a client with certain risk factors? That "comfort level" is a very powerful means of persuasion.

post #34 of 35

I'm just giving my opinions, I haven't read anyone else's post on the thread yet. I also have no medical training and so am giving my utterly lay opinions on this matter.

Originally Posted by IdentityCrisisMama View Post


  • Should risk factors and HB be regulated


It's complicated. People who feel strongly enough about a HB will just UC if they can't find a willing midwife. Which I think indicates a problem with the nature of hospital births that needs to be changed. I've never seen someone feel that strongly because "Well, I just don't care about my/my child(ren)'s well being"- the reason for feeling that strongly is due to things like past birth trauma at the hand of hospitals or the local hospital not offering enough.


I think that people with risk factors, especially multiple risk factors, need to be genuinely educated about the risks so that they can make an informed decision. That, at minimum, should be the case. If a MW genuinely believes that HB is a bad idea, the MW should say so. If the MW doesn't feel able to give the necessary level of care, the MW should say so and not take the person on as a client.

Birth as a whole shouldn't be medicalised. But risk factors- those aren't the body working as it should, then it does get into the realm of medical problems that often need medical solutions.


  • What are the ethical considerations when a MW takes a client with risk factors? 


I think that taking a client when an MW genuinely believes that HB is unsafe for that person is unethical because it is helping that person to take risks that they should not take.


Taking any client means accepting risks. If the MW doesn't feel adequately prepared to handle the risks, that MW should not take on the client. MWs should also not put undo pressure on people ot HB. Some people have told me that their MW demanded a non-refundable downpayment before the birth- I think that this is ridiculous and puts undo pressure on people to have a HB that they aren't comfortable with. If, in the last few weeks, complications arise or the person just realizes they aren't comfortable with a HB, "but I already put down the downpayment" should feature nowhere in the decision process.
(The MWs I work with told me that, while they do take payment beforehand, it's refundable if you end up not needing them- say due to emergency hospital birth/whatever before they could show up to attend the birth. I think that's a good compromise.)


  • Do we consider risk to be on a spectrum? Or would we like to see some hard lines about what is considered risk and what is not? 


Yes, it needs to depend on the risk factors and individual case. Some people have loads of risk factors that make a home birth incredibly dangerous. Some people have one mild risk factor. Those two cases can't be treated the same, it needs to be decided on a case by case basis- unfortunately, our system dislikes doing that.


  • How does the issue of lack of availability for care options in the hospital impact this issue. For instance, is the lack of availability for VBAC in a local hospital justification for HVBAC? 


I definitely think that hospital care is a HUGE impact on this. I've never seen someone who had risk factors say "I don't care about risk factors, I don't care about my or my baby's health"- people who have risk factors and still want to HB very often want to HB because they've done the research, believe they can do things the hospital won't let them (ex. VBAC), so feel that HB is their only option.


Birth trauma from past hospital births also features into this, from what I've seen. Based on the reading I've done on birth trauma, most research indicates that birth trauma comes more from how people are treated than from the specific procedures being done/complications arising/etc. A person who wanted a natural birth and ends up needing an emergency c-section is less likely to feel traumatized if they feel supported, respected, and like their needs were prioritized. A person whose birth went off without any complications or pain may feel traumatized if they felt ignored, disrespected, and like the hospital's convenience was put over their needs. Hospitals need to work on preventing this.


  • What role (if any) does choice regarding testing impact risk? 


I don't really know.


I know I said I didn't, but I'm actually briefly browsing other responses while reading this,a nd one person talked about how people can't choose to get testing if their MW tells them it's unnecessary or downplays the importance, and that reminded me of what happened to me.


I needed to get a fetal echocardiogram. The OB I'd been working with told me the second he heard about my mother's heart condition that I'd need to get one, that I'd have to go somewhat far away because only one hospital in the state does them, because every child I have has an increased risk of having it. The risk is very small, but the condition is severe enough that HB would be a bad idea, probably life threatening, if my baby had it. I needed to get that echo before I could truly decide to HB.


The midwives I was working with dragged their feet. The first time I mentioned my mother's heart condition I didn't say exactly what it was, but I said I needed an echo and she acted as though I was mistaken, giving a derisive "did the doctor tell you you needed that?". After that response, I tried telling her exactly what it is (it's a technical term that I was still in the process of memorizing, I never asked exactly what it was before I got pregnant), she cut me off and didn't bother listening.


It took over 2 months to get them to agree to let me get the ultrasound, 4 weeks after it's suggested to be done. Very soon after this happened, they posted a link on their facebook group about scaremongering of "ultrasounds might cause autism!" (there weren't even any studies listed, the science behind it was damn weak). I'm not 100% positive, but I really think this is why they pushed me not to get the ultrasound I needed to ensure that my HB wasn't putting my baby in severe danger. I can understand not feeling ultrasounds are necessary when there's no indication that there's a problem- but dragging their feet on allowing someone with my family history to get one? That is not responsible.



....this is probably off topic, just, uh, wanted to share.


  • Do you think that a woman choosing HB in the presence of risk factors is primarily driven by the mother or by MWs? What are the ethical implications of this difference? 


It really depends. I've mostly seen people choosing to HB in the presence do so before finding an acceptable MW, and only doing so because their OB/hospital wouldn't give them the options they wanted (ex. VBAC), so MWs are not the ONLY driver. In cases where risk factors show up late in the game, I fully believe MWs can be part of the problem.


I think OBs are sometimes part of the problem as well. I really wanted to work with MWs AND an OB throughout the pregnancy just in case. My mom has a heart condition that, if any child of mine inherits it, would make an HB not an option- so, if nothing else, I at least wanted to work with a MW and OB until I was sure that HB was a definite chance. The OBGYN I'd been working with refused to do this, apparently their office is really anti-HB so get offended by the idea that someone will see them for routine prenatal check-ups then give birth at home. They told me straight out that if I requested that my records be sent to the MWs, then they would stop considering me a patient.



