A Tale of Two Births

I have two sons, both healthy happy boys, both brought into this world in very different ways.  I work in healthcare and like many readers of THCB, the business of healthcare is often viewed through the business lens.  When we become the healthcare consumer, and are knee deep in the conundrum that is our healthcare system, the perspective changes dramatically.

Ezra was born in a major medical center, under the supervison of state of the art OB/GYNs, with all of the greatest technology, and under the care of the best nurses.  My wife wanted a “natural birth”, so natural that I affectionately describe it as a “granola birth”.  We were active duty military at the time so our choices were limited.  She hired a birth doula, read Ina May’s “Guide to Childbirth”, chose to see a Women’s Health Nurse Practitioner for her wellness visits, and was adamant that she did not want an epidural.

As we approached 40 weeks the adventure began.  At 36 weeks she could no longer see the NP, she had to now see the OB/GYN.  The OB/GYN began to make reference to not allowing us to go past 40 weeks, it would “endanger the child”.  My wife began to feel very uncomfortable and that she was slowly losing control of the experience she wanted to have.  At the 40 week visit, the OB/GYN gave a very stern warning that an “induction was now necessary for the safety of the baby” regardless of there being no indication that Ezra’s wellbeing was compromised.  We resisted as much as possible (with the help of no beds in the maternity ward) but at 41 weeks and 2 days, doctors’ orders brought us into the hospital for an induction.

The induction was the beginning of the end of my wife’s “natural” experience. The induction led to administration of Fentanyl, which led to an epidural, which led to Oxytocin, which led to contractions so powerful they resulted in fourth degree perineal tears and ultimately the arrival of Ezra.  Soon after Ezra’s arrival, the pediatrician arrived, we had a problem.  The group B strep swab that was negative at 34 weeks had expired (there only good for 4 weeks).  An error in the chart had failed to capture this prior to the delivery (a new swab could have been done) and prior to his birth (if caught, mom could have received a simple dose of IV antibiotics); Ezra would now have to be treated as Group B unknown.  Both my wife and I being RNs, were furious at the news the pediatrician delivered and even more furious and what was being requested; IV Antibiotics, blood, urine, and cerebral spinal fluid, all done in the NICU.  We were fearful for our sons safety, not because he was now “group B unknown”, but because he was now entering deeper into the labyrinth of our healthcare system where 90,000 people are still killed every year due to medical errors.  We watched helplessly as more blood was drawn, urine collected, IVs started, and a spinal tap performed (which after 5 attempts and 5 misses was finally abandoned).  Ezra survived his ordeal as did mom and dad, and after a 3 day stay we were all discharged home.

Fast forward two years and we welcomed the news of our second son; Silas.  By now, we were out of the military and my wife welcomed the idea of having her real “granola birth” experience.  We went out of our network insurance to use a birthing center that was staffed by Licensed Midwives.  We paid $4,000 out of pocket because our insurance would not cover due to “liability concerns”.  Given that I work for the company that is also the insurer (yes, I work for an insurer), I was able to discover how much a delivery would cost at a hospital in our market; $7,500.

Each visit with the midwife lasted between 45 minutes and an hour.  The assessments were very thorough, our questions were answered, and Ezra accompanied us on the visits.  We were introduced to a new world of naturopathic healing (this was new to me) for headaches, backaches, and sleeplessness.  We had options where we wanted to have the delivery, at home, the birth center, in a warm tub.  Birthing positions and techniques were reviewed (on your back with feet in the air was not on the list of suggestions).  We were given choices of what vaccinations we wanted, literature was shared on what research has shown on the risk of exposure to group B strep, and we made the decision on how we wanted to proceed.  Only two ultrasounds were done, 6 weeks and 24 weeks cutting down on utilization.  Emergency procedures were reviewed in case something went wrong, the on call physician would be notified or we would go to the emergency room.

40 weeks approached and my wife became concerned, friends and co-workers admonished her for putting her baby at risk.  “It’s dangerous” they would say, “this is not good for your baby”.  The midwife was never concerned, “your baby will come when he is ready”.  We went to 42 weeks before Silas arrived.  We called the Midwife at 12:00am and talked through what the contractions were like; she met us at the birthing center at 12:30 am.  My wife labored for 4 hours with the gentle guidance of the midwife and no medications.  She stood up, she lay down, she lay on her side, she walked around, and she was never tied to an IV, nor confined to a bed or birth monitor.  At 4:00 am a bathtub was filled with warm water which eased the intensity of the contractions and at 4:30, Silas was born.  We had previously decided that the newborn screening and Erythromycin eye ointment were all we wanted him exposed to, vaccinations could wait.  By 10:00 am, we were home with the second addition to our family.

I recently attended a panel discussion of hospital CEOs and CNOs.  Two of the executives were touting how their facilities had just recently “stopped all non-emergent inductions and elective cesareans prior to 36 weeks”.  They were so proud of this decision to “do the right thing” but lamented how it had impacted their bottom line.  Why did it impact their bottom line?  Because they experienced a significant (25%) reduction in NICU days.  I wanted to stand up and shout “why would you induce or deliver by cesarean any expectant mother if it is not medically necessary?”

Our healthcare system is broken but it is our own behavior as providers, payers, and consumers that have allowed it to happen.  Why would any provider want to induce a mother at or prior to 36 weeks?  Who decided elective Cesareans were a good idea?  Since when did uncomplicated child birth have to take place in the hospital?  Why can I pay bills, adjust my home thermostat, email across the world, and make dinner reservations with the device I have in my pocket, but health information cannot be tracked and shared in a way the prevents costly and deadly medical errors?   Why don’t payers reimburse care that is delivered by mid-levels in a safe environment at a lower cost?  I don’t claim to have the answers to these problems, but I do know that until we change our own behavior, we will continue to see the same results.

