Birth Story #380: A Seizure at Home

I've been writing up several home birth transfer scenarios in the Birth Stories recently. This is in preparation for a post series on home births in Rural, CA. and also because I have been entering into some interesting dialogues with other alternative birth proponents. I never had any experience working with home birth clients before moving to Rural, so the last few years have been a crash course for me. I have had a number of wild and goofy experiences working with home birth clients who decided to transfer to the hospital, and a number of stranger situations that really made me wonder about the psychological dynamics of birth. Barbara had one such birth.

Barbara was a first-time mother, a really beautiful young woman, fit and healthy. Like Dahlia, she always came to clinic looking incredibly well put-together--hair artfully wild, face made up, lovely artistic clothing. Meeting women like her make me nostalgic for my early adulthood, when I was fresh-faced and effortlessly lovely. That phase of my life lasted about 20 minutes. Barbara made me remember those 20 minutes fondly.

Barbara was working with Kathleen and her midwife partners, hoping for a home birth. One of Kathleen's partners, Celia, confided that she wasn't sure Barbara was an ideal candidate for a home birth. Kathleen wasn't worried, but Celia questioned Barbara's motivation at times. "She keeps talking about an ideal birth and isn't making concrete plans to get her house ready or whether she wants her mother to be there. She talks about other women who have had a home birth as if they're professional athletes or something. I just worry that she thinks there some kind of merit badge in having home birth, or that she's got something to prove."

Celia's a pretty shrewd judge of character, and I meditated upon her concerns about Barbara's suitability for home birth. The midwives who attend home births in Rural interview their prospective clients carefully. They are looking for healthy young women who can adhere to a rigorous program of self-care (healthy diet, regular exercise, yoga, standard prenatal visits at our clinic) and who are prepared to take responsibility for the outcome of their birth. This last quality is nebulous but critically important. By opting to give birth at home, a woman must prepare herself for the possibility of neonatal and maternal injury, illness or death--and the possibility that these outcomes might have been avoided by a hospital birth. Kathleen discusses this commitment pretty frankly with her clients, and her services as a doula for a hospital birth are always offered as an alternative. The discussion is not limited to their first meeting but is renewed regularly during the course of a woman's pregnancy. It is a model example of informed consent as an ongoing dialogue rather than an isolated discussion.

Celia's concerns went to the heart of the choice of home birth over hospital birth. Although there are many reasons for a woman to want to give birth at home--comfort, autonomy, desire to avoid medical interventions--most of the home birth midwives would not encourage a woman to give birth at home solely to join the elite network of women who did so. Yet there are some women who pursue the option for just that reason. This is not to disparage the home birth movement, because I don't believe that is what it is about, but somewhere along the line there has developed a subculture of women who are determined to give birth at home because it is the cool thing to do, rather than the right thing to do.

In my interactions with Barbara, I came to agree with Celia's concerns. Barbara always listened to what I had to say, and when I gently inquired about childbirth education and any preparations she was making for going through labor, all she said was "Oh, Kathleen and Celia are teaching me all about it." Her speech was airy and unconcerned, and this troubled me. Most women who have contemplated giving birth have a healthy respect for the process, and I like to see an openness to the unknown develop over the course of pregnancy, because none of us know how a labor will progress.

Why are these important issues? Because a woman's psychological preparedness for giving birth really matters. Women have to reach deeply into their inner selves during labor, and they need to have some self-reflection to get to those deep places. It was possible that Barbara had reflected upon her inner self and was putting up a strong public show, but I sensed a true avoidance of the issues from her, and this is what was worrying.

Despite these doubts, Celia was with Barbara on the evening she went into labor. The early part of labor was uneventful. I heard nothing about it all day, when I was rounding on a difficult hospitalist service. Finally, late in the evening, after seeing 20 patients, I was staggering home. One block away from my house, I received a page from Labor and Delivery.

"Celia's sending a home birth patient in by ambulance," Roberta, one of the nurses, informed me. "It's Barbara, you know her? Well, apparently she had a seizure at home. House supe wants to know if she should call in the OR crew for a C-section."

I was pretty tired and a teeny bit grouchy. "Why would we need A C-section?" I asked. "I mean, even if she's eclamptic--" I started to turn the car around and head back to the hospital.

