At the end of the article, Dr. Norwitz leaves us with a notion that obstetric care providers need to do more in the way of providing emotional and social support. My question is… What in the world are you waiting for?
Obstetric care has a very long way to go before the focus moves meaningfully toward handing back some of the power of choice to the pregnant woman, something early feminists championed. That would require the obstetrician to honor and listen to the woman as she begins to formulate a delivery plan, to support her input at every step of decision-making, to provide her with or refer her to sources of information about delivery alternatives—the very types of alternatives that are readily available in midwife-attended births.
Jacquelynn Cunliffe, MSN, PhD
Wayne, Pennsylvania
We all want a healthy infant
Regardless of the type of training or level of experience, all obstetric care providers want the same outcome: an uncomplicated delivery of a healthy infant under conditions that are safe and supportive.
Contrary to popular belief, Nature is not a good obstetrician. It is estimated that between 1 in 50 and 1 in 500 fetuses reach maturity in utero and are subsequently involved in a catastrophic event that results in severe neurologic damage or perinatal death.3 Many of these catastrophic events occur during labor. Even a woman categorized as “low-risk” throughout her pregnancy can become “high-risk” in a matter of minutes if she develops a complication during labor such as cord prolapse or placental abruption. Risk factors for such intrapartum complications have been described, but these complications can develop in anyone at any time, even in women with no risk factors at all.
As noted in the letter from Dr. Cunliffe and the article by Cheng and colleagues,4 the level of training of the person attending the planned home birth may well affect the outcome. The less skilled the provider, the less likely he or she is to anticipate and recognize a complication and the more likely an adverse event. The existing literature on this topic should not be interpreted as a criticism of the training or skill of certified nurse midwives. Even the most skilled birth attendant is ill-prepared to deal with the potential catastrophe of an intrapartum complication during a planned home birth, given the limited resources of a home environment.
The issue of planned home birth is an emotive one. Although every effort should be made to ensure that the birthing experience is a positive one, it should not be done at the expense of safety. Ms. Hilderbrandt’s claim that “Planned home birth with an appropriate provider is safe” is not supported by the existing data. Even in countries where home births are integrated fully into the medical care system, such deliveries are associated with a twofold to threefold increase in the odds of neonatal death.5 In the United States, where no such integration exists, a planned home birth is simply dangerous, although the absolute risk of a serious adverse event is low.
If a pregnant woman ever wants to know the safest place to deliver her baby, the unequivocal answer is: in a hospital setting. The question of who is best suited to attend the birth is far less critical, so long as the person—either a physician or a certified nurse midwife—has completed an accredited training program.
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