David Overton is the patient management director of the San Antiono Dedicated Units at Aetna.

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  2. That experience must have been a fright, especially since you had no idea whatsoever of what was gonna happen, at the time. Congratulations on your baby boy! I do recommend that you give Memphis Gynecologist a call, though. If you’re planning to have your third angel. Just a heads up. 🙂

  3. Dear David,

    Thank you so much for sharing your family story and doing so in such a clear and heart felt way. We need more of such stories in medicine as they help us understand policy and make appropriate changes as needed. Rather than a focus on home birth vs cesarian, I felt your piece focused on the stresses you and your wife felt as you were pressured to act in a way that was not in alignment with your wants or needs during the first birth experience. Such individual experiences coupled with science has led to the initiative in HHS to limit elective c-sections prior to 39 weeks, which is helping children start life in their mother’s arms rather than NICU beds.

    If you ever would like to join those of us who wear such stories as paintings on our backs feel free to contact me. And for those of you who do not think this writing appropriate for The Healthcare Blog I wonder how long you have been reading here… Matthew Holt wrote about my soft emotional story full of feeling way back in 2009. From those “feelings” I worked on policy for the past four years.

    Remember all data, all science, all statistics, starts out as a very simple story and becomes powerful in the aggregate.


    • AMEN. Well said and on point. Thank you for seeing past the smoke coming out of some of the other writers’ ears.

  4. I don’t know why other posters have not discussed the “disaster” or the “near disaster” as others have labelled the first birth but I know why I didn’t. Like lots of birth stories it doesn’t completely make sense and it’s discussing the management of a specific case when you don’t have all the facts is unfair to either/both the parents and doctors involved.


    Whether the doctor wanted to induce earlier or not, induction at 41 +2 weeks is reasonable. It’s debatable, but I do think it’s much harder for most mothers who plan to give birth without pain medication to succeed if they are induced. I have seen it done. But it’s not too common. So maybe the induction led to the Fentanyl. Did the Fentanyl lead to an epidural and pitocin? Well, labor pain likely led to an epidural. Did the pitocin and epidural lead to a fourth degree laceration? Some (old) evidence says epidurals can lead to an increase in vacuum and forceps births, and that can lead to more fourth degrees, but I think you would have mentioned if she had forceps. What’s implied in all this is a very likely long labor with prolonged ruptured membranes.But that isn’t stated.

    Now there is a baby. And suddenly the GBS status is noted to be unknown. If they had discovered this error in labor, hopefully your wife would have had antibiotics. I have to wonder what about the baby made them notice the culture was old. Because the treatment of the baby is extreme even if you knew the baby was GBS postive and lets say the antibiotics had been missed in labor. It just doesn’t make sense. Which makes me think they thought the baby might have had symptoms or other risk factors. It isn’t my hospital’s protocol or CDC protocol to do so much invasive testing on an otherwise healthy baby (GBS positive, negative or unknown). It doesn’t make sense.

    So I’m guessing other people were wiser than I was and just declined to comment. But if they work in the field that’s what they may have thought about the first birth. Not disaster, or near disaster, but … huh?

    Regarding the difference between one and two, what would be unusual would be for number two to not be markedly easier. And I have seen homebirth transfers for fourth degree lacerations as well.

    Birth story dissected. I am embarrassed I did it. I guess it’s your “business as usual” that made me think I’d take a stab at why I didn’t comment on the first story. Which doesn’t remotely approach the level of disaster of a preventable perinatal death.

    • “It isn’t my hospital’s protocol or CDC protocol to do so much invasive testing on an otherwise healthy baby (GBS positive, negative or unknown). It doesn’t make sense. ”

      Testing is a profit center. There are plenty of badly run hospitals who will happily run pointless tests.

      Anecdote from a different specialty. Given severe digestive problems and a clean endoscopy and colonoscopy, the reaction of two (incompetent, should-have-had-medical-license-revoked) gastroenterologists was “Let’s do anther expensive colonoscopy!”. The reaction of the third (competent) one was “OK, here’s what I know about what can cause these problems with a clean colonoscopy: there are five causes I know of, and here are the possible treatment regimens. We can’t test for any of them. All the treatment regimens have downsides. There may, of course, be a cause I don’t know about. Tell me what you’d like to do.”

      Competence is rare in medicine.

      • Wow you are really pissed about having that camera shoved up your butt so many times arent you? How did it feel? Tell us about it! LOL

  5. Military hospitals have a bad rap. I hear issues about them all the time. I wouldn’t generalize all doctors and hospitals across the nation to a military hospital. Why did she get her GBS at 34 weeks and not 36 weeks? Did the doctor feel she might deliver early? Does it matter? I speculate most doctors and hospitals would have accepted that 34 week GBS result. You may not have received antibiotics or you could have received them empirically. The baby could have been watched carefully after birth and only get the sepsis work up if signs or symptoms were present. I feel the doctors and the military hospital let you down. But you don’t get into an accident in a Volvo and decide you are only going to drive a Ford Festiva for now on. You left licensed doctors, with accountability and malpractice coverage for unlicensed, undertrained, lay midwives with no malpractice coverage. Had your baby developed hypoglycemic encephalopathy or hypoxic-ischemic encephalopathy with subsequent CP, or if you wife had a post partum hemorrhage and died, or any of the other not so common complications that can occur like Erb’s palsy’s from shoulder dystocia, what recourse would you have to reap benefits from them. They have no malpractice coverage.

