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Comment by burfog | Hacker News Reader

This is a big part of why homebirth is gaining popularity. It's just family and maybe a midwife. Nobody is going to do a meth test. The doors don't lock you inside, unable to escape without permission. (that security is NOT to protect the baby from strangers; it's so CPS can take your baby)

Also: There is no need to drive madly to the hospital. There will be no incentive to keep you for exactly how long your insurance will pay, nor to perform surgery. You get to sleep in your own bed, without constant beeping and light from the hallway. You can have as many visitors as you want. You will never be separated from your baby, not even for a moment. You won't be treated like a potential criminal. You get respect.

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The baby's heart rate dropped during contractions, as monitored by the hospital equipment. The mother was put on oxygen to help. Later, they chose to do an emergency C-section because the heart rate dropped too low.

In a hospital, all that was easy to access. If this had been a home birth, it may have been catastrophic.

Driving to the hospital and not being in your own home is an unfortunate reality. We do not live in hospitals.

Disrespect, misalignment of insurance incentives, and inflexible criminal treatment are all bad things. But their damage is amplified because the alternative - homebirth - lacks the medical advantages of being in a hospital. Draconian policies like this literally kill children at the margins.

"The baby's heart rate dropped during contractions, as monitored by the hospital equipment."

That's about as reliable as:

"The dog moved funny, indicating it found drugs, so we have to search your car."

(it's totally normal for the heart rate to drop)

The sad reality is that the facility for C-section is not financially viable unless you use it on a regular basis. There is an incentive to use it. When used, it is profitable.

Doctors who push back on profitability find themselves replaced.

In any case, those who have trouble at home can get emergency C-sections. Since prepping takes time anyway, there is no added delay if you call ahead. Situations where mere minutes matter are rare to the point of being pretty much non-existent.

A baby's heartrate (as measured by either an external transducer, or a probe hooked into the baby's scalp) is an objective measurement. Comparing it to the completely subjective "signaling" of a police dog is absolutely absurd.

Much of the 'prepping' requires the mother to be present (administration of anesthesia, monitoring, etc). The prep of the OR is generally done in parallel with those tasks. If it takes you 30 minutes to the to the hospital, you are delaying a c-section by at least 30 minutes.

Additionally, measure that can be taken to reduce fetal stress (while waiting for the OR to be prepped, in the event that is delayed) are _much_ easier to accomplish in a hospital, rather than in a car, or the back of an ambulance.

> (it's totally normal for the heart rate to drop)

No it is not!

We are not talking going from an exercise heart rate to a resting heart rate. We are talking about a resting rate to a lower-toward death rate.

> "(that security is NOT to protect the baby from strangers; it's so CPS can take your baby)"

Uh no, it's really not.

It's not to protect the baby, thefts of children (etc) are rarer than lightning strikes.

> It's not to protect the baby, thefts of children (etc) are rarer than lightning strikes.

Maternity ward infant abduction is an ongoing thing, though now fairly rare (and even more rarely successful, with dozens of attempts stopped within the ward for each successful abduction) because of the security measures that have been instituted by hospitals in the last few decades.

But that's a success of the security measures, not an indicator that they aren't necessary.

And lightning does strike, some times, some places. Putting fences around every tree to keep people from hiding under them would save some lives.

But in this case there's a rather large negative of being trapped.

It's not enough that there be some theoretical benefit, but that the benefit outweighs the costs.

Actual thefts? Sure. Related issues (family disputes, unwanted guests, etc)? Far more common.

Keep the guests out with a door that's locked from the outside, sure. But lock people in? Recipe for disaster!

I trust my smoke alarm - to probably give me extra warning. I don't trust it to unlock the door and let me out.

it is also there to prevent unmonitored/uncontrolled access to babies. Prevent things like babies being mixed up. Aides taking wrong child for testing etc.

And if there's trouble and the kid[0] dies[1] you can just say that was "their journey" and wash your hands from it. Hell, you might even "get respect" and praises for having killed your kid, go you.

But hey, CPS didn't get to take your kid[2], so there's that.

[0] or the mother, or both

[1] which is anything but rare, even in the UK under obstetric care[3]

> The risk of dying on the day of birth (0.43 per 1000, or 430 micromorts) exceeds that of any other average day of life until the 92nd year.

and matches the risks of major surgery. Homebirth, especially with completely unqualified midwives (which is the rule in the US) is almost an order of magnitude more risky[4].

[2] the coroner did, to check for foul play

[3] http://onlinelibrary.wiley.com/doi/10.1111/1471-0528.12544/f...

[4] https://olis.leg.state.or.us/liz/2013R1/Downloads/CommitteeM...

That's just an ignorant response. There are plenty of board-certified midwives, birthing centers, etc. Importantly, a great deal of risk can be ascertained before labor, and like any other medical procedure you're either a good candidate for non-hospital birth or you're not.

It depends heavily on the quality of the midwife and how well they can recognize complications. If they miss something (which very likely would turn from from a required test in a hospital), by the time the baby has stopped breathing, it might be too late to save them.