Preeclampsia describes a medical complication of pregnancy that usually develops in the third trimester and is characterized by high blood pressure; measurable protein in a patient's urine; and swelling of the hands, face and feet. Preeclampsia may also be diagnosed on the basis of other blood tests and findings, but the classic diagnosis is made on the basis of the three findings mentioned. Eclampsia describes a complication of preeclampsia, namely the progression to an eclamptic seizure. These are usually tonic-clonic or "grand mal" in type, although I have heard of focal eclamptic seizures as well. Of course, other diseases may cause seizures in pregnant women, including epilepsy, but these are usually identified before the onset of labor. Seizure occurring after the onset of labor is highly suspicious for preeclampsia.

By the time I arrived back at the hospital--again--Barbara had been transferred from ambulance gurney to hospital bed. Labor and Delivery was in full crisis mode, with the House Supervising Nurse standing by and staff nurses running all over the place. Barbara's mother, Nan, and her husband, Doug, were also there, as was Celia. Kathleen had stayed at home with Doug's older child from a previous relationship. When I entered the room, Barbara was lying drowsily on her side. Roberta was starting an IV, and Holly--another nurse--was strapping on fetal and contraction monitors. Phones were ringing and all the lights were on and there was a general sense of being on the verge of chaos in the room.

I was looking at Barbara. I ignored everyone else, including Nan who was wringing her hands and Celia, who was trying to bring me up to date. I wasn't trying to be rude, but one thing I have learned in my short career is to focus on the patient. Especially when there is an emergency. What I saw was a woman who did not show any evidence of seizure at the moment, whose blood pressure was only 136/88, who was contracting every 4 to 5 minutes, who panted and moaned through the contractions, and whose fetal monitor showed a normal heart rate although only moderate variability. In other words, things were fine at this moment. No need for a C-section at this time.

I explained this to Celia, Nan and Doug. An eclamptic seizure is not an absolute indication for delivery by C-section. In fact, the anesthesia risk is greater in a woman with preeclampsia, so the decision to do a C-section should be made for good reasons. I could tell Nan didn't like this answer, and Doug looked uncertain.

Barbara's IV was in and I started a large bolus of magnesium sulfate, which is the standard treatment for preeclampsia. The standard labs had been drawn and were completely normal--no protein in the urine, no abnormalities that went along with the other types of preeclampsia. Furthermore, Barbara's blood pressure hadn't been higher than 138/88 since arrival, and she had no signs of any edema in the face/hands/legs.

Was it possible that Barbara didn't have preeclampsia? I couldn't really get a sense of what was going on from her, because she was really drowsy now that the magnesium was running continuously. The baby's heart tracing looked fine, and Roberta reported a cervical dilation of six centimeters. I knew we had some time to figure out what was going on, because mother and baby were OK. So I reviewed the events that had occurred at home with Celia and Doug. Nan preferred to hover over her daughter, and I think she was mad at me for not endorsing the C-section idea.

Apparently, Barbara had a long early labor but coped well by alternating short walks with showers and warm tub soaks. Her waters had broken spontaneously and then labor picked up pace. Celia knew things were getting very intense by the volume of Barbara's vocalizations. "She was yelling and thrashing around with contractions. I was trying to get her to focus, get her to squat or do something in rhythm with the contractions, but in between she panted and wouldn't listen to me," Celia explained. "Then, suddenly, she closed her eyes and flopped back in bed and it was if she couldn't hear any of us. Then she started shaking all over."

Doug agreed with this description. I tried to get them to be more specific about the movements Barbara had demonstrated. Were they flexion/extention movements? Or tremor? "It's like she got tight and she just shook all over," Doug said.

"I'm not sure if she bent and extended her arms and legs," Celia said. "I'm sorry, I'm really not sure." The strangest thing, she and Doug agreed, the most worrisome thing was that Barbara had just stopped talking to all of them. They called her name and patted her hands and even shouted but she kept her eyes closed and wouldn't answer.

I was in the middle of a diagnostic dilemma. On the one hand, I doubted the diagnosis of preeclampsia/eclampsia. The seizure episode didn't sound right, the blood pressures and labs were all normal, and there were no other symptoms. On the other hand, it is possible for a woman to have an eclamptic seizure without the other findings, although this is unusual. The event Celia and Doug described really didn't sound like seizure. It sounded more like a dissociative episode--a retreat from consciousness, perhaps precipitated by acute physical and psychosocial stress--or even a pseudoseizure. But I hadn't been there to witness it.

