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Comment by coffeemug | Hacker News Reader

Do you think it likely that an entire field that evolved over a period of thousands of years, has thousands of people doing the job all over the world daily, and is so common and important that there is scientific research performed on it pretty much not-stop, just missed this idea?

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The field itself is fractured. Many midwives make the point that a complication free birth is not a medical event, and the majority of births are complication free. Have the medical intervention nearby for an emergency, but don't make it the default.

There is a line or argument that intervention is a self-reinforcing cycle, in that the initial intervention raises stress levels in the mother, which promotes a fight-or-flight response, which causes the birth process to regress, which increases the likelihood of more intervention, and so on. This isn't to say intervention should be avoided, but only do it if it is necessary, since it does have consequences.

> The field itself is fractured. Many midwives make the point that a complication free birth is not a medical event, and the majority of births are complication free.

Midwives are not part of the field of obstetrics, any more than sanitation workers are part of the field of engineering.

Don't be absurd. Midwives are practitioners in the field of child birth. Some will have acquired a highly developed sense of what works and what doesn't. It is foolish to ignore their experience.

Midwives are practitioners in the field of child birth in the same way barbers used to be practitioners in the field of surgery. Yes, they engage in the practice and for a long time they were the only game in town. But it's not a systematic discipline and therefore experience isn't cumulative.

This isn't true. Midwifery is a serious discipline and you must be licensed in the US. Also, they even have Doctors of Nurse Practice (DNP) of Midwifery at the respected Baylor [1] and other schools. I would recommend watching "The Business of Being Born" (it is on Netflix) - it is very enlightening about the safety and discipline of midwifery, and why hospital births are unnatural and in some ways incredibly unsafe.

[1] http://www.baylor.edu/nursing/nursing_grad/index.php?id=5668...

The University of Washington educates midwives alongside do tors and nurses: http://nursing.uw.edu/node/371

My wife's cousin is going through the program right now and will graduate with the equivalent of an MD. She's doing residency at a large hospital in Seattle and did clinical at another in Boise. When she graduates she'll be working adjunct at either another hospital up here, or through Stanford. I'm no medical expert, but I trust her experience and expertise. I'm not sure where you're information is coming from, but I think you may be misinformed.

Not only are they serious medical professionals now, but they have been for a while. Watch the British TV show Call the Midwife. Even back in the 50s midwives were well-trained specialized nurses who dealt with serious medical issues on a regular basis.

I think you're thinking of midwives from a few hundred (or more) years ago, before the fields of medicine and nursing existed as they do today.

I think you are mistaken. In Britain, the term 'midwife' means specifically a postgraduate qualification on a general nursing degree. They are certified medical professionals and have a level of specialised knowledge akin to a ICU nurse or a surgical nurse. Indeed, midwifes attend Caesarean sections, as part of the surgical team.

I have a cousin in Australia that is a midwide - it's the same deal, she started out as an RN before getting her postgrad midwife quals.

Doctor's are no more than overpaid, highly inconsistent expert systems.

And midwives aren't even that.

Midwives are certified medical professionals (comparable to specialized nurses or physicians' assistants), at least in the United States. You're either talking about somewhere else or you don't actually know what you're talking about.

In the US, deliveries are done by CNMs, CMs, and doulas. Only the former has a nurses level of training.

Yes, because obviously nurses are just there to do menial labour that it would be demeaning for doctors to do. This is the most ignorant thing I've seen you say on this website, ever.

In France they are. At least my French neighbor has what might be considered physician assistant level education in France and she would run the show during a birth. The US is very different in this regard.

Western medicine treats pregnancy and childbirth like a disease. So, yes; I do think they probably get delivery wrong.

In what way?

Western medicine treats pregnancy and child birth like a high-risk situation, which it is. It's the same principle behind having doctors standing by at a boxing match, except the natural rate of maternal mortality in child birth is far higher than the mortality rate of even the dirtiest fight scenes.

Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2742137/

"The rate of perinatal death per 1000 births was 0.35 (95% confidence interval [CI] 0.00–1.03) in the group of planned home births; the rate in the group of planned hospital births was 0.57 (95% CI 0.00–1.43) among women attended by a midwife and 0.64 (95% CI 0.00–1.56) among those attended by a physician."

No offense, but the data says you're wrong.

The average woman who plans to have a homebirth is having a complication free pregnancy, and anecodotally, everyone I know who has had one it has been for their 3rd or higher birth after complication free deliveries in hospitals.

You can't compare those numbers, they aren't the same populations of pregnant women.

The problem with such comparisons is that high-risk pregnancies won't be planned for home birth to begin with. Also, in a hospital, a physician will be called in at the first sight of any complication, so midwives won't be attending births that go wrong.

A comprehensive study in Oregon found death rates 6-8x higher in home births than hospital births: https://olis.leg.state.or.us/liz/2013R1/Downloads/CommitteeM....

