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Comment by Causality1 | Hacker News Reader

Something I think people should be aware of is how the resurgence of midwifery in the Western world is a response to our increasing negligence in taking care of expectant and birthing mothers. In the United States, my sister giving birth today is almost twice as likely to die in childbirth as her mother was thirty years ago. A few months ago Ars Technica covered a study on the reasons why, and it boiled down almost entirely to doctors and nurses neglecting their patients or even straight-up ignoring them. https://arstechnica.com/science/2018/07/why-do-so-many-moms-...

I would absolutely urge anyone to hire a midwife to attend a hospital delivery. It's the only way to guarantee at least one professional in that room cares.

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This might be true in the US but hardly in the entire "western world". Here in France you can give birth in a hospital without ever having a doctor intervening, only midwives, and it is not a new thing.

Yeah, same thing in Denmark. When my girlfriend gave birth, we had 3 midwives assisting. When she lost what they deemed to be too much blood, they called in a doctor to take a look. Everything was fine. If she hadn't passed some specified threshold for bloodloss, we would not have seen a doctor (or a nurse, come to think of it) at all throughout the birth. Only midwives.

Same in Israel. For all three of my children's hospital births, only a midwife was present. In the first two, by my request, she instructed me what to do instead of doing it herself. And being in a hospital there was a doctor on call should any issues have come up.

My wife's obstetrician's office is about half ARPN-CNMs (Certified Nurse Midwife). She saw the Dr for a few appointments, but mostly the CNMs. A CNM delivered our son in the hospital. The CNM had the Dr available to her if things went badly. For our daughter, we came to the hospital with my wife 9cm dilated and the CNM was unable to get there fast enough. In the end it was good that the Dr was there instead as she was born not breathing and eventually ended up on life-support. Even in that case the CNM was the primary care provider for the entire pregnancy.

We live in the US. I think not enough women use CNMs, but it's not some universal thing that you have to use an obstetrician in the US.

As a counter to this point there have been scandals in England (eg Morcambe Bay, but there are others) where midwives killed babies through a combination of incompetence and arrogance, creating a dysfunctional culture that promoted midwifery to the exclusion of other professions - all because they had an unrealistic belief about "normal birth".

Normal birth is defined here: https://betterbirths.rcm.org.uk/resources/read/defining-norm...

Here's the Kirkup report: https://assets.publishing.service.gov.uk/government/uploads/...

Here's the RCOG response: https://www.rcog.org.uk/globalassets/documents/news/rcog-res...

The RCM dropped their campaign around "normal births" shortly after Kirkup, and launched "better births": http://www.rcmnormalbirth.org.uk/

A news report that's a nice summary: https://www.theguardian.com/society/2017/aug/12/midwives-to-...

In England it seems the safest option is to have a mid-wife led birth with medical help available. Having a consultant obstetrician available appears to decrease rates of intervention, not increase them.

Oh definitely. Giving birth outside of a hospital is a bad idea.

Not at all. Hospitals are lately notoriously unclean and eager to intervene and interrupt. A home setup can be very clean and healthy, and the hospital can still be there as a backup if extra equipment is required. Our midwives were quite equipped, though. Oxygen, IVs, fetal monitors, etc. Most of all, it's comforting at home, especially at such an important time

To quantify, at least in the US: your baby is twice as likely to die during birth in a birth outside of a hospital, compared to a birth at a hospital.

And this despite the fact that higher-risk deliveries are more likely to occur in a hospital, so that if the environments were equally dangerous, you'd expect the stats to tilt the opposite direction.

Source? I've never heard that and it sounds like fear mongering. Homebirth, for example, is statistically very safe

How much of that is Simpson's Paradox, though? What I'd think of as 'homebirths' are typically informed, prepared, healthy mothers with no known complications...

Here in NZ, midwife care has taken over to the point where you can no longer get a doctor involved in your primary care at all unless you go fully private obstetric care, which isn't even available where I live.