  6. Not to worry. You’re in the right place. I think we all can accept that, data or no, your first experience was a disaster. It’s just hard for some people, particularly those in the throes of a busy practice, to hear some of it (Can’t you just hear them screaming, “But I’m right, dammit!” as the patient walks away?). And need I add that, with the emphasis on data collection and justification, the engagement of the patient/family in the process is only going to be more problematic. “MD in 23 days” has a tough row to hoe.

  7. I have been amused by the array of reactions to the choice of a midwife and the very few comments about our first birth experience. I guess that experience is just business as usual these days and we are bored of that conversation?

    “I’m embarrassed to see such an article at a health care blog”. I’m sorry, I wasn’t aware this is “the clinicians blog”. Please let me know where the blog is where it is welcome to discuss medical policy, consumerism, and patient engagement.

    • Mr Overton – have you ever thought about the fact that first births are almost always longer and more difficult? Intrinsically? People think that doing something different next time makes the difference, but second births are generally faster and easier – no matter what you do. I don’t know what your job is with the insurer, but it would seem to be important to understand both causation and risk.

      What if your first birth had occurred in a lay environment without resuscitation facilities, and the lay midwife had been blithely unconcerned? What if that had resulted in intra-partum injury? This article might be quite different.

    • It’s embarrassing because it reflects a total failure to investigate the real risks of this decision. Health care should be evidence-based, not “feeling” based. If you didn’t have a good first experience with one doctor, the decision should not then to be consult a quack.

      • While data are nice, and a data-educated decision is a good thing, it’s good to keep in mind that ‘the facts change’. Mr. Overton has acknowledged his mis-step. Perhaps a better question for the shouting breast-beaters in the crowd is why *so many* people ‘consult a quack’ every day in this country. Wake up! However much we want it to be, however much we want our patients to trust us and just do what we tell them they should do, it clearly is NOT just about the facts, and Mr. Overton has done a good job of trying to remind us of that. We need to get past our outrage at being bypassed for a quack and try to see why, in the face of what’s so blatantly obvious to us, we are indeed being bypassed so often.

  8. I’m embarrassed to see such an article at a health care blog. In particular this line:

    40 weeks approached and my wife became concerned, friends and co-workers admonished her for putting her baby at risk. “It’s dangerous” they would say, “this is not good for your baby”. The midwife was never concerned, “your baby will come when he is ready”. We went to 42 weeks before Silas arrived.

    I nearly fell out of my chair. The midwife was never concerned? Do you have any idea of the relationship between post-dates and stillbirth?

    You think it’s good that your health care provider wasn’t concerned? It isn’t even worth concern that your risk of stillbirth is multiplying and that induction is shown to decrease that risk?

    I don’t think I’ve ever seen such a succinct example of why this midwifery nonsense has no business being practiced in modern medicine. Tuteur is right. This is a data-free disinformation piece that blithely ignores the real risks associated with a non-professional providers. In their worship of the naturalistic fallacy, they ignore real data about real birth outcomes and interventions that may prevent the death of your child. The title of your piece should be “we got lucky”.

    • Try and put yourself in Mr. Overton’s position after the near-disaster of his first birth in a “data-full” situation (as opposed to your ‘data-free disinformation’). Why did he and his wife elect what they elected the second time?
      First time around they did The Right Thing, went with the official ‘data holders’, and barely made it through. Having “all the data” didn’t prevent the Birth #1 problems. Just because you have the data doesn’t mean that you’ll use it well, correctly, or humanely for that matter.
      Birth #2 did not have good data support but seemed The Right Thing for his family because of the problems at Birth #1. Bad choice based on data? Sure. Bad choice based on all the non-data factors? Probably not. Sadly, for a lot of reasons, data doesn’t always trump the other factors. As physicians we should, like ‘MD in 23 days’ says, ask ourselves why! Should it? Does “lies, damned lies, and statistics” sound familiar? Is the data always solid and irrefutable? On which facet of our behavior is ‘the data’ going to change its mind on this week? Why have physicians lost the trust in their skill and judgment (that they ‘knew what they were talking about’) that used to exist? Non-data-related skill sets? Too much ‘data’ that didn’t hold up to scrutiny?
      Lots of questions, few solid answers.

      • The data on stillbirth increasing with post-dates birth is based on a meta-analysis of multiple trials that I linked, you can look at it yourself. While it might have “felt” better, the midwife not being concerned that the dates went to 42 weeks is a sign of incompetence. That the author did not have the medical sophistication to realize that is not surprising. He and his wife had a better experience. But, they greatly increased the risk of a dead baby.

        It’s unfortunate their first birth experience was unpleasant. But as Dr. Tuteur has amply demonstrated, the risk of death of your newborn is between 3-9x higher with out of hospital midwife delivery.

        The reaction to a poor birth experience is to find another provider, another location that suits one better. It’s not to abandon science and evidence for the sake of a better experience, unless you’re happy with between 3 and 9 times more dead babies.

        • Actually, the author stated that his midwife was not concerned at 40 weeks, and the baby came at 42. Normal, natural gestation is 38-42 weeks. 40 is the middle of the bell curve, but this does NOT mean that above 40 is abnormal. This is a misconception, and unfortunately it is being acted on every day by the obstetrics community. If the baby is not in distress, it should be given the time to come out on its own. Especially considering the limited understanding we still have about what exactly it is that triggers the initiation of spontaneous labor, and what this might signify about the babies readiness to be born.

