Home Births, Hospital Deaths

By the time she arrived at the Emergency Room she had already lost a lot of blood. She was rapidly transferred from the ambulance to an ER bed and within a matter of minutes the life-saving transfusion was started. Had she waited just minutes longer to call for help she may not have survived. Her new baby would have been motherless.

For the doctors in the emergency room the treatment was common, a matter of routine. The reason for her brush with death was not. Post-partum hemorrhages are usually handled on the maternity floor, not in the emergency room. If her baby had been delivered in the maternity floor the bleeding would have been handled faster and the transfusion averted. Unfortunately she had chosen to avoid the maternity floor and have her baby at home. Her decision almost cost her life.

It was a decision that I had repeatedly and strongly argued against. I was her doctor for the first 4 months of her pregnancy. She had made it clear that she wanted a “natural” experience and I had promised her that this could be done in the hospital. I understood that many women preferred a natural delivery and had extensive experience managing natural childbirth. I was confident that her wishes could be honored and promised her they would. When she made the decision to deliver at home I had to resist and released her from my care. From my perspective as a doctor and as a father choosing home birth was and is one of the most selfish choices a woman can make.

Home birth goes against the two values that define obstetrical practice- Protect the health of the mom. Protect the health of the baby. These values guide all obstetrical care. The maternity unit is the only place in the hospital where the health care team begins with healthy patients and then works to keep them that way, so bad outcomes are especially tragic. Everything done by the nurses and doctors is directed at early identification of problems and preventing complications. The only acceptable outcome is a healthy mom and a healthy baby and no action or decision that makes that outcome less likely is tolerated.

While the goal of healthy mom and healthy baby is non-negotiable there is plenty of room for maternal choice during the course of labor and delivery. Birth positions (sitting, squatting, lying down), analgesia choices (epidural, narcotic or none at all), eating during labor, avoidance of IV lines and episiotomies, early nursing and skin to skin contact were all a part of births I attended. I often bent over backwards to meet the mother’s needs even if it meant spending extra hours in the hospital. My willingness to honor maternal wishes had one limit- I would not do anything that put the baby at risk. This is why I opposed home delivery.

In spite of opposition from the medical profession home birth seems to be making a comeback. While there are many possible explanations for the trend the facts support the conclusion that the choice to deliver at home is less about love and health and more about personal feelings and selfishness.

The patient who nearly died of a hemorrhage gave reasons for desiring a home delivery that were typical. She wanted a natural delivery and the experience of delivering at home in a supportive and comfortable environment. These desires seem worthy but they are not, for both place the feelings of the mother ahead of the health of the baby. Babies have no recollection of the room in which they are born, do not grow up feeling more loved and desired because the lights were low and the bed was soft. The baby does not care. Home deliveries are all about what the mother wants and not about what is best for the child. Is this not the very definition of selfishness?

The argument against home delivery is simple. It needlessly places the baby’s life at risk. While the risk is not massive (life threatening complications are rare in most pregnancies) the risk is always present. The American College of Ob-Gyn estimates that newborn mortality in home births is triple that of babies born in a hospital. Why would a loving mother make a choice that needlessly increased the chance that harm would come to her child? What warm feeling or joyous experience can justify that risk?

Current research suggests that as many of one in three women attempting home delivery will need urgent transport to a hospital due to a complication in labor. The transfer rate is lower for women who have previously delivered vaginally but it is still significant. Like every physician who has practiced obstetrics for any length of time I can share a number of stories where being in a hospital delivery room saved the life of a mom or baby.

Consider this analogy- If a young mom announced that she was foregoing the use of an infant car seat because she wanted the child to be in her lap while she drove she would be reported to the authorities. Her arguments that it made her feel close to her child, that bonding was important and that the risk of accident was low would fall on deaf ears. It would not matter that she was a safe driver and that because of cell phones medical help was never more than a few minutes away. Everyone would agree that it was irresponsible and selfish to risk the life of her child in such a way. How is this different than choosing to deliver a baby at home?

I have heard that home birth is gaining in popularity, part of the recycled fad of interest in all things “natural.” I doubt this post will change the minds of those who do not trust the knowledge or intentions of the medical profession but there is one thing of which I am certain. When it comes to the place of birth the baby does not care about the experience. No one remembers their birth experience.

