Regarding this New York Times story about a baby who died during a home birth attended by a midwife — a few observations …
The fact is that most of the time you don’t need a doctor to have a baby. For that matter, you don’t need a midwife, either. The fact of the matter is that most of the time you could have your baby alone on the floor of a gas station restroom, and you and the baby will be OK. I’m not recommending that; I’m just sayin’. High maternal mortality rates of the past were mostly caused by postpartum infection, known as “childbed fever,” which these days can be treated with antibiotics.
My understanding is that most of the time good prenatal care is more important to a good outcome than what happens during the delivery. There are all manner of studies that show a correlation between how early a woman begins prenatal care and her chances of delivering a healthy, full-term baby. But most of the time hospital deliveries are medical overkill, and if you have to ask how much they cost, you can’t afford them.
The big argument in favor of going to hospitals is that the sorts of things that can go wrong often go wrong very suddenly and catastrophically, and the mother’s or baby’s life can hang on how quickly physicians with high-tech medical gizmos can address the problem. And you have to go to hospitals if you want the mostly effective and mostly safe anesthesias they have these days.
The argument against midwives with no medical training is that they might not recognize a serious problem as it develops and know when to call in the experts. Remember, even a midwife with no idea what she’s doing will be successful most of the time, because most of the time babies will be born just fine if nature takes its course. An untrained midwife with a few good deliveries under her belt might not realize how much she doesn’t know. I can’t tell from the article if the midwife in question did anything wrong, however.
Over the years, every now and then, somebody proposes that trained registered nurse-midwives work under the supervision of physicians. If the physician doesn’t believe the delivery will present complications the midwives can attend the births at home if the mother wishes to give birth at home. And they would be able to recognize potential problems and would know when to move the show to the hospital or call 911 for emergency assistance. This seems like the best of all worlds to me. I suspect the biggest reason this plan never seems to be implemented is medical liability.
Full disclosure — I had both of my babies in hospitals, with no regrets, mostly because I didn’t have to be concerned about cleaning up. Childbirth is messy.
I loved your full disclosure comment!
I had my baby in a hospital also – The Ohio State University Hospital. I had 3 hours of labor and a saddle block. I wouldn’t want to clean up any mess either.
My cousin had her baby at home with a midwife attending, and I got elected to clean up the mess afterward. As they say, you can get used to anything.
I’ve often described my job–obstetrician–as hours of boredom punctuated by moments of sheer terror.
As you note, babies can almost deliver themselves much of the time. And most moms and babies do well.
But there can be catastrophic failures. The cord can prolapse, a placenta can abrupt, a baby can go into distress for many reasons. Minutes can make a difference between life and death or disability. And moms can and do bleed to death (the most common cause of maternal death worldwide).
Half a million women a year die worldwide from obstetric complications. Most of them are in the third world, where they don’t have access to modern prenatal or intrapartum care. And most die at home, often because they can’t afford a hospital (or even birthing center) delivery.
As I tell my patients, if we could predict who would have complications, life would be much easier. But we usually can’t. And that’s why we encourage all our pregnant women to have hospital deliveries.
Disclosure: I work as a hospital doc at a medium risk hospital. But I also work (as a volunteer/educator) at a midwife-based (with doctor back-up) labor unit in a small hospital in India, so I’ve experienced bad obstetric outcomes more so than most US obstetricians.
Not awfully long ago I was waiting at a local hospital and noticed a person watching out a window an ambulance across the street. I later learned that the ambulance crew was assisting a woman with a childbirth problem (I do not know what). The woman had come into the hospital for help and was turned away as the hospital did not do childbirth. Whatever complication the woman had it was taken care of on the sidewalk of a busy street in America. So why sue a midwife that at least is trying to assist!
Disclosure up front: I had both my kids in hospital. If I had been at home, it probably would have been curtains for me.
I do, however, believe in the value of trained midwives, though I would rather see them working in hospitals.
True story: a friend of mine, after suffering numerous miscarriages and an ectopic pregnancy that left her with only one Fallopian tube finally carried a pregnancy to term. Throughout the pregnancy, she was followed by the high-risk team in a large, well-known hospital. She went into labour, went to the hospital, was hooked up to every possible machine to monitor her and all was going fine until the baby gave one huge kick (while still inside her) and then died, strangled by the cord.
With all the technology in the world and the best high-risk doctors, babies still die. Sad but true.
My late Ma was an obstetrics nurse, so I’ve heard a few stories. Also as a child I used to look at the photos of “high risk neonates” in her professional journals, so I’m aware that when stuff goes wrong it can go really, really wrong. I never considered giving birth at home, even though my kids pretty much popped out like toast. There was much about my hospital stays I found annoying, however, and from what I hear after all these years not much has changed.