Thursday, May 10, 2007

This independent midwife insurance thing

So I'm reading Dr Crippen the other day and I read this here, about how independent midwives - those who choose not to work for the NHS because of its lack of, um, woman-centred care - may soon be required to get professional indemnity insurance before they can work. And they don't like that, the independent midwives. Why not? Two reasons:
  1. They can't get professional indemnity insurance because there is no insurance provider that will insure them. No provider has offered insurance since 2002, and even then the premiums ran to over £15,000 per midwife.

  2. Which is wholly unreasonable, because apparently negligence "isn't really an issue" for independent midwives.

Just in case anyone didn't follow that - negligence isn't really an issue for independent midwives, which is why no insurance provider will insure them. Okay? Okay.

The Independent Midwives Association is pushing for one of two "solutions" to this problem:
  1. The Government should "ensure that affordable indemnity insurance is made available to all midwives". Of course, they don't say exactly how the Government might go about compelling insurance providers to make insurance available to independent midwives. If anyone can think of a way to do it, do please let me know, because I have been thinking really really really hard when I should have been working and I still just can't think of a way. Apart from the Government indemnifying independent midwives itself, of course. (Don't you DARE, Government. I mean it.)

  2. Independent midwives should be exempt from any requirement to have professional indemnity insurance in place.

Why is it so important for independent midwives to carry on practising, even without insurance? Because, the IMA says, they provide "woman-centred, autonomous midwifery practice".

(You know, the sort that women had up until the nineteenth century, when women were most likely to die in, or of, childbirth, as I think were babies.)

And why is that so much better than the NHS? Because the NHS is all boring and masculine and unfriendly, with its not-remotely-cuddly "Trust policy and protocols, which are often obstetric-led and therefore focus on the abnormal". Midwives, you see, are "experts in normal birth". Woman-centred, autonomous experts in normal birth. Sounds great, doesn't it? Until you think about what it actually means - which is that if you are at home with your autonomous expert in normal birth and your birth turns out to be scarily abnormal, you might as well have drawn a smile on a sack of potatoes and propped it up next to your birthing pool.

(That's not quite fair. At least an independent midwife can dial 999.)

Okay, I'm losing my temper a bit. I am sure I am being very unfair on independent midwives, who are probably very good at reassuring nervous women and dealing with normal births. I think insured midwives, preferably in hospital, are a very good thing. It's just that if I was giving birth, I wouldn't want the whole thing resting on a woman-centred autonomous midwife who knows how to do a normal birth. Normal birth is, well, normal. In theory you ought to be able to do a normal birth on your own. But you don't, in case it goes wrong. And if it goes wrong, you want someone who knows what to do when it goes wrong. You want an obstetrics-centred doctor who has some idea of how to save your life and your baby. And you also want someone who is insured so that if they fuck up someone will at least pay for you to get the help you need.

Now, independent midwives are obliged to tell their clients that they aren't insured. But I wonder if they tell them why. The reason independent midwives aren't insured is because they are too much of a risk. That's how insurance companies work. They evaluate risks and basically they take an informed bet. Apparently they don't think that midwives are a safe bet. And when you think about what insurance companies will insure, that's pretty scary. They'll insure you to build a house for other people and pay out if it falls on their heads. They'll insure you to operate on people and pay if they end up needing round the clock care for the rest of their lives because you were flirting with the nurse and accidentally removed all of their limbs and half their head. They'll insure you to represent clients in legal proceedings worth tens of millions of pounds. They'll insure an 18 year old boy to get behind the wheel of a VW Golf and pay out when he ploughs over a red light and into a taxi killing three and leaving two brain damaged. And, of course, they will insure doctors and hospitals to preside over births, even abnormal ones, and pay out when they fuck up.

But they won't insure an independent midwife.

If independent midwives can't get insurance, perhaps they should stop being independent and go into the NHS, where they can spread some of that woman-centred love around with proper obstetric support on the next floor down if it all goes wrong halfway through. But whether they continue to be exempt from the requirement to obtain insurance or not, if I ever have children I'm having them in hospital. Even if the paint's peeling and the doctor is unfriendly and they won't let me have a paddling pool. Because if the insurance company won't bet its cash on an independent midwife, I'm not going to be the one who bets my family on them.


Anonymous said...