          • “Normal, natural gestation is 38-42 weeks. 40 is the middle of the bell curve, but this does NOT mean that above 40 is abnormal. This is a misconception, and unfortunately it is being acted on every day by the obstetrics community.”

            This is yet another piece of evidence that physicians, on the whole, do NOT understand statistics. Better to go with professionals who do understand statistics, eh? Apparently the midwife who Mr. Overton found *did* understand statistics, while MarkH does not.

            Who’s medically sophisticated? Not MarkH.

  9. After doing considerable research, I learned that another highly regarded nursing facility nearby would take Mom and provide her with the skilled care she needed, but not if she stayed in the MA plan. That facility had years ago decided not to participate in MA plans like the one my mother was in because what happened to Mom was happening to other patients. Utilization review nurses at MA plans – not the patients’ treating physicians – where making the ultimate decisions as to whether nursing care was medically necessary. They still do.
    I’m confident that Mom is alive today – and not completely broke – because she disenrolled from her MA plan and returned to traditional Medicare with a Medicare supplement plan to cover out-of-pocket expenses. And I’m confident after reading Riley’s study that there are hundreds of thousands of other people just like Mom who had similar experiences. And that the traditional Medicare program is paying more than it should because of the practices of many MA plans.

  10. I think it’s really interesting that Mr. Overton concedes that lay midwives, not certified nurse midwives, delivering his son in an out of hospital setting was not the safest choice, yet it was the one that was best for his family. What if a mother felt that, although her doctor said otherwise, that smoking while pregnant was, although admittedly not the safest choice, one that was right for her and her family? What if she said that eating tons of unpasteurized cheese, raw eggs, and sushi while pregnant, although not the safest choice, was the one that was right for her and her family?
    There are certainly mothers who smoke, eat unsafe foods, etc. who have perfectly healthy babies. But they don’t tend to go bragging about how awesome it was on public health care blogs and say how glad they were that they could use their healthcare dollars to find a lay practitioner, whom their health insurance company wouldn’t pay for due to liability concerns, who would support their smoking, sushi eating, etc. choices.

  11. “what happens” equals data collection, but once these numbers lose their personal fingerprint they become much less meaningful to the lay person who is not able to relate personal experience to the language of biology (or other sciences) and statistics….

    I like that, because it often seems to me that most people who think homebirth risks are good odds have never held a dead baby…or been the person to hand her to her parents.

  12. I am about to graduate medical school, and over the past couple of years I have become especially interested in the counterculture of mistrust of the medical model.
    It seems that there is much we physicians can learn about customer service from alternate models, but this should not take away from are commitment to optimizing benefit vs. risk.
    How do we know benefit and risk in order to compare them? Both groups claim to be educated, so how does one know which is correct? After all, each group claims the other is essentially indoctrinated. One can approach this problem by asking the question, “How does each group know what they claim to know?” For homebirth advocates, they “know” because of anecdotes, logic based on “common sense” or “intuition” rather than actually “what happens.” Physicians, although apparently cold and heartless due to our limited time, anecdotal inaffectiveness at giving patients what they want, and decisions that do not always make sense to the lay person, assert our truth based on “what happens” over and over again. In simplistic terms, “what happens” equals data collection, but once these numbers lose their personal fingerprint they become much less meaningful to the lay person who is not able to relate personal experience to the language of biology (or other sciences) and statistics.
    This is why I believe that a physician is more likely to “know best” than a midwife, among other reasons. Maybe this knowledge of safety (ability to minimize RISK) does not outweigh the BENEFIT of personalized, more emotional care to everyone. Then stand strong in that belief! Because to argue that OB/GYNs are not acting in a way to provide the best outcomes to mothers and babies is simply ignoring “what happens.”
    Dr. T states this same argument over and over again. I suppose I am just trying to restate it in different language.

    • The major problem is that most physicians base their “knowledge” on anecdotes, illogic based on “common sense”, received “wisdom” based on the old wives’ tales of previous physicians (in other words, habit), and so forth.

      I know a crapload about biology and statistics. I know how to do research, too. Quick quiz: if someone has a clinical potassium deficiency, in the US, what is the most likely dietary causes? What, you don’t know the answer? Neither do most physicians. (It’s magnesium deficiency.)

      The fact is that most doctors have a couple of dozen things they can diagnose and treat, and if anything is outside that list, I’m better off researching it myself on the Internet. Doctors are, with occasional honorable exceptions arrogant idiots who will insist that there are NO POSSIBLE diagnoses or treatments other than the 24 they know. They are invariably wrong.

      This is why people don’t trust MDs: because the MDs are just as unscientific and nearly as ignorant as the “naturopaths”. I’ve met rare exceptions, but they are rare. The MD credential doesn’t seem to signify anything in the way of actual scientific attitude.

      • Wow I’m not even a doctor or a scientist and yet I can still smell your BS from miles away.

        First off, you are wrong on your little “quiz.” Quick internet search of the Cochrane database shows a 2007 study looking at the causes of 300,000 patients hospitalized in 7 different countries from 2000 to 2005 with hypokalemia. Hypomagnesemia came in #4 on the list. Try again!

        MDs are certainly NOT scientists, however they are the best “scientists” available out of all the other so-called “health” professions. MDs make up about 20% of all NIH R01 research grants. How many NPs, PAs, naturopaths, chiropractors, midwives, RNs get R01s? Less than 0.5%

        MDs are the worst scientists available, EXCEPT for all the other ones.