At one point in pregnancy, while I was reading about the birthing center at our nearby hospital (VERY nearby, literally 5 minute car ride away), I actually had a moment of "Wow, I think I'd actually be okay giving birth there". The options they had sounded really nice, I'm pretty sure that they're a baby-friendly hospital, etc. But at that point, I was at 35 weeks- even if I found a OB right then, I'd only have been working with them for a few weeks before the birth, I wouldn't have established enough trust. Not that I established enough trust with the MW who actually attended my labor...


I don't know if I would have actually decided to have a hospital birth, but this was definitely a big pressure not to change my mind about the HB. If I had to do a hospital birth- it would have been with complete strangers, not with doctors that I'd been working with and getting to know throughout my pregnancy. That's a terrifying thought for me, and I'm sure many people.


I don't know how common this is- I'm really hoping that the OB I was working with was just a megajerk- but if it's common, that's part of the problem.


  • What about consent? Are mothers who choose HB with risk factors given adequate information about HB and risk factors? What would/does this look like?  


I don't know if they are, but they need to be. The MW needs to make sure that the person understands the complications and risks. Most people aren't medical doctors, it needs to be laid out in a way that a lay person can understand.


  • What do you think about the term "variation of normal"?


I think it has it's place.  That doesn't mean it isn't overused.



  • How do your own experiences with HB impact your opinion this issue? 


I don't think it does, I felt the same way beforehand. MWs, like doctors, vary. Hospitals sometimes push patients to do things that help hte hospital without regard for the patients' needs. MWs sometimes push patients to do things that go with their philosophy without regard for the patients' needs. Both are irresponsible. The only difference is that hospitals usually have the tools on hand so that, when it goes horribly awry, people are less likely to die.


I was frustrated with both sides going into it- the highly medicalized treatment of birth is something I never want to experience, the highly idyllic "nothing ever goes wrong when nature takes its course" is naive at best and deadly when things do go wrong.

I'm frustrated with both sides for what happened with my birth. I'm incredibly upset with the MW who attended my labor, I still hesitate to call what I experienced birth trauma, but it was traumatic. I'm also very upset with the OB for drawing a line in the sand of "Well, if you want to set yourself up for a safe home birth, then I refuse to work with you".



Originally Posted by mothercat View Post

As a midwife the thing I always worry about is how the woman who has just given birth will be able to care for herself and her baby after a blood loss. For some women, it doesn't take a lot of blood loss for them to have trouble getting out of bed. Others can lose what I think is a lot and they seem to be fine. My job as a midwife is to check their hemoglobin (or better a CBC) to be sure it is in a decent range and help them keep it there. The other part of my job is to minimize blood loss after the birth so she can enjoy the baby. We never know how any amount of blood loss will affect any given woman, but we do know that a postpartum hemorrhage can damage the pituitary gland and seriously effect her milk supply, possible never recovering even for another pregnancy and a baby who nurses well.


Always better to err on the side of caution and have a couple of back up plans in case the first line of treatment doesn't work. Having access and knowing when to administer  Pitocin, methergine, and cytotec is key, as well as knowing when too much blood loss is too much and transferring in to the hospital.


This happened to me. After reading the thread, I think I had low iron (I was tested at 29 weeks and had been fine, but the week or two before birth I just got horrible in every way- low iron is definitely possible). After the birth, someone I know hw's a nurse and heard what happened kept asking me about my iron/hemoglobin levels. I don't know when/how often people usually test iron, the change probably happened pretty late.

No one had talked to me about iron since the first trimester, though... :/

post #35 of 35
My take on the comment that risk should be regulated and should match the OBs criteria of high risk. While I agree some midwives take too great of risks the flip side can be true. Some OBs deem women high risk too easily.

My 6th child is a perfect example. My 5th child was a 35 week preemie. I felt from the get go that his being preemie was the result of stress from a medically over managed pregnancy. I started the pregnancy higher risk due to a sub chorionic hematoma. I was put on bed rest. At 12 weeks I went to the ER for severe vomiting and had been told to go. The ER Dr told me I lost the baby. I was shocked and stunned. The Dr wanted me admitted for a D&C then. My CNMW and I refused. The diagnosis was made based on my HCG dropping 50% in a week. I said but at 12 weeks the placenta takes over and you can see a drop. I was told not that much. Midwife learned an U/S was not done and ordered one ASAP. My baby was fine but my bleed was larger.

20 weeks the bleed was finally gone and my pregnancy was now normal risk!! Yay. Only now I was told since that since I was high risk to start and refused to consent to induction at 37 weeks like the head OB wanted I was not allowed to see the CNMW any more. I stressed and tried to find a home birth midwife (and toyed with a UC) till a migraine due to stress hit at 35 weeks and raised my blood pressure to an unsafe level. I consented to pain meds because of the blood pressure. I did not react properly because as soon as the meds too effect labor started.

So with my 6th child I was confident as long as I could avoid pressure to induce too early and stress from OBs I could go longer. The CNMWs said I had to see an OB because I was over 35, multipar, and had a 35 weeker. I asked if I could transfer to a midwife at 36 weeks. I was told I would be lucky to see 35 weeks pregnant I would never see 36 weeks. I felt with attitudes like that the midwife was right. I switched to an awesome Homebirth midwife whose only concern was would I deliver early and if I did I would have to transfer. Well my baby was born on his EDD.

I was fine the risk factors were ther e but they were not an indication I would have issues.
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