Midwife-led care has become a weird sort of political and social issue here. It's intricately tied into a narrative about how natural childbirth is better, regardless of the evidence, and much of the culture surrounding it is basically dogma. It's also heavily gender-based - I've never heard of a male midwife here, and a lot of the muttered suggestions about the general terribleness of conventional medical ante-natal care clearly paints male doctors as the bad (or at best, uncaring) guys. There was a study released detailing that our support is not anywhere near as good as we would like to believe (see https://www.stuff.co.nz/life-style/parenting/pregnancy/birth...), which the Ministry of Health got involved in trying to quash and ultimately succeeded in having ignored. I understand the midwives' vested interest in trying to control this narrative, but the only reason I can think of for the Ministry to get involved is that they like midwife-led care because it's cheaper, or that they don't want to admit that going as far as we have down this route might not have been the best idea.

We had a terrible experience with midwife care, and if we were able to have another child (we're not, in part because of the first delivery) we would move somewhere that allowed us to have actual medical professionals involved in our care.

There's a really worrying narrative in all of this, along the lines of that doctors are either incompetent or somehow uncaring about childbirth or women's issues relating to it. Massive reduction in maternal and neo-natal death and complication rates is one of the most amazing results of modern medicine and science in general, ever. I'm still embarrassed to admit how I got sucked in by the alternative narrative despite being someone who likes to look at evidence.

Are your midwives the equivalent of APRN-CNMs in the US? Most people that talk about midwives never specify the type of midwife and that can vary wildly.

I don't know - I don't know what APRN-CNM means and I wouldn't know how to evaluate whether the training here is equivalent or not. Midwives here receive 4 years of training I believe.

> An Advanced Practice Registered Nurse (APRN) is a nurse who has at least a master's degree in nursing, and sometimes a doctorate in nursing.

> A Certified Nurse Midwife (CNM) is a medical professional who oversees every facet of a woman's obstetric care. This includes pre-conception counseling, prenatal care, labor and delivery, and post-partum care. The requirements for becoming a CNM are a nursing license, a midwife license, and a certification from the American College of Nurse Midwives.

> narrative about how natural childbirth is better, regardless of the evidence

Can you point to some sources for this?

To be totally honest I have no idea what the evidence says one way or the other. I do know that most the people I know have had more complicated births when not in midwife led units.

We had 3 natural midwife only births (the last 2 were at home). The final baby we delivered at home totally on our own. It was great to be able to say, “it’s ok, we can do this - it’s totally natural”

Sure, it's totally natural. What is also totally natural is things going seriously wrong during childbirth, with disastrous consequences for the mother and/or child. Historically, a huge number of women and children died during childbirth, or lived in pretty terrible suffering afterwards (see here for an example: https://www.theguardian.com/global-development/2014/may/07/n...). Obviously those conditions are exacerbated by primitive living conditions, but that's been the "natural" way pretty much everywhere until very recently in human history. Even here, my wife's gynaecologist said that roughly a third of all women suffer some degree of prolapse from vaginal delivery, and that rate goes up steeply with more children. Our experience confirms that - it's not something that people talk about because the side effects are embarrassing (urinary and faecal incontinence, problems with sex etc), and socially in a lot of the western world it's somewhat frowned upon to discuss anything that's negative about having kids. We received no information about the risk of prolapse during our ante-natal care, including the standard "you're going to have a baby" book they give to everyone here. But my wife refused to participate in the cone of silence and openly discussed it with people, and a lot of women we know personally have prolapses of varying degrees.

Here's a quote from the article I linked:

The differences she and Sarfati found were not small; across the five-year study of more than 244,000 babies, they found those in doctor-led care had lower chances of poor birth outcomes.

This included 55 per cent less chance of oxygen deprivation during delivery, 39 per cent lower odds of neonatal encephalopathy, and 48 per cent less chance of a low Apgar score, a measure of a baby's wellbeing after delivery.