        You are not forced to trust MDs. By all means, self-diagnose over the internet. Hell you can even order medicine from online pharmacies in Mexico without getting a script or seeing a doctor! I highly encourage you to pursue this pathway! LOL

  13. The fact that you are “tired of doctor knows best” has absolutely no bearing on whether doctor does, in fact, know best. If you are making the argument that doctor doesn’t know best, you are going to have to provide some evidence. Which is going to be an uphill battle, since several doctors on this board have already demonstrated they know a lot more about you do on this subject.

  14. I was followed by a military CNM during my pregnancy, but because of rules on residency at the Military Treatment Facility and because I was active duty myself , was not permitted to have the CNM attend or deliver at a birthing center. Everyone was busy on the day my water broke (ironically during my Bradley class). A carrier must have pulled in nine months earlier because it was standing room only and I managed to snag the last bed (all the other unfortunate women got to labor in the hallways). I was now up against the clock because I was not dilated; only my bag had ruptured (then magically resealed). I ended up with a drip, threats of a C-section, and finally delivered via the ED doctor who was called up to catch for maybe the 2nd time in his life my 5 lb, 13 oz daughter. I didn’t have my glasses on (and no contacts, obviously, and I complained bitterly to my husband that the doctor shouldn’t have been up against the door. My husband assured me the doctor was always at the foot of the bed, but that wasn’t the feeling I had) I too left with a 4th degree laceration and the resident vigorously chewing out the ED doc outside the door when he made the fliappant remark, “You’ll have to stitch that up because I’m not certified.”

    My second child was also born in a hospital, but this one didn’t switch up providers at the end. They didn’t make me have an IV, they let me labor naturally with my doula, and, although I was more comfortable on my hands and knees, when it came time to push, the doctor made me turn over and do it on my back because it was easier for him.

    I could hear the other women bellowing across the hall, but that wasn’t me as I surfed the waves of the contractions. I HATED the first experience and was dreading a repeat. What a difference a culture of patient centeredness as well as a desire for intervening only when necessary. And also for having adequately trained staff on hand. I should never have had a 4th degree tear.

  15. I should correct a previous statement that Dr. Tutuer pointed out, I was referring to elective inductions at 39 weeks and not 36 weeks as I previously stated. However, this was not shared with me by the bald faced lying midwife. The Leap Frog Group has driven significant change in that space. I have also heard it on multiple occasions from hospital administrators, usually in the context of “it was the right thing to do, but our bottom line really suffered because of the reduction in NICU bed days”.

    “there is NO ONE who provides safer care for American women than American obstetricians” said the status quo. Shame on me for expecting more for my health care dollars. I should have fallen in line like a good little lemming, despite our first experience which very much was a “Whew! Got away with that one” experience.

    I have enjoyed the commentary on our choice to use a midwife. I am not impervious to fact and it has given me a lot to think about. With that in mind, I will concede to the assertion that it might not have been the safest choice. Touche! We chose to see a midwife because we chose NOT to experience what happened with our first son. Right or wrong from a scientific point of view, it was what was right for our family.

    I will state again, I am not advocating for the use of midwives or homebirth. I am stating that consumers of healthcare (employers, the government, and all of us) are tired of “doctor knows best”. It has become obvious that was not apparent in my original post. The same facts that point to the risks of homebirth could also be used to dissuade any high school educated consumer from stepping in the doors of a hospital for an elective procedure. Tens of thousands of people still die every year and many more than that are injured.

  16. …”Ultimately, Mr. Overton, the reason that homebirth seems better, safer and cheaper to you is because you were lucky and nothing went wrong.”–A. Tuteur
    I’m happy Mr. Overton clarified his original posting because I now understand better what he was trying, unsuccessfully in my view, to communicate. My initial reaction was similar to the Tuteur quote above and it reminded me of my patients who didn’t want to pay their consultation fee because they didn’t like the opinion. If I had told them what they wanted to hear, though it would have been bad advice, they would have been happy. Mr. Overton was happy with his second birth most assuredly *not* because it was all done in a manner best suited to the survival of his wife and child (aka “The Correct Answer”), but because the results were OK. “Whew! Got away with that one!” might have been the rest response. As pointed out by Dr. Tuteur in a different way, it’s a big mistake to conflate results with process. It’s not only intellectually and scientifically dishonest but helps perpetuate disinformation. God knows we have too little good information (evidence/facts) in medicine now. What we surely don’t need is more disinformation.
    That said, Mr. Overton’s observations about the large holes in the swiss cheese that is medical care are well put and should, as have many other similar observations, encourage overdue changes in a system which is still far too hidebound for its own, or its patients’, good. I think it can be argued that CNMs became much more utilized precisely because of the people who ‘voted with their feet’ and sought a less regimented, more ‘friendly’, option. Push/pull.
    It’s an evolution, but hopefully one driven by what we’re now calling evidence-based medicine (the word ‘facts’ always seemed sufficient to me). All the evidence won’t help if we ignore the personal aspect of medicine, something the alternative providers figured out a long time ago. It IS what you say; it’s also how you say it.

  17. I did not mean to imply that the birth center was affiliated with a hospital. It is located within the boundaries of a medical center but is freestanding.