This is one of the most frightening prospects of home birth: the development of a grave complication away from the presence of experienced witnesses. Try as they might, Doug and Celia couldn't really put together an accurate description of the physical event Barbara had gone through. They were focused on her inattentiveness, they were worried about her--but they hadn't really looked at what was happening to her. I don't blame them at all. But it put me in a tight spot.

I decided I had no choice but to proceed on the assumption that Barbara had experienced an eclamptic seizure. The clinical picture wasn't right but there was enough concern that it made sense to continue magnesium and actively promote labor. Delivery of the infant is the ultimate cure for the disease.

By this time, Barbara's cervical exam was 8 centimeters. She was still drowsy and inattentive, but if I brought my face close to hers and insisted she open her eyes, she understood me well enough. I explained the possibility of preeclampsia, the need for magnesium, and now the need for a bit of Pitocin because her contractions were spacing out. Even though she was dilating steadily, I didn't want her labor to lose any pace. Magnesium would hopefully prevent another seizure, but preeclampsia never gets better, and doesn't go away until the baby is born.

This is my obstetrical side. I like to think of myself as extremely liberal and open in my approach to normal labor and birth, but if things become abnormal, I am a doctor and my job is to intervene. Whatever had happened at home, Barbara's labor had veered far from the normal curve, and I was going to manage her labor aggressively.

Roberta started Pitocin. Within an hour, Barbara's cervix was fully dilated. Her initial pushing efforts were perfunctory. In retrospect, I may have got her pushing too early. Women on magnesium feel heavy and drowsy, and it might have been better to wait until the Pitocin had labored the baby's head down, but Barbara thrashed and moaned with each contraction and I thought it would help her to push with the discomfort, to have something to do with it, rather than have to put up with the sensation. The "take charge" approach did nothing for Barbara. When we encouraged her to push, she grunted briefly then resumed moaning and thrashing. She listened to no one--not me, not Celia, not Doug, and certainly not her mom--but she was definitely not seizing.

Thankfully, night shift came on and Roberta was replaced by Vicky. Shift change can feel disruptive at times, but other times a new face with new energy is revitalizing. Vicky is a no-nonsense, can-do kind of person. She entered the room, introduced herself to everyone, and observed Barbara for a while. After a while, I felt her moving forward, into the dysfunctional energy surrounding the labor bed.  Vicky took Barbara's face between her hands and said: "Listen to me. No, listen to me. You're going to stop carrying on now, and you are going to start pushing. I'm going to help you."

Vicky rearranged the room, repositioning Barbara in bed, seating Nan in a chair so she wasn't hovering too close, and stationing Doug and Celia on either side of Barbara for support. I became one of her minions too, and quite happily so. Vicky told me to give posterior pressure and she counted each push out to ten. The energy in the room was brisk and positive, instead of fearful and uncertain as it had been for many hours. At first Barbara fought all these efforts, but soon she was hypnotized by Vicky's energy, and she pushed.

Young Liam Alexander was born about an hour later. Barbara's blood pressures and Liam's heart tones were fine throughout the second stage. There was a minor laceration, but otherwise the birth was uneventful. Doug bonded with his new son right away, but Barbara was unwilling to hold him at first. I took note of this but didn't worry too much--some women don't have that overwhelming joy you're "supposed" to have at first sight of your baby, and magnesium will sap the pleasure out of almost anything. After a few hours of rest, however, she met her son with delight.

To this day, I have no idea exactly what happened with Barbara. In the medical record, I said she'd had an eclamptic seizure, gotten appropriate interventions, had a spontaneous vaginal delivery, and an unremarkable postpartum recovery. I believe the truth is much more complex than that. I just wish I had been there when she'd first closed her eyes, and refused to answer to her name.

Comments

[momwithastethoscope]

As the pediatrician, I am on the receiving end of this story. I often don't get to hear the inside track of a mom's labor. Like you, I focus on my patient. But I am perturbed when mothers come to this process with an agenda - spoken or otherwise. Often these agenda seem to be much more about what this person wants than what is best for both mother AND baby. We're seeing this in the media more as celebrity mothers have become "too posh to push" (a borrowed phrase from Time magazine)and opt for c-section delivery because it suits their schedules. The agendas often don't stop with delivery - there are many expectations that the baby won't spit-up, sleep through the night from the first night home, and generally behave like a doll. It's a rude awakening to some parents that newborns are people, too. Thoroughly enjoyed your post and look forward to more!

[AnnR]

This mother didn't sound nearly as frustrating to deal with as Dahlia. At least when you got the drill Sargent there she responded.