See also this meta-survey of the literature: http://www.ajog.org/article/S0002-9378(10)00671-X/abstract ("Less medical intervention during planned home birth is associated with a tripling of the neonatal mortality rate.").

Your first point is spot-on. Home births are bound to be statistically more successful because they are (usually) only planned for low-risk pregnancies.

However, the increased death rate in the Oregon study is

a) localized to that state, and b) attributed to an overabundance of uncertified midwives:

> But out-of-hospital births are not as safe as births in hospitals in Oregon, where many of them are attended by birth attendants who have not completed an educational curriculum designed to provide all the knowledge, skills and judgment needed by midwives who practice in any setting.

In other words, there are a lot of "birth attendants" practicing midwifery in Oregon who aren't necessarily CNMs (certified nurse-midwives) or CMs (certified midwives) -- which is perhaps closer to the barber acting as surgeon analogy.

EDIT: Here's a rebuttal to the Wax study: http://www.midwiferytoday.com/articles/ajog_response.asp

From the study's abstract:

"Studies of planned home births attended by registered midwives have been limited by incomplete data, nonrepresentative sampling, inadequate statistical power and the inability to exclude unplanned home births. We compared the outcomes of planned home births attended by midwives with those of planned hospital births attended by midwives or physicians."

and

"We included all planned home births ... and all planned hospital births meeting the eligibility requirements for home birth that were attended by the same cohort of midwives ... We also included a matched [my emphasis] sample of physician-attended planned hospital births (n = 5331)."

For what it's worth, the Netherlands was well knowm for a long time because we defaulted to midwife supervised hone birth with effective escalation in case of complications.

Up until I think 10 or so years ago we had one of Europe's best delivery success rates with that.

After that it seems that hospital deliveries became a safer choice and we've had relatively bad percentages since then because we culturally still value home births highly.

Perfect example of selection bias.

Given the fairly extreme historical levels of death during/immediately following childbirth, isn't that pretty reasonable?

You would be surprised. The cultural norm (not scientific, mind you) to have women give birth on their backs in reclining position was French royalty and aristocracy, according to our birthing coach. Why that continued into modern medical practice is unclear, and many women are in so much pain, they do not question. Doulas, or birth coaches, try to tell you early to force yourself to stand or hold yourself on arms and knees on the bed, if possible.

Source: Doulas, certification info at: http://www.icea.org/content/doula-certification

If only. I strongly recommend this documentary: http://www.thebusinessofbeingborn.com/

Yes.

[edit] Part of it is that the patriarchal doctor wants to be "in charge" of the situation and treat childbirth like some kind of medical operation.

(This is not to say that modern medicine saves many children's and mother's lives. A modern, optimal, approach is to have a traditional birth with ready access to a hospital for a c-section, etc if necessary.)

Why haven't any researchers run a trial to compare the two and revolutionized this area of medicine after pronouncing dramatically better results for the traditional way?

Because the ethics committee is never going to sign off on an experiment that has even a hint of risk to mother or child who aren't already at greater risk from a lack of intervention.

It's the same reason you don't conduct Phase I clinical trials of new chemotherapeutic agents with people who don't already have cancer.

Birth is already risky enough. "Let's science that, to see which has the best outcome," while a completely rational approach not only to decreasing harm, but also to increasing health, just isn't going to fly.

They have, in the UK when you have your first appointment with the midwife they encourage you to consider it as an option. If you decide to do this you will then be assigned an experienced midwife who will attend the birth at your house, will monitor the situation for complications and will have an ambulance on standby at the first hint that things are not progressing normally. Also, if there is any hint of complications at all during the pregnancy you will be strongly recommended to have a birth in the hospital.

No, the modern optimal approach is to have a birth in a giant hospital so 1) you don't risk leaving the medical decision of whether intervention is necessary to someone without medical training; and 2) you don't risk the time lag of transferring to a hospital when a distressed baby is getting more brain damage from a lack of oxygen with every second that goes by.

It's possible to give birth in a giant hospital with medical professionals present without being prone and sedated, though.

You're not sedated during birth. An epidural is localized anesthesia.

You seem to be avoiding addressing the "prone" part of the equation.

As you know, any field is constantly advancing and sometimes it returns to an older idea and uses it in a new way. This is happening in obstetrics right now. It isn't that the downsides of sedated, prone births were "missed" so much as that they were part of the best birth technology of the time and innovation and changes in viewing that technology do not happen quickly. That model is now being replaced by births that combine medical advances with the mother's natural abilities more effectively.

Every scientific advancement must be preceded by a time when that advancement was not known or known but not used, no matter the age of the field.

Yes. Perhaps not all medical people personally, but as an institution, the medical field totally did.

As with politics, follow the money.

That leads to another useful heuristic: since the people currently practicing in a field are making money, the current practices and norms in any field are always wrong.

The research is often there, but not read or understood by the practicing doctors. I found the book “Expecting Better”[1] to have a great analytical approach to the existing research.

[1]http://www.amazon.com/Expecting-Better-Conventional-Pregnanc...

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