    The purpose of my post was not to lament that I couldn’t get coverage for a midwife. The purpose of my post was to showcase two different birth experiences. The first section was to show what happens all too frequently in hospitals. I guess that hospital errors and injuries in hospitals are so common place now that we are bored with that conversation.
    The second part was to share an experience in a non-traditional setting. Dr Tutuer happens to be very passionate about midwives and homebirths so the majority of the commentary has gone down that route.
    The third part was to question how we ever arrived to a space where elective inductions at 36 weeks are commonplace. There has been recent trends to reverse that practice, but it still merits discussion.
    Thank you for the additional clarification on the differences between midwives as you are exactly right. I should mention that my wife wanted to go with a CNM first but could not find one listed in our area. Again however, the intent of my post was not to be solely about the use of midwives.
    As you point out, I think the discussion on their place in the delivery of newborns is merited. As Dr. Tutuer points out, licensure for the practice varies by state. Some states probably do it better than others. Dr. Tutuer could probably share some stats in that arena. I wonder how the medical establishment would view the mainstream use of midwives if it were more closely regulated. Would that be a welcome addition or a threat?

    • “The second part was to share an experience in a non-traditional setting. Dr Tuteur happens to be very passionate about midwives and homebirths so the majority of the commentary has gone down that route.”

      What I am most passionate about is misinformation, and that’s why I reacted so strongly to your post. I know you didn’t realize it, but it is filled with misinformation that you received from homebirth midwives (a birth center staffed by LMs is the same as a homebirth, just in a house that isn’t your own).

      For example, I am not aware of any hospital anywhere in the US that routinely induces women at 36 weeks gestation. That assertion is nothing less than a bald faced lie; I presume that is what you were told by other homebirth advocates, but it is simply propaganda.

      We face a small but growing public health problem in this country because lay people who couldn’t be bothered with or lack the academic credentials to be accepted to a real midwifery program, are masquerading as “midwives” by awarding themselves a credential that they made up. These self-proclaimed “midwives” are doing everything in their power to confuse women into thinking that all midwives are the same.

      The mortality rates of these pretend “midwives” are hideous and they are doing everything in their power to hide that fact. Indeed, Ina May Gaskin, whose book you cite approvingly, lost one of her own babies at homebirth when she refuse to seek medical care for prematurity. The baby struggled to breath for 12 hours before he died.

      If someone as sophisticated about health issues as Mr. Overton could be so easily fooled, then anyone can.

      Ultimately, Mr. Overton, the reason that homebirth seems better, safer and cheaper to you is because you were lucky and nothing went wrong. It’s easy to use less technology and less money when you don’t bother with lifesaving equipment and personnel.

      It’s also more pleasant, uses less technology and is cheaper not to perform mammograms and do breast exams instead. That’s great as long as you aren’t the one who has a small breast cancer. Why do we do mammograms? Because they are part of preventive medicine. They allow us to diagnose breast cancer earlier, begin treatment earlier and improve survival rates. Why do we have all that “unpleasant” technology in hospitals? For exactly the same reason. It allows us to diagnose life threatening pregnancy complications earlier, begin treatment earlier and improve survival rates. Modern obstetrics is preventive medicine.

      There is much room for improvement in the way that obstetric care is delivered, but there is NO ONE who provides safer care for American women than American obstetricians. I don’t doubt that the LMs offered a more pleasant experience, but they didn’t offer safe care.

      And that answers the central question of your post. Why don’t hospitals copy the pleasant, cheap methods of licensed midwives? For a very simple reason: babies die preventable deaths as a result.

    • I do not believe the pitocin caused your wives large laceration. This is unfair for you to post. Larger degree lacerations are generally due to larger babies or malpositioned babies such as face up OP positions. They also generally occur in first time deliveries or when vacuum or forceps are involved. This brings up the widely known knowledge that first labors and deliveries are generally longer with more time needing to push with a more predisposition for lacerations. Second or third pregnancies generally have a shorter labor with less time needing to push with less chance of lacerating. That is a huge confounding factor that you omitted when comparing hospital to birth center births.
      I don’t know why you post the idea that doctors commonly feel compelled to induce after 36 weeks. Even ACOG and every hospital that I ever worked at require elective inductions to be done after 39 completed weeks. New evidence shows worse outcomes when pregnancies deliver after 41 weeks. I know home birth midwives often have no problem allowing women to go past 42 weeks (post dates), but the evidence reveals this is probably not advisable. And your wife was induced at 41 weeks and 2 days. Not even 40 weeks let along 36 weeks.
      Of course insurance companies will cover healthcare benefit to, hospitals will give privelges to, and malpractice coverage is awarded to competent health care professionals. Hint hint. Actuarial science evidence probably determines where the real risk is. As Dr T points out, data set after data set shows increased risk to newborn morbidity or mortality. Even the BMJ has published evidence about the Netherlands that low risk women being treated by midwives have worse outcomes than high risk moms treated by doctors in the hospital. Who is going to pay for all the cost of special needs children with neonatal encephalopathy related to hypoxia, ischemia, or hypoglycemia?
      I love when I perform a delivery that even my 15 year old child could have delivered. Easy labors, with no epidurals, with no lacerations happen often enough. But work in an inner city L&D department for one week and you will begin to understand how much risk goes with childbirth.