Was this mother going to breast feed?
I guess that's a story the Pediatrician will write.

[CountryMidwife]

Re "experienced witnesses": to be fair, I would bet that L&D nurses, in the crisis of the moment of alleged seizure, would not be able to fully recount details of mom's posturing either. You know how those things become a clusterbeep in hospital!

I want people who rally for the safety of hospital birth (vs home birth) to realize that said benefit of hospital environment does not occur in the majority of hospitals, especially in rural areas. Unless you have docs, anesthesia, OR, and NICU in house 24/7, there's no more safety than in a homebirth. Yes, we have to get our ladies into the hospital, but you have to get your docs and team in as well.

The safety lies in choosing a quality professional midwife, her having a rigorous risk assessment before and during labor, an effective transport system, and a collaborative team on the hospital end so that care can be rendered seamlessly.

Do address some of the risks of hospital birth, sometime if you will Rural Doc. And talk w/ your community midwives about all the GOOD outcomes too!

[RuralOB]

No obfuscation please ruralmidwife!
There are NO proper peer revied RCT that demonstrate the safety of home birth over hospital birth. Anecdote does not equate to evidence no matter how you try to spin it re the risks of hospital birth. Talking about good outcomes is NOT science - it is village shaman type hogwash.

"The safety lies in choosing a quality professional midwife, her having a rigorous risk assessment before and during labor, an effective transport system, and a collaborative team on the hospital end so that care can be rendered seamlessly"

This statement is dubious at best - much of the danger is inherent in the process regardless of the "rigorous risk assessment" and as some of my midwifery preceptors always said:
Normal delivery is a retrospective diagnosis .
As to the transport process - 5 minutes can mean the difference between life and death - is there a Bell Jetranger on hand at every home delivery?
Sweden has recently stopped their " flying squad" response system for home deliveries as their M&M stats were similar for "low risk" home deliveries when compared to stats for high risk centers. Despite this , I have NO objection to women delivering at home , provided:
a. They are properly informed of the actual risks.
b. I am not expected to pick up the pieces when things go pear-shaped (as if!)
The decision for home delivery should be an informed one and not an ideological one.

[Aussie Doc]

Sounds like hyperventilation and alkalosis.

[Nata Invicta]

More nonsense but financially motivated guild monopolist physicians.

First, "There are NO proper peer revied RCT that demonstrate the safety of home birth over hospital birth."

Ha, ha! Is that the standard you hold all your procedures to? You'd be out of business, I'm sure. Why is it only non-physicians must be evidence based.

Notice how you frame the debate. By your own admission, there is no peer reviewed RCT evidence that hospital births are safer than home births. Given that it is A FACT that hospital births involve cutting opening women's uterusues, slicing their vaginas, infecting them with flesh-eating bacteria, mixing up their babies, giving them the wrong medicines, forcing their bodies to be unwilling manikins for manipulation by med students, etc., it would seem that you would evidence that hospital births are safer. THERE IS NONE. As a consumers, all we have is a choice between different sets of risks. No one knows which is "better."

Second, pediatrician-woman, the "baby's health" is not the only object in birth. That's vile sexist Victorianism--when doctors would risk the mother's life so that she could produce children for her husband-master. Mothers and babies are party of a shared process--a process of shared risk in which both of their well beings must be considered. To assert otherwise, as you do, indicates the hatred you bear towards your own sex or perhaps some deep, unresolved psychological problems you have with motherhood.

[Theresa]

Thank you all for commenting, although I will ask that readers from ALL sides of this issue address each other respectfully and reflect upon their own assumptions *about each other* as well as their assumptions about birth philosophies.

As I have said in several posts, I am supportive of home births for low-risk women. I plan to write more about my position in future posts.

However, I agree with momwithastethoscope's observation that many women/parents appear to be motivated by an ideological agenda in the decisions they make about birth and childrearing.

I also agree that a woman should have ongoing discussions about the risk/benefit scenario of choosing a hospital or a home birth. I tend to sympathize with people who are suspicious of hospitals and I am willing to recognize that a home birth may be a more acceptable set of risks, as Nata Invicta points out, than the set offered by a hospital birth. I think the evidence for safety of home vs. hospital birth is tainted on both sides, and I *don't* think it helps the dialogue between birth choice advocates to let the dialogue degrade into a battle between whose-evidence-is-best.