"Planned out-of-hospital birth was associated with a higher rate of perinatal death than was planned in-hospital birth (3.9 vs. 1.8 deaths per 1000 deliveries, P=0.003; odds ratio after adjustment for maternal characteristics and medical conditions, 2.43; 95% confidence interval [CI], 1.37 to 4.30; adjusted risk difference, 1.52 deaths per 1000 births; 95% CI, 0.51 to 2.54). The odds for neonatal seizure were higher and the odds for admission to a neonatal intensive care unit lower with planned out-of-hospital births than with planned in-hospital birth." [1]

"Midwife home births had a significantly higher total neonatal mortality risk than deliveries by hospital midwives (1.26 per 1000 births; relative risk [RR], 3.87 vs 0.32 per 1000; P < .001). Midwife home births of 41 weeks or longer (1.84 per 1000; RR, 6.76 vs 0.27 per 1000; P < .001) and midwife home births of women with a first birth (2.19 per 1000; RR, 6.74 vs 0.33 per 1000; P < .001) had significantly higher risks of total neonatal mortality than deliveries by hospital midwives. In midwife home births, neonatal mortality for first births was twice that of subsequent births (2.19 vs 0.96 per 1000; P < .001). Similar results were observed for early neonatal mortality. The excess total neonatal mortality for midwife home births compared with midwife hospital births was 9.32 per 10,000 births, and the excess early neonatal mortality was 7.89 per 10,000 births." [2]

[1] http://www.nejm.org/doi/full/10.1056/NEJMsa1501738 [2] http://www.ajog.org/article/S0002-9378(14)00275-0/abstract

Rounding up your first statistic slightly, that's a difference of two severe incidents per thousand births. That's a reasonably big risk factor in absolute terms, but small enough that it's not unreasonable to take in order to get other things that you care about.

Like, these are "am I willing to make this tradeoff" numbers similar to choosing to drive to work daily, rather than "fuck no, go to the hospital" numbers.

Midwives don't sell themselves on the increases risks, they talk about the (largely) cosmetic benefits of home birth.

Look up earlier in the thread for my comment, but anecdotally, almost every parent that I have told my story to has changed their opinion on home birth vs. hospital birth.

If you're talking about certified nurse midwives (CNMs), yes. If you mean certified professional midwives (CPMs), no. I liked this NYT piece on the subject, "Why is American Home Birth So Dangerous?": http://www.nytimes.com/2016/05/01/opinion/sunday/why-is-amer...

> That's just an ignorant response.

It's an educated and sourced one, as opposed to your flippant comment.

> There are plenty of board-certified midwives

Not only are there plenty of midwives which are not that, how meaningful board accreditations are depends strongly on the board, CNMs are true professionals[0], CPMs are pointless layabouts.

> birthing centers

The comment I was replying to was about homebirth.

Birthing scenters are usually professionally staffed, attendant to hospitals, carrying necessary emergency materials and will immediately transfer to their linked hospital in case of complications. And good birth centers will plain refuse at-risk patients and direct them to hospitals.

> Importantly, a great deal of risk can be ascertained before labor

Which is already included in the statistics above.

[0] and even with CNMs homebirth mortality is significantly higher than hospital birth.

There are some very nice birthing centers that are not associated with hospitals.

From what I've seen, hospital-associated ones are bait-and-switch. If you show up early, then you take longer than allowed and they transfer you to the regular hospital. If you show up late, then they also transfer you!!! (this shockingly lame excuse was actually used on a friend) Clearly, there is a purposely narrow window because the hospital makes more money if you end up in the regular hospital area.

I find it strange that you think homebirth midwives don't carry necessary emergency materials. Just considering the obviously visible example, every one I've seen lugs around an oxygen tank.

Homebirth midwives are not doctors, so carrying around "necessary emergency materials" is not enough in the case of a medical emergency.

A birthing center isn't your home.

If you have to deliberately compare to the worst case scenario "with completely unqualified midwives" to try to make your point, then it is not a good point.

True. Though as an EMS provider, I'll definitely say that I've run the gamut of calls to midwifes/birthing centers/home births from "completely competent professional I'd have no issue managing my partner's birth" to "I really need to call the DOH after this". Situations where, upon handing us a cyanotic baby with severely deficient APGAR score (https://en.wikipedia.org/wiki/Apgar_score) the midwife's primary care was 'respect for the process and the environment', wanting us to take off boots and "try not to be too loud or overactive".

If you've already been handed the baby, your boots should be on their way to the emergency room as fast as your truck can go. It really isn't right how you people turn every call into an excuse for searching without a warrant. Unrelated stuff going on in the home or birth center is none of your business.

What on earth are you talking about?

"You people"?

Unrelated stuff going on in the birthing center?

I am describing a situation where the midwife/ doula was MORE CONCERNED with maintaining a "positive and serene energy in the birthing space" (her words) than she was about what we would do to take care of a critically ill neonate.

I can assure you, my methodology on such a call is not to "stay and play" but to "stabilize, ideally while transporting". Let alone a fishing trip. To wit, I could not care less what else is going on in the home, be it legal or illegal, unless it directly affects the care I am or need to provide. My reference to DOH was not a "fishing trip", but in regards to a provider who, in my professional opinion, was being actively negligent in caring for what was their patient, until transferred to me.

I think your biases are showing.

I don't see any reference to 'searching'. It is very standard practice for a healthcare provider to give a verbal report when handing over care of a patient, even (_especially_) in a critical setting.

You realize paramedics are qualified in neonatal resuscitation, right? While "scoop and run" is absolutely the right thing to do in some cases, if I'm handed a blue baby, I'm going to spend some time in stable, well lit environment getting an airway established. The sooner that happens, the better the baby's outcome is going to be (and it's much harder to do bouncing down the road in the back of an ambulance).

> If you have to deliberately compare to the worst case scenario

What in god's name are you talking about? Infant mortality is the one primary risk of childbirth and the primary measure of perinatal and neonatal care alongside maternal mortality, the risk of the child dying is the very first thing you compare when talking about childbirth.

> with completely unqualified midwives

And that is a very common risk in the US because most states don't require any formation (let alone certification) to call yourself a midwife.

>What in god's name are you talking about?

I was very clear, I do not see how you could genuinely be confused.

>And that is a very common risk in the US

It is not a risk, it is a choice. You don't call up the midwife store and say "send me a midwife" and hope for the best. You choose one. People can choose one that is trained and certified.

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