Everyone remembers when a baby dies.

-          Bart

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Autism, Measles, Vaccines and Truth. Protecting the Lives of Innocent Children

He had never been embraced by his adolescent daughter, never heard her say the words “I love you,” never had a conversation with her at all. Autism had stolen all of this from him, her condition was that severe. So moving were his words that as the man testified before congress, the hearing room was uncharacteristically quiet. In addition to being the father of a daughter with autism he was a professor of infectious disease at San Diego Children’s Hospital. While dealing with the challenges of being parent of a severely disabled daughter he continued his duties at the hospital  where he witnessed firsthand the damage brought by measles, polio and other vaccine preventable diseases. I vividly remember his concluding remarks. He told the members of congress that after reviewing the data on vaccine safety and autism, after experiencing the pain of his daughter’s condition every day of her life, and after seeing all of the diseases in question, he was certain. If he had to make the decision again, he would immunize his daughter in a heartbeat.

I was stunned by his testimony. Not only by its power, but by the fact that I had even come across it. I was channel surfing while on vacation and landed on CSPAN by accident right as his testimony began. It seemed almost providential that as a physician dealing with immunizations on a daily basis I would so fortuitously come across such a valuable story.

I have repeated his story many times over the years in conversations with mothers and fathers about vaccine safety. Over the course of dozens upon dozens of such conversations I have realized that vaccine questions come from two perspectives. There are the honest questions from those who want to protect their children from diseases but are nervous and are seeking reassurance, and then there are the confrontational challenging questions from those who are convinced that vaccines are harmful. The testimony of the San Diego doctor has reassured many in the first group and had no impact at all on the second.

I have often wondered why that is. Why is it that there are some people who seem to feel that 9 years of education, 3 years of training and 20 years of practice add no value to my opinion beyond that of someone with a computer, a web browser and some time on their hands? If my knowledge and experience mean nothing, how do I reach such people?

The answer to the first question, why some people do not respect my opinion, seems to be a cultural one. From the 60’s onward children were taught to question authority and to be wary of placing trust in those in power. Since the 70’s, an emphasis has been placed on self-esteem. Everyone’s opinion matters, everyone’s opinion counts, and to an extent, everyone’s opinion is equal. The end result is that the physician/patient relationship has seen a new dynamic. Gone are the days when doctor’s recommendations were readily accepted and followed. We are having to prove our knowledge, even in common areas of practice such as vaccines.

I cannot trace its rise, but there is another factor as well, the apparent desire of people to be in an elite group, the group that is “in the know.” Knowing something that others don’t, discovering a “truth” that has been hidden, seems to be a powerful elixir. In my discussions with those adamantly opposed to vaccines this attitude has been common. There is an air of “other people may be duped, but I am better than that” that pervades the conversation. This attitude allows for dismissal of any argument I may offer.

The internet has made the situation worse, as misinformation and misapplied data abound. Evidence to support one’s preconceptions is never more than a few mouse clicks away. I have noticed in the anti-vaccine crowd it is never the reputable sites that they quote. Immunize.org, the CDC and the Mayo Clinic are passed over for activist sites that proclaim the “truth.”

What has amazed me the most in my discussions with patients (and in the responses to my blog post) is the emotion and anger associated with the anti-vaccine movement. Physicians and Public Health officials are not simply mistaken or wrong, we are often characterized as evil, deceptive, “in the pockets of Big Pharma,” or motivated by greed and avarice. The most gracious of the anti-vaccine responders express pity, displayed in condescending remarks that suggest I have been duped or am simply unaware. To imply that we physicians would either knowingly harm a child or remain willfully ignorant of information that may benefit a child under our care is an accusation I find difficult to process.

I have had so many conversations and my response to vaccine questions has evolved over the years. As there simply is not enough time in the day to engage in 30 minute discussions with every family about vaccine safety I have reduced my comments to a few simple points.

I tell my parents that life is full of risks. They risked the life of their child when they strapped her in the car seat and drove to my office that morning. A risk free life is not possible. I use the example of seat belts and airbags, reminding them that every year in America people are injured or killed because of seat belts and airbags but that we continue to use them in the knowledge that they save far more lives than they harm. This is the truth about vaccines. In rare cases some children may have a harmful response to an immunization and in exceedingly rare cases the reaction and harm may be severe. The alternative, not immunizing children, is much, much worse to society. One child may get away with it if all of the other parents immunize, but if society follows that path many innocent children will die.