This article on independent midwives is poorly researched and written in a hysterical style. In theory hospital births should be safer. Sadly they often are not due to staff shortages (midwives and doctors)especially if you are 'low risk' because if the delivery unit is busy - which is almost always is, then no one is going to check on you or your baby. This is why the UK now has one of the highest infant and maternal mortality rates of any developed country in the world - disgraceful. Katy should try having a baby in her local NHS hospital and she'll see what that's like. She won't be mocking the alternatives then...

Katy Newton said...

I am always impressed by people criticise my writing styles but don't have the cojones to provide their own details. Hospital births ARE safer than home births. Fact. If you've got figures that say otherwise put them in here for me to look at - although I doubt you have or you'd have followed your criticism of my research with some of your own. I agree that NHS facilities are far from ideal across the board, but I do not agree that they are "often not safer" than a home birth with a midwife, because it is abnormal births that result in danger to mother and baby and midwives by their own admission are experts in normal birth. And, of course...

(fanfare please)


Yeah? Not as good as four-star service... but better than an uninsured midwife in my living room. In my humble opinion.

Katy Newton said...

Of course, anyone who wants to criticise the sentence I am always impressed by people criticise my writing styles has a clear field. Oh, the irony.

Anonymous said...


You are entitled to your opinions but your article does appear 'lightweight' as you do not back up your opinions with any facts and figures. Unfortunately it comes across as a series of teenage rantings, which is unfortunate. Can you provide information on the medical negligence payouts made against independent midwives prior to 2002 when they still had insurance or prior to 1994 when they were insured by the RCM? I would be pleased to see any such data. Regarding safety record, I would refer you to the independent midwives clinical statistics available on their website: I would also refer you to and urge you to read 'Why Mothers Die' and have a look at the rise in death rates over the last 15 years. The reports on neonatal & perinatal mortality are also worth a read. As you may or may not have seen on last week's Panorama, the WHO (World Health Organisation) has singled out the UK as having one of the highest infant mortality rates of the world's developed countries. In terms of medical negligence payouts made by the NHS, these totalled £1bn last year and two thirds were accounted for by obstetrics. I think that it is simplistic to say women should have homebirths or women should have hospital births. Women should have choice and midwives and doctors should work in partnership to deliver high quality, safe care. Sadly in many hospitals this is not happening at the moment. Following the enquiry into Northwich Park, this has been acknowledged - sadly nothing has been done to improve the situation in other maternity units and more cutbacks have been made to maternity services. I find your references to peeling paint and unfriendly doctors funny. If these were the issues pregnant women were worried about that would be a laugh. How about no registrar or consultant in the middle of the night, when you are haemorrhaging in hospital - that's more the kind of issue women are actually experiencing these days.
Please provide your references for your assertion that hospital births are safer than home births. There is lot of research on this, so I'm wondering which studies you are referring to ?

Chairwoman of the bored said...

Women shouldn't be attended by the uninsured.

I am licensed to drive, but not without insurance. Surely people who are licensed to deliver babies should have a similar caveat on their professional activites.

Katy Newton said...

How about no registrar or consultant in the middle of the night, when you are haemorrhaging in hospital - that's more the kind of issue women are actually experiencing these days.

Really? How about no registrar or consultant in your living room, and no insured hospital to sue when it all goes wrong? It isn't about choice for women, it's about safety. And about an insurance safety net when it goes wrong, which independent midwives don't have and hospitals do.

Please provide your references for your assertion that hospital births are safer than home births. There is lot of research out there

Then I am baffled by the fact that you aren't linking to it for everyone to see. I've set out my stall. If I'm wrong, you show me why.

Anonymous said...