  18. Since this is a prestigious blog read by health professionals it is important that people understand this issue. Certified Nurse Midwives and other midlevel providers generally do not have any problems getting hospital privileges, getting malpractice coverage or being accepted as providers on health insurance plans. CNMs are well-respected, highly educated providers. Our practice has an amazing CNM in the practice. She is excellent and gives patients who want a midwife option a great alternative. She is on insurance plans, has malpractice insurance and has hospital privileges. I think what Dr. Tuteur is pointing out is that choosing a non certified nurse midwife practice is what lead to your inability to get insurance to cover your delivery. There are options for CNM care where coverage would not have been a problem. Most CNMs are on insurance plans, many work within Obgyn practices and many have birth center and hospital privileges. I am glad you had a wonderful experience but by choosing a midwife who is not a CNM this limited your ability to get insurance coverage. Hospitals do not grant privileges, insurance providers do not accept non CNMs on their plans and malpractice carriers do not provide coverage as they have determined that direct entry midwifes or certified professional midwifes do not have adequate training. We could certainly debate whether or not that is a good and accurate stance by hospitals, medical boards, insurance carriers etc. I just wanted to emphasize that there is not an issue with CNM’s because I suspect most readers do not know there are different categories of midwifes in the US.

  19. Most insurance companies do cover and reimburse for care from midlevel providers. We have a Nurse Practitioner, a physician assistant, a certified nurse midwife and work closely with CRNAs. We have never had any problems getting them on insurance plans. the care they provide is essential to our success.
    I suspect the reason you could not get insurance coverage was that this birth center was not staffed with Certified Nurse Midwives. CNMs have a very high level of education — usually a Masters or phD in advanced practice nursing. Insurance providers recognize and validate their status as mainstream health care providers.
    If the birthing center you used was staffed only by licensed midwives or what is commonly called a certified professional midwife or direct entry midwife it is highly unlikely that an insurance company would recognize their degree as adequate to meet the requirements for credentialing.

    • Jeff, The Affordable Care Act (Section 2301) actually mandates that state Medicaid programs reimburse licensed professionals working in birth centers, including certified professional midwives who are licensed by most states. And most CPMs working in licensed states do get reimbursed by insurance companies, just as other licensed professionals do.

  20. It’s deeply unfortunately that you are repeating the propaganda that you heard from homebirth midwives and apparently have no idea that none of it is true. A few basic facts are in order:

    1. All the existing scientific literature, plus local and national statistics show that homebirth with an American homebirth midwife dramatically increases the risk of perinatal death.

    2.PLANNED homebirth in Oregon with a LICENSED midwife has a neonatal mortality rate 9X HIGHER than term hospital birth.

    3. PLANNED homebirth in Colorado with a LICENSED midwife has a perinatal mortality rate that is more than double the rate for the state as a whole, including high risk births and premature babies.

    4. CDC data fshow that PLANNED homebirth with a non-nurse midwife has a mortality rate 3-7 times higher than term hospital birth.

    5. “Licensed midwives” are NOT real midwives. They created their own credential and awarded it to themselves. They are not eligible for licensure in the Netherlands, the UK, Australia, Canada or ANY first world country. In all other first world countries midiwves are required to have a university degree. American homebirth midwives just “tightened” their requirements to include a high school diploma.

    6. We already have the best educated midwives in the world (certified NURSE midwives). Licensed midwives, in contrast, are lay people who call themselves midwives. They do not need any education to get the credential.

    7. The Midwives Alliance of North America,(MANA), the organization that represents homebirth midwives, has amassed a database of 27,000 PLANNED homebirths attended by members. They’ve released the C-section rate, the iintervention rate, and the transfer rate. They have REFUSED to release the death rate. Even they know that homebirth incrases the risk of periantal death.

    8. The ONLY people who think homebirth is safe are the people who make money from it. (midwives, doulas, childbirth educators). Everyone else knows that homebirth dramatically increases the risk of perinatal death.

    • You’re right Dr. Tutuer, we walked right into that birth center and drank the Kool-Aid without having done any research and without concern for the wellbeing of my wife and son. I can imagine that had we consulted with you prior, you would have reassured us with line item statistics about how safe our hospitals are and the our first child-birth experience in a hospital was just a fluke right? That never happens. Let’s not make assumptions about people’s judgment.
      I visited your website and respect your passion on this subject. In our situation, had their been even the slightest indication that something wasn’t right during the course of the pregnancy we would have consulted an OG/GYN. We would have no issues turning care over to an OB/GYN had the circumstances dictated. Both pregnancies were uneventful, with the exception of the delivery process which I shared in my anecdotal post. Thank you for sharing the information you have provided.

      • Did you know that all the existing research on American homebirth, as well as all the state and national statistics show that homebirth substantially increases the risk of perinatal death? If not, then you really didn’t do research.

        How many of the scientific papers on homebirth did you read (not the abstract, the entire paper)? If you didn’t read a representative sample of the scientific literature on homebirth, you didn’t really do research.

        Were you aware that licensed midwives aren’t eligible for licenses in ANY other first world country? If you weren’t, you didn’t really do research.

        Reading the propaganda put forth by homebirth advocates and Googling homebirth websites is not research.

        It says in your biographical information that you are a patient management director. Do you think someone could do internet research on patient managment and determine whom to hire for a patient managment director? Would you consider someone who had a high school diploma and an apprenticeshipt managing 20 patients qualified to do your job? If you don’t think that’s sufficient to determine whom to hire as a patient manager, why should anyone think it is sufficient to determine whom to hire as a safe, qualified birth attendant?

        • You are clearly passionate about the topic of homebirth. We didn’t have a homebirth; Silas was born at a birth center located within a major medical center (but I suspect that won’t matter to you). My post was not meant to be solely about the use of midwives, in fact it is only one piece of the story. I am not advocating for homebirth. The intent of my post is to highlight two very different experiences in our healthcare system. One, the traditional experience that went terribly wrong, the other, very non-traditional, that for my family was a very pleasant experience. I wrote it from the perspective of a healthcare consumer. Thank you for sharing your perspective as a Harvard Professor.