The honest questioners, those with open minds and hearts and who do not believe that the healthcare industry is guided by evil forces, accept my words and have their children immunized. The oppositional deniers try to argue with me. At that point I simply tell them that I cannot provide care for those who do not think I know what I am talking about and who do not trust my judgment, who think I would harm their children. Out of concern for other patients in my practice, I suggest they find care elsewhere.

While this works for my practice society has a more difficult challenge for being unvaccinated does not only place the individual in jeopardy, it carries with it the risk that others may suffer. The recent outbreak arising from Disneyland is a powerful illustration of this risk, as children too young for the vaccine became infected by others. So what do we do?

I am not a politician or a legislator, but difficult decisions need to be made. I am of a bent that places great value on individual liberty and I am reluctant to suggest actions that infringe on parental rights yet I do think an argument can be made to stiffen immunization requirements, especially for school admission and particularly for those diseases that are most contagious. We need to be careful about drawing lines in the sand over contagious diseases which are almost impossible to transmit in a classroom setting but should be willing to make a stand with readily contagious diseases such as measles. We should not expect innocent children too ill or too young to be immunized to be made to pay the price for the decisions of others.

As a culture we need to be willing to say that not all opinions are equal and that our public health decisions will be based on science and not emotion. It is not an overstatement to say that the lives of our children are at stake.

- Bart

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Love is never Hopeless.

waiting for a boy to become a man can be hard!

It is very hard to look at a 13 year-old boy and accurately forecast the probability of future success. For my son Nate it was darned near impossible. The standard indicators of future success- a clean room, completed chores, and finished homework, were noticeably absent. At that age it seemed that his greatest hope for success in the world was dependent on there actually being a zombie apocalypse or an alien invasion. If there was one (or two) things he was really good at it was killing aliens and zombies. It was a skill honed and developed through hours of practice that arose out of a singular devotion to duty.

As a father it was incredibly frustrating. Like many dads looking at his cluttered room and hearing the endless video game explosions led to visions of my son standing at an intersection with a piece of cardboard that said “Will work for food.” (Although the thought that he might actually be willing to work was slightly comforting.)

My frustration was in large part my own fault. I had unreasonable expectations for a 13 year-old. (My wife will say that I also had unreasonable expectations for a 14, 15, 16, and 17 year-olds as well.) I was basing my opinion totally on what I saw with my eyes. I was ignoring two important things that I could not see- the goodness of his heart, influenced by the Biblical teaching that was a large part of his life, and the bigness of our God, who Nate had made a commitment to at a young age.

I was allowing present circumstances and performance to completely determine my perception of the future of my child. I was stupid, and on many occasions I did not show him love as I should have, for love does not only believe in the good intentions of someone’s heart for the present time, love believes that goodness of heart will result in good in the future. This belief that the future will be better has a name. It is called Hope.

Paul listed Hope as one of the characteristics of love in 1 Corinthians 13. “Love always hopes.” Even when current evidence is lacking, even when someone is failing right in front of us, when it comes to relationships with those we love, our family, especially our spiritual family, true love brings hope. Hope that the future need not be defined by the present. Hope that God is able to make broken people whole, that God can change lives for the good.

It is difficult to hope sometimes, difficult to believe that the future can be better. We need God’s help to love like this, need Him to remind us that He is in control, need to trust His ability to work in the lives of those He loves. But if we love others and love God we must trust, for love always hopes.

I had hope for my son. If I had allowed his dirty room and video games to define him, I would have not encouraged him to be more and do more. My hopes were not disappointed as he has since exceeded my hopes for him. He is a good man, a loving husband, and a devout believer. He is still equipped to deal with the coming zombie apocalypse, but he is also finishing a law degree at UCLA, and working for the District Attorney, where he is displaying a talent for dealing with real life bad guys. Thank God for hope.

-          Bart

This is the 13th post in a series on love based on 1 Corinthians 13. If you have been encouraged by this post, please consider sharing it. If you have a story or comment to share, please share it in the comments. You can be sure to receive all future posts in your email by subscribing to the blog as well. (Link is upper right on a computer, at the bottom of the page on a mobile device.)