Firstly, yes you are baffled as you definitely haven't done your homework on this subject. Secondly, you haven't 'set out your stall' as you have not substantiated any of your arguements. It is clear that your knowledge of midwifery is lacking. It would appear that you do not actually know what a midwife, NHS, independent or otherwise, actually does and what his or her skill set and role is. You are also very ill informed about the role of the independent midwife and the problems relating to PII. I am cutting you a lot of slack because you haven't been through the childbirth NHS treadmill and you've decided to base your article on info from 'Dr Crippen'! If you were to opt for a homebirth with an independent midwife, you wouldn't have an emergency in your living room. Problems would have been spotted early on because you are getting one-to-one care and you would have been transfered to hospital. Midwives can handle all aspects of labour, but their role does not overlap greatly with an obstetrican so they work in partnership with them and handover when certain complications arise e.g. surgery looks likely. Having a homebirth doesn't mean that you're not allowed to go to hospital. If you did have to transfer to hospital you have the independent midwife with you who will be able to support you and act as an advocate or if you are lucky deliver your baby in hospital. If you are in hospital, nowadays you are likely to be being 'looked after' by a midwife, who will often also be looking after 4 other women in labour at the same time. If something goes wrong, then what? It's very scary. As well as midwife shortages on the NHS, medics are also thin on the ground too. What has been shown through numerous studies is that women and babies have the safest outcomes if they have continuity of care and one to one support from a midwife during labour. This has been shown to be the 'gold standard' of maternity care. It is currenly only available on the NHS in the Torbay area and around Peckham via the Albany Trust. The government has now enshrined this 'one to one continuity of care' as a key goal for maternity policy in the UK and it is supposed to be available for all by 2009. However it looks highly unlikely that this will be achieved. If you want the proven gold standard of care and you don't live around Torbay or Peckham then you need to hire an independent midwife. Independent midwives do not want to operate without insurance, but the lack of insurance does not make them less safe. Insurance does not improve the standard of care it can only pay out if negligence by a midwife or doctor is proven. It is important to realise that proving negligence and getting that insurance payout can be very difficult. You make the point that if things go wrong the NHS will pay out. That makes it sound so so easy. Do you really think the NHS will write you a cheque for your stillborn baby when you are ready to leave hospital? The millions of pounds paid out to bereaved families have been hard fought for, sometimes the fight for the truth can take years. Which would you rather have, better care so an immense personal tragedy DOES NOT happen to you during childbirth or would you prefer the current standard of NHS care, a lengthy court battled and some money?

I would go for better care. You haven't provided any of the data I have asked you for, so I have attached a list of research which supports the one-to-one midwifery care model currently offered by independent midwives in the UK.

If you want to debate this further I would be delighted to, but please inform yourself properly of the issues. It would make for a better standard of debate.


Benjamin, Y Walsh, D & Taub, N (2000) ‘A comparison of partnership caseload midwifery with conventional team midwifery care: labour and birth outcomes’. Midwifery. Vol 17, pp234-240.
Biro, MA (2000) ‘Team midwifery care in a tertiary level obstetric service: a randomised controlled trial’. Birth. vol 27, no 3, pp168-173.
Biro, AM., Waldenstrom, U. Brown, S. and Pannifex, JH. (2003). ‘Satisfaction with Team Midwifery Care for Low- and High-Risk Women: A Randomized Controlled Trial’. Birth. Vol 30, no 1, pp1-10.
BirthChoiceUK. (2004) Maternity Statistics 2004.
Available online at:      [accessed 1/6/2005]
Brodie, P. (1996) ‘Being With Women. The experience of Australian Team Midwives’.
In: Stapleton, H. Kirkham, M. Thomas, G. and Curtis, P. (2002a) ‘Midwives in the middle: balance and vulneraility’. British Journal of Midwifery.  Vol 10, no 10, pp607-610.
Department of Health (2004) National Service Framework for children, young people and maternity services: Supporting local delivery. HMSO, London.
Department of Health. (2003a) Choices in Maternity Services, 9th Report of the Health Committee. HMSO, London.
Department of Health (2003b) Keeping the NHS local: a new direction of travel. HMSO, London
Department of Health (2000a) The NHS Plan: a plan for investment, a plan for Reform. HMSO, London.
Department of Health (2000b) Implementation Programme for the NHS Plan. HMSO, London.
Green, J Renfrew, M and Curtis, P (2000) ‘Continuity of carer: what matters to women? A review of the evidence’ Midwifery. Vol 16, pp186-196.
Henty, D (2004) ‘Caseload midwifery and its contribution to increasing normal birth’. MIDIRS Midwifery Digest. Vol 14, no 1, supplement pp25-27.
Hillan, E. (2000) ‘The Aftermath of Caesarean Section’. MIDIRS Midwifery Digest. Vol 10, no 1, pp70-72.
Hodnett, ED (2004) ‘Continuity of caregivers for care during pregnancy and childbirth (Cochrane review)’ In: The Cochrane Library  Issue 2, 2004.
Homer, CS Davis, GK, Cooke, M & Barclay, LM (2002) ‘Women’s experiences of continuity of midwifery care in a randomised trial in Australia’. Midwifery. Vol 18, no 2, pp102-112.

Katy Newton said...

Goodness, I do like your manner. It makes me much more sympathetic to the cause of independent midwives. If this is the sort of non-patronising woman-centred approach that I can expect from an independent midwife throughout my pregnancy... No, but seriously. I'll cut you some slack and ignore your digs, because you have a stake in this argument whereas I just find it interesting. You misunderstand the point of my original post, I think. I don't doubt that women would prefer continuity of care throughout their labour - most clients in any profession want to be under the care of one person they trust, don't they? Nor do I doubt that many women would like to give birth at home. They may well do.

But my post is not really about what midwives do day to day or about whether it is easy or difficult to prove negligence. (I hate to break this to you but I am a lawyer by profession, and whilst it is often hard to prove medical negligence, it can also be very easy, which is why I find the suggestion that midwives are somehow immune to the human errors and lapses of attention that constitute negligence. Let's not get too complacent, eh?) It isn't even really about whether pregnant women like midwives. What my post is about insurance, and the fact that independent midwives can't get it, and what inference can be drawn from the fact that they can't.

You've recycled a lot of the arguments that can be seen on the IMA website (to which I linked in my original post), which basically downplay the importance of insurance and in favour of the importance of choice for women. You've also linked to lots of articles about continuity of care and what women want. From what you and the IMA say, anyone would think that insurance providers were deliberately setting out to deprive women of choice out of spite - and if that is what you think, I'd like to know why.

But I don't think you have posted any statistics comparing safety of home births under the care of an independent midwife to safety of births in hospital. Nor has the IMA on its "Save Independent Midwifery" site, which I find odd, if such comparative statistics exist which prove that independent midwifery is as safe or safer than hospital birth. I appreciate that such statistics may be difficult to find and that safety may be a subjective concept which can be defined in a number of different ways. But I do place considerably more value upon insurance than you do, and whilst I take your point that insurance does not protect against negligence happening or guarantee better care, in my personal opinion that's a much less convincing argument when you're trying to come to terms with your profoundly disabled child without any prospect of being paid the millions of pounds that looking after such a child may cost.

But we could argue about insurance versus better care all day. The really interesting question is why insurance providers won't cover independent midwives, but will cover births in hospital and doctors and midwives who work within the NHS. And that's a question that none of your articles address, that you don't address in your comment, and upon which the IMA's site is strangely silent. You've asked me why I haven't provided details of insurance payouts in respect of independent midwives. I will admit immediately that I can't find any data on that - but I am afraid I don't need it. Because the fact is that insurers love to insure safe professions. They are commercial organisations. It means they are less likely to pay out. And if not one insurer will now provide cover to independent midwives it can only be because they found that they were paying out too much to make providing cover commercially viable. There is no other feasible reason why they would refuse to do it, or at least none that I can think of.

If there is another reason that they refuse cover, I'd love to know. I have no great stake in this debate and I'm more than happy to change my view if you give me reason to do so.

And I will point out that although I have been fairly robust in the expression of my views, I haven't been nearly as personally offensive to you as you have to me. I really don't think you are in any position to lecture me about raising the quality of the debate.

Martin said...

I was born at home, with an independent midwife at my mother's bedside. That's where people were born and occasionally died in the olden days. Some people would still like to give birth at home - you know, exercise their freedom to choose.

I'm surprised to read such a reflexively authoritarian, illiberal rant on this site.

The solution isn't cheaper insurance by regulatory diktat, nor is it a re-nationalisation of yet more healthcare provision: it is an end to frivolous and/or malicious lawsuits which seek to apportion blame whenever an individual dies during medical treatment, when in reality sometimes people just die. Including mothers and babies during labour.

And if women are prepared and wish to take the additional risk of giving birth at home, they should be free to do so.

If you choose to do anything which does no harm to another person, then you should be free to do so. That's textbook libertarianism.

Chairwoman of the bored said...