          • You wrote that your son was born in a birth center staffed by licensed midwives but not covered by insurance because of liability concerns. Yet you also say that the birth center was located within a major medical center. It is my understanding that licensed midwives cannot work in hospitals in Texas and that in-hospital birth centers are covered by the same insurance as the rest of the hospital, but I’d be happy to be corrected.

            Which hospital based birth center in Texas is staffed by licensed midwives and not covered by health insurance?

        • :rolls eyes:
          Your incredibly inaccurate and uninformed statistics have me convinced. Good job.

    • Do you have citations for your assertions? And did you know that the U.S. ranks #50 in the world for infant and maternal mortality…with countries such as Singapore having less baby and mother deaths than the U.S? And that countries with higher midwife-attended, out of hospital births rank far lower in infant and maternal mortality and morbidity? Oh and I actually have citations for those facts:


      “According to recent World Health Organization (WHO) data, the United States ranks 50th in the world in maternal mortality,[10] despite the fact that the United States spends more on health care than any other country.[15] Both WHO and Centers for Disease Control and Prevention (CDC) vital statistics data show a substantial increase in the maternal mortality ratio over the last 2 decades”

      While every other developed country is seeing an DEcrease in maternal mortality, ours had a 96% INCREASE sine 1990. Even non-developed countries and very poor countries, like Sudan, did better than the U.S. European countries have the best stats of all, which is not surprising since midwifery, natural childbirth, low C-section rates, and evidence-based, low intervention pre-natal care is the norm there.


      I had 4 homebirths. They went beautifully. I was respected and cared for by a woman who had taken care of moms and babies for 30 years. Her hospital transfer rate was about 2%. C-Section rate was >1%. She has never in 30 years lost a mother and only ever lost 2 babies, both to known birth defects. Compare that to the local hospitals: C-section rate of 31%, and a very high intervention rate, with high percentages of NICU stays and infant mortality, You can bet I chose the licensed, experienced midwife. Your assertion that people who research only choose hospital birth is laughable. Your bias is showing. I did my research, Doctor. You obviously are the one drinking the Kool-aide.

  21. ” Emergency procedures were reviewed in case something went wrong, the on call physician would be notified or we would go to the emergency room.”

    Really? You thought you would roll into the ED with a Labor and Delivery emergency? That was part of your plan? You will be going straight to L&D unless she is complete and pushig. If you deliver in the ED it definitely will be natural.

    ” An error in the chart had failed to capture this prior to the delivery ” Pleae elaborate, as this blog is all about EMR. Was there one?

    “Since when did uncomplicated child birth have to take place in the hospital?” Since the 1930’s if you cold afford it.

    “Our healthcare system is broken but it is our own behavior as providers, payers, and consumers that have allowed it to happen.” You are so right. It is because the consumer and the payor are not one and the same that we have this mess.

    • Yes, in the case of something going wrong we would have gone to the ED. When medical interventions are taken out of the picture (pitocin and epidurals) the risk of complications decreases.
      Yes, the department of defense has had an EMR since before EMR was cool. The problem; their ambulatory system (where the group b results were hanging out) doesn’t talk to the inpatient system (where the delivery was taking place).
      Yes, since the 1930’s and the evolution of childbirth in the hospital is astounding. Ever heard of twilight sleep? Child birth in the hospital certainly has contributed to elective inductions at 36 weeks.
      Consumers, payors, AND providers are not one in the same. All have played a part in arriving to our sick care system.

  22. All of you “our health care system is broken” types would have your changes a whole lot faster if you abandoned your irrational objections to true tort reform. Spend your energies encouraging a real debate about what true tort reform would look like, and the other things that need changing get easier. Every single unnecessary medical intervention foisted upon poor little Ezra was due to a broken Tort system.

    • I agree with you Dr. Mike that tort reform is a piece of the puzzle. However in the case of Ezra, his physicians were active duty military. The DoD protects their physicians in a way that active duty personnel who are harmed in a military treatment facility cannot pursue litigation against their treating providers. You cannot argue that a military physician practices defensive medicine because they are shielded from litigation. If Ezra had been harmed, we would have had not recourse. All of the unnecessary treatment that Ezra received was due to medical errors and a lack of communication amongst the medical team.

      • Unfortunately, I can tell you as an ex-military MD myself, that fear of Tort is alive and strong in EVERY physician. I was even trained in a military residency. It is pervasive. And what’s more, something that your attending once learned the hard way (i.e. through a tort) gets passed on to you as “standard of care” and you do it that way from then on without ever knowing that it is only “mandatory” to do it that way because of the “lessons” learned by attendings after tort cases or the tort cases of their colleagues. Most of the attendings were civilian trained even in the military residency. The culture is one of hiding mistakes, not in any way is it an opportunity for learning except to know how to protect yourself. “Mistakes” even it the military are hush hush affairs (and yes there are more factors at play then just fear of tort, but fixing the tort system is the first necessary step before all the other ills of dealing with medical mistakes can be addressed)

        • Tort has absolutely nothing to do with it.

          Physicians can be sued for performing unnecessary surgery, and if the surgery caused damage, the physician will lose. And will pay a hell of a lot of money. If physicians were actually concerned about malpractice suits, they would perform FEWER procedures.

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