There is no way to conduct "best evidence" studies of home vs. hospital births. Simply put, women will not be randomized into a birth experience. This violates all tenets of Western ethics. This is the ultimate limitation to the hospital-birth proponents view. However, the home-birth proponents tend to cite evidence of higher M&M in hospitals that, I believe, fails to take into account that hospitals are referral centers and therefore likely to receive mothers and infants who have a higher baseline risk than those who birth at home.

In any case, I think there are faults on both sides of the argument and I think it is a mistake to let the debate degrade into jargon, statements of ideology, and name calling.

Nata Invicta, I would like to reassure you that I have been a staunch advocate for vaginal deliveries in my community, and have never given in to recommending a C/S for no good reason. I do not routinely cut episiotomies. None of my patients have been infected with flesh-eating bacteria. There have been a few cases in which my patients have received the wrong medication, but these did not result in any lasting harm and occurred in less than 1% of my cases. There was a single incident in which a woman was given the wrong baby to nurse, at my residency hospital, and indeed this was a "never event," but against that fault I was proud to have contributed to the safe delivery of >3,500 infants per year at that hospital, mainly to undocumented and low-income women who received excellent care and had complication rates well below national averages. And yes, I did introduce medical students into the care of these women because that is how you learn to respect and honor labor and birth: by being present, observing, and participating.

As for your response to momwithastethoscope's comment, I will say only this: it is the last refuge of a losing argument to attack the psychological foundation of your opponent's position.

All are welcome to comment on this blog, but I require respect for opposing views.

[Nata Invicta]

"As for your response to momwithastethoscope's comment, I will say only this: it is the last refuge of a losing argument to attack the psychological foundation of your opponent's position."

Hmmmm . . . that's a technique I learned from a physician, S. Freud.

Your understanding of the data is quite shaky, I'm afraid. Studies that show the safety of homebirth include carefully conducted prospective cohort studies that control for risk (as best as possible).
http://www.bmj.com/cgi/content/full/330/7505/1416

Your grasp of Western ethics is shaky. Nice randomized, controlled studies concerning modes of midwifery care have been performed in that hive of unethical barbarism, Sweden.
http://www3.interscience.wiley.com/journal/119185892/abstract

I'm so glad, Doctor, that you haven't infected any of your patients with flesh eating bacteria and that you've limited to an acceptable number (at least to your self-congratulatory self) the amount of drug errors and mixed-up babies.

You seem upset, Doctor, that people don't respect you, your posters, and, indeed, your profession. Well, given that we spend 17X what Albania does per capita on health care and have average life expectancy of only 2-3 years longer . . . . and given the resistance doctors put up to cheaper, less invasive substitutes for their "skills," I don't think my attitude unwarranted.

[Theresa]

Nata Invicta wrote:
"Hmmmm . . . that's a technique I learned from a physician, S. Freud."

I'm sorry you chose Dr. Freud, of all physicians, to emulate.

Regarding the evidence for safety of home birth, I think we approach the interpretation of the studies you cite differently.

The BMJ study, while using the most rigorous methodology possible given the topic under study, still relies upon self-report and opt-in by participating midwives. Given that home birth rightly takes place in the presence of only those people a woman wants at her birth, and not trained observers, this is appropriate. I still see it as a major barrier to conducting a satisfactory study on the subject.

There is also a problem in comparing the hospital outcomes between women who transfer from home and women who elected to have a hospital birth to begin with. The comparison group in this study is a subset of data from a national registry; the women in this group were not contacted for their self-report of the experience. Neither were their birth attendents. We therefore can't know what factors compelled them to plan a hospital birth over a home birth, or whether this decision was motivated by some underlying greater risk (diabetes, hypertension, other comorbidities). The hospital sample of singleton, vertex births at greater than 37 weeks does not specify whether other comorbidities were present.

As for the Karolinska study, I believe you mean the study was conducted in Australia, not in the hive of unethical barbarism that is Sweden. In any case, the study compares randomization of low-risk women to midwifery vs. standard obstetrical care within a hospital. It therefore does not specifically examine home birth compared to hospital birth. The study found excellent outcomes within the midwifery group, which I do not dispute. I think the midwifery model of care is wonderful, and my own practice style is much more aligned with midwifery than obstetrical medicine. However, I do not believe you can generalize from hospital-based midwifery to home-based midwifery outcomes. Hospital-based midwives have all the monitoring equipment, invasive and noninvasive testing, and subculture-specific concerns that hospital-based physicians do. Of course, they choose to use these resources less frequently, and perhaps more appropriately, than their physician colleagues. However I do not think you can generalize from the practice style and outcomes of hospital-based midwives to the potential outcomes of home-based midwives. This is a topic on which I'd like to hear more opinions from both types of midwives.