Those are really serious consequences for the kid. We have a friend of a friend here whose daughter suffered oxygen deprivation during birth. She's 4, still doesn't talk, can't walk properly and is generally seriously mentally impaired. It is incredibly distressing for the parents. You mentioned that your friends in doctor-led care had more complicated births, but what would have happened if they didn't have that care? In our ante-natal group of 12 families, in the end 6 of them ended up with c-sections due to delivery difficulties, and none of them regret it in the slightest because at the end of the day their kids are ok.

We initially tried to have a home birth, and when things weren't working we were taken to hospital. Our hospital is literally 5 minutes drive from where we lived, but it took in total 45 minutes from deciding she should go to actually being in a hospital bed. I'm here to tell you that 45 minutes is a really long time when your wife is screaming in pain. I wouldn't recommend a home birth to anyone. I'm really glad it worked out well for you (seriously, I think it's awesome that it all went well), but there is a large degree of luck involved in that. I just don't think the risk is worth it when the potential downside is so huge.

In terms of sources, I don't have any to hand, and in general it's really hard to find good data because they inevitably end up comparing very different things in different circumstances. There was a big article in a national magazine here a while back trying to analyse the data they could find, and broadly speaking they found the risks of a birth requiring some sort of non-emergency intervention and a standard vaginal delivery were different but broadly comparable. e.g. vaginal delivery has a much higher risk of prolapse, but c-sections have a much higher risk of endometriosis. Generally speaking planned (either elective or pre-programmed due to birth risk) c-sections are very safe these days, but emergency ones are much riskier. But that might be because by definition they're used when things are already going really bad. As women get older the risks of vaginal delivery go up considerably, and for women pushing 35-40 the recommendation seems to be to seriously consider an elective c-section if that option is available to you.

Edit: found the article: https://www.noted.co.nz/health/health/trial-of-labour-is-a-c...

Is this in the US? Are midwifes an optional thing? I've had experience with births in Australia and the UK where hospital midwifes led the process, from antenatal to birthing and postnatal.

I think he is confusing midwife with doula. You don't hire a midwife to join you at the hospital. I think in the US, they are referred to as nurses more than midwives in hospitals. Here in Aus it's all midwives. Therein lies a bit of the problem as the profession should be seen as different to conventional nurses.

I don't think he's confusing anything; doulas aren't medical personnel.

Not sure how much this is regional, but in Poland, you absolutely can hire a midwife at some maternity hospitals. It's an extra private service, through which you can select a particular midwife from the hospital to be available to you for consultations and be there to lead and care for you during birth.

In the US it depends on what your obstetrician's office has in many cases. The practice my wife chose has about 50% APRN-CNMs (Certified Nurse Midwife). We had a CNM for our first delivery and the Dr for the second (timing didn't allow for the CNM to make it to the delivery).

Midwifes are an optional thing in the US; lots of hospitals are OBN/GY-lead & they handle all the ante-natal, post-natal, and delivery stuff.

We found one of the few midwife-led hospitals in the Bay Area and had a very similar experience to the NHS Scotland midwife-led birthing centres.

Maybe. I’m not sure I believe that. Recall that a greater proportion of births are now coming from poorer people in worse conditions and often worse health to begin with. If you are middle class+, You’re probably at top tier rates competitive with the rest of the world.

Mortality rates are often twice as high for non whites in America likely due to wealth effects.

https://www.kff.org/other/state-indicator/infant-mortality-r...

The US has 2 levels of obstetrics professionals -- MD/DO and Certified Nurse Midwife. CNM's are nurse practitioners with a Masters or Doctorate degree. They don't do surgery, and the smart ones don't do births outside the hospital.

In the US you also have "Professional Midwives", Doula's and Certified Professional Midwifes -- none of which have any real health care training requirements. In most other countries when they speak of midwifes, they mean nurse midwives.

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