"That's where people were born and occasionally died in the olden days"

I am left breathless by this sentence. In the 'olden days' childbirth was the greatest cause of untimely death in women. It was not an occasional incident at all. Thankfully, due to the scientific advances made, this is no longer the case. And this is compounded in hosptial births by the close proximity of operating theatres, and bloodbanks, not to mention additional medical help.

But this is not what this post is about. Nor is the right of women to choose where and how they give birth, nor the efficiency or professional competence of midwives, be they independent or NHS. It's about responsibility.

Surely it is irresponsible of any professional to practice without indemnity. The builder putting an extension on the house next door to me has to have public liability cover, or the householder has to get it on their behalf. And you must remember that insurance doesn't only cover the patient, it also covers the midwife. It stops her losing her home should a mistake happen, and she is sued.

But at the end of the day, Martin is right. If people are stupid enough to employ non-insured people to look after them in a potentially life threatening situation, then on their own heads be it. As long, that is, that they understand that their practitioner is not insured, that they sign a document to say that they understand, and they guarantee not to seek legal redress in the event of a tragedy.

Katy Newton said...

Sure, whatever. I couldn't agree more. I think that women who use uninsured midwives are taking what in my opinion is an unacceptable risk, that I personally would choose to give birth in hospital, and that the IMA's justifications for exempting midwives from insurance don't hold water.

I'm not sure what's illiberal or authoritarian about that. Every time an uninsured professional cocks up, the taxpayer foots the bill, leading to more financial misery for the country plus a pretty inadequate standard of care for the victim of negligence. The beauty of insurance is that it's an example of the free market in action: a private individual decides that he can make a profit from insuring against certain risks; when he pays out he still makes a profit and at the same time relieves the taxpayer of the burden of supporting someone who's ended up unable to take care of themselves because of the negligence of another taxpayer. What's not to like?

"Frivolous claims" are a red herring. If insurers stopped insuring professions on the basis of frivolous claims, no one would be able to get insurance at all, not just midwives.

Anonymous said...


Thanks for raising your game a bit in terms of your responses. It seems we do have a lot in common actually. I am a lawyer too.
In response to your main points. Firstly at no point have I suggested that independent midwives are superbeings immune from human error. The point is that they are currently able to provide a higher standard of care than on the NHS, so mistakes are less likely. Yes, it is unfortunate that insurance is not currently available. You basically say that I don't rate insurance, this is also not the case. I would like to see the independent midwives get insurance and I understand that they do too. I do take issue with your suggestions in your original article that independent midwives are somehow not competent and only there to dial 999. I do feel strongly that there is a perception that we as women are safe in hospital when giving birth. I believed this too. Unfortunately, it isn't always the case and cutbacks mean that safety in maternity units is being further compromised - problems are not being spotted. As women we are being short changed. In terms of why independent midwives can't get insurance, you are right to question this. The reason is that there are only around 200 independent midwives in the UK. Premiums reached about £15K. The sad fact is that even with the best care for women during pregnancy and childbirth in hospital or otherwise, there is still an element of risk. Basically childbirth is inherently risky for mother and baby. If a baby is starved of oxygen during childbirth, but survives and negligence is proven (a key point), then the payout would run into millions due to the care requirements over a lifetime. So this is the reason why insurance is difficult for independent midwives. If all 200 of them could afford premiums and paid then, then this would not be enough to profitably cover any potentially big payouts. As a group the independent midwives could pay about £3m p.a. to an insurer. Having worked internationally for a large health insurer, this isn't attractive profit wise. If you check through the IMA website etc, you'll see that they do refer to these issues. You say that the NHS can get insurance. The reason for this is the economies of scale. The ratio between Trusts paying premiums and the size of premiums is commercially viable for the insurer. You discuss in your latest article, that taxpayers are or will foot the bill for the uninsured. We as taxpayers are already footing the bill for the medical negligence payouts on the NHS as we fund the NHS - it isn't free and we have to pay for the spiralling premiums. Hence the introduction of CNST.

It should be noted that the government is currently planning to extend CNST to cover independent midwives. This may or may not be the right solution. However it does look like independent midwives will be insured.

I think that your planning to have a hospital birth is your choice, just as someone else may prefer another approach. Most women do have hospital births and I campaign to improve the standard of care available to women so they and their babies are as safe and content as possible. I hope that all efforts to improve maternity services will improve the standard of care for you and your friends when you have your kids.

Finally you have very much a independent midwives homebirth verus hospital birth approach. This is too simplistic. I have been trying to convey this to you. Some independent midwives can also deliver babies in hospital. This isn't a home vs hospital issue. NHS midwives also deliver babies at home.

Devil's Kitchen said...

And if women are prepared and wish to take the additional risk of giving birth at home, they should be free to do so.

If you choose to do anything which does no harm to another person, then you should be free to do so. That's textbook libertarianism.

Fuck, I'm really tired of people displaying this kind of argument and then backing it up with nothing but libertarianism.

Look, the mother is not taking the risk simply for herself, she is also putting her baby at risk.

The fact is that home births are more dangerous. Full stop.

They are more dangerous than a hospital birth, budget cuts notwithstanding, and so the mother is forcing an unacceptable risk on the child.

As the baby cannot choose, the mother is then initiating force against the child, and it is not libertarian.


Katy Newton said...

And also what Mr Kitchen said.

Anonymous, I've just repeated my original points, so I am not sure what you mean by "thank you for raising your game". My game is exactly the same as it was to start with. You, however, have finally raised yours to some extent by dealing with the insurance issue and why midwives don't get it, which was my clearly stated point both in my original post and in my subsequent comments here.

My understanding is that birth in hospital is considered safer - not "absolutely safe", that is not something that I have ever said, I am well aware that negligence can and does happen in hospitals - but safer than birth at home. I repeat: if you have figures which demonstrate otherwise, I'd like to see them. I am well aware that NHS midwives deliver babies at home and I am also aware that some hospitals - although not many - will permit independent midwives to deliver babies in hospital. What's the difference between them and independent midwives? NHS midwives are insured. This is NOT about NHS versus privatisation, or home births versus hospital births, or how or where individual midwives deliver babies. This is about what safety net exists to compensate mothers and babies if something goes wrong, and the fact is that NHS midwives do have a safety net and independent midwives don't.

Which is why my post suggests that midwives should work within the NHS (or, equally, for private hospitals) and work to change the NHS protocols and policies that they feel adversely affect women's right to choice, rather than working independently, which at the moment means that they are taking responsibility for the lives and health of mothers and babies without any means of compensating them if they cock up.

As women we are being short changed.

In terms of NHS facilities being poor? Sure. But let's face it - independent midwives are not the answer to that problem, are they? Leaving aside insurance and safety issues, independent midwives are a luxury that most women in this country can't afford. That one to one continuity of care costs £2000-£4000 a pop. It's for rich, middle-class women who ten years ago would have been too posh to push. I don't have a problem with that, free marketeer that I am, nor do I have a problem with elective Caesarians - contrary to what Martin thinks, I am a libertarian - but it does make me laugh when the IMA paints this insurance initiative as taking choice away from vunerable women, because for the majority of women in this country it was never a choice in the first place. The sort of woman who would use an independent midwife is likely to be a woman of means and/or private health insurance who therefore doesn't have to go anywhere near the NHS in the first place.

Anonymous said...

The CEMACH perinatal mortality report 2005 noted 668,681 live births [in England, Wales & N Ireland].
7225 deaths were notified, including 3676 stillbirths, and 2356 neonatal deaths.

Rates of stillbirth have hardly changed since 1992, 50% are unexplained, 48% are attributed to immaturity.

Nontheless, wide and unexplained variations in perinatal mortality exist between hospital Trusts.

So who is at most risk ?
Mothers birthing with independent midwives ?

Not according to CEMACH - the highest small coffin count was found most commonly amongst;
Deprived mothers [based on the Index for Multiple Deprivation], their chance of stillbirth being twice that of your average micro-celeb or professional bod.

Women of black or asian origin have signifcantly greater risk of undertaker involvement than your average white mother.

The findings for deprived or non-white mothers are consistent with previous patterns of perinatal mortality.

16737 mothers were born at home [in 2005] 119 babies died. It was noted that 75+% of these births were not actually planned homebirths.

Of those that were 13 babies died, including four stillbirths, and four deaths relating to intrapartum causes.

Independent midwives won't get insurance unless there is either a big enough work pool, or an external agency willing to underwrite the risk.

They do not have optimum support for the rare occassions when a homebirth goes catastrophically wrong but for the other 7,000+ babies who died in hospital there may well have been opportunities for a different outcome, certainly the Northwick Park report into 10 maternal deaths did not paint a very flattering picture of a struggling NHS maternity unit.

the A&E Charge Nurse

Katy Newton said...

Okay... so you've given us figures that don't distinguish between independent midwives, NHS midwives and consultant-led units; you haven't provided any figures for death of mothers or of other problems arising in relation to mothers, and you haven't given us figures for any problems that babies might suffer that don't lead to them dying.

Because of this, your figures don't really take things much further. On the figures that you have given, it looks as if approximately 1% of babies born die whether born at home or in hospital. Assuming for a moment that that is right, then there is very little to choose between an independent midwife and birth in hospital or with an NHS midwife apart from the fact that...


... independent midwives aren't insured.

And if that is the case, I'd still rather have the insurance-backed option, and I still think that anyone who wouldn't is insane.

Katy Newton said...

I think I'm starting to repeat myself a bit, so here's my final position:

Even if there is no appreciable difference in safety between births presided over by independent midwives and hospital births or births with NHS midwives - which, by the way, I do not for a moment accept - the fact remains that independent midwives are not insured which means that a mother who births with an independent midwife is taking a risk that she wouldn't otherwise be taking.

It seems to me that that's unanswerable, but what do I know?

Anonymous said...

Katy, Iook at 'Why Mothers Die' [2000-2002] if you require further data on causes of maternal death.

During this period 391 deaths were reported, most women died from a pulmonary embolus.
Eclamptic mothers were another significant group with a potentially preventable cause of mortality.
17 women bled to death, with an increased rate of post-partum haemorrhage [compared to the previous 3yrs].
67 women died from a ruptured ectopic pregnancy.

CEMACH did not identify the role of independent midwives as any type of risk factor in maternal deaths.

Independent midwives have premiums of £15k pa to provide the sort of care SOME mothers prefer.
There are only 200 or so practising in the UK.

Despite the change in legislation homebirth will still be provided by midwives, but only those employed by the NHS - in these circumstances the employer accepts vicarious liabilty for any adverse outcome.

I'm sure there will be a vast improvement in NHS maternity services once this last handful of dedicated practitioners has been squeezed out of the market.

the A&E Charge Nurse.

Not Saussure said...

I'm not completely convinced by the argument that there being no insurance for independent midwives means they must be a particularly bad risk.

Insurance, as you say, is a reasonably well-informed bet. So if you're not familiar with area, you'll tend to stay out of it. Is there sufficient data available for the underwriter to decide what sort of risks he's taking on if he insures independent midwives for home births? As you rightly say, if something goes wrong, he's going to find himself paying out rather a lot of money, so if he's not sure -- because the data isn't available, or the market doesn't look large enough to make it worth his while researching it -- he'll be best advised to stay out of the area.

There's a second, related, problem. In some ways, the insurer is more akin to a bookie than to a punter, in that if he's doing his job properly he'll be able to cover his pay-outs from the stakes on bets (insurance policies) on which he doesn't have to pay out, and still turn a profit. In consequence, since he knows he's going to face a massive pay-out if something goes wrong, and he's only got a comparatively small number of independent midwives to whom he can sell his policies, he's going to be forced to charge them pretty enormous premiums to cover himself.

I mean, if I start insuring independent midwives and work on the basis I'm only likely to face one claim a year for something going so badly wrong that the child will need nursing care for the rest of its life -- no other claims at all, only that one -- that is a very expensive annuity I'm going to have buy for that one child a year. We're talking several million pounds, at least.

I've got loads of newly-qualified drivers, most of whom won't plough their car into a lamp post, though I know a lot will, to whom I can sell policies, and thus spread my potential liabilities. Among how many independent midwives am I spreading the risk?

Anonymous said...


You're talking rubbish.

People like you cut and paste "evidence" from websites and think it looks impressive. Unfortunately you're arguing with people who know how to analyse papers. Your "evidence" is nothing of the sort.

As you're a lawyer, you know little about quality of statistical studies. The studies you quote are horribly biased.

Here are some good studies:

Hodnett ED, Downe S, Edwards