I do not dispute the notion that a home birth can result in a maternal/infant outcome that is as desirable and more satisfying to the mother and her family. I am a supporter of home birth for low-risk women for this very reason.

My purpose in writing about these topics on this blog is to encourage dialogue between participants from all sides of the issue. To that end, I require a respectful approach from all commenters. Whether or not anyone respects me or my profession is something I cannot control and therefore not at issue here. The environment of this blog, and its comments, is a matter of concern. I will remove any flames or off-topic comments, but I am not removing yours, Nata Invicta, because I think you have something important to offer to the dialogue and you obviously feel passionately about the subject. I only ask you to consider the tone of your comments, and whether they advocate for the women and midwives you support. There are some readers of this blog who are trying to educate and inform their opinions of home birth an other birth practices, and I suspect they will draw more influence from your comments if you deliver them with less invective.

[CountryMidwife]

Another confounding and immeasurable variable when comparing hospital vs. out-of-hospital outcomes has to do with future risk. We know that a scarred uterus significantly increases risks to future childbearing. With nearly 1 out of 3 women in hospital being delivered surgically, these women face future morbidity and mortality rates that are likely to be higher than those who chose not to be in hospital. Can I prove that? Not yet. But does 1 + 1 = 2?

I appreciate the chance to dialogue and suspect that no one wants an interminable thread. I think that unlike ACOG and the AMA, we all respect the right of women to chose where to birth, and that's the first and most important point.

[Theresa]

Good point, CountryMidwife. However, not every hospital has a 33% C/S rate--ours is closer to 15%, including repeats. I think we should be working to lower C/S rates AND we should be doing more to promote VBAC. Yet I hope women would not be motivated solely by a desire to avoid C/S in choosing a home birth.

Thanks for participating in the dialogue.

[CountryMidwife]

15% is a good rate, you're doing good work. Rural hospitals - in part because of the lack of OBs hovering over and generally less anesthesia - do have lower rates.

Our birth center / homebirth practice (going strong for our 30th year now) has consistently a 5-6% c/section rate, most planned for known breech births. C/Sections are important and sometimes life saving. FYI this year we will have over 400 out of hospital births.

But the national average IS over 30% (32+ I believe at last count?) and that is, we can all agree, terrible.

[Disco Mommy]

Had almost identical experience with my first-born. As I await the birth of my second, I'm looking for insight into this occurrence. How can I prevent a repeat? Any help appreciated.

[Queen Janet]

Actually, for the BMJ study, participation was a requirement for re-certification as a CPM (certified professional midwife). Only something like 3 or 4 individual MOTHERS (out of more than 5,000) declined to be part of the study.

That's one of the things that makes the BMJ study so spectacular. No study of physician attended birth could ever come close to having 100% participation of providers.

While it's true that the BMJ study was self-report, it was also prospective, and, as any good researcher will do, charts were randomly audited. (For those out there wondering what prospective means: each mom was registered towards the beginning of the pregnancy, making it impossible, or at least really really difficult, to hide bad outcomes at the end).

The real problem is that organized medicine (you know -- ACOG and AMA) are pointing to two very flawed studies that greatly exaggerate the risks. The Washington Study (Pang et al.) was retrospective and relied on birth certificate data of anyone giving birth at home at 34 weeks or later who had a midwife or doctor listed. (34 WEEKS???? No one delivering a 34 weeker at home should retain their license, IMO). And there's an Australian study that included high risk moms in extremely isolated parts of the country. Clearly these two studies do nothing to add to a sincere discussion of planned home birth in America.

For the record: I am a consumer living a state that has no licensure for CPMs, so women where I live wanting a home birth must either book with one of the 4 home birth CNMs in the whole state the nano-second see that + sign, or rely on an underground network of unlicensed providers. THAT'S the real problem -- failure of half of the United States to license CPMs while ACOG, the AMA and state doctor's groups and hospital associations pour literally millions of dollars into campaigns to stop consumers like me who need access to licensed home birth care. If ACOG really cared about home birth women and their babies, they'd stop making policies blocking access to collaborative care and stop blocking licensure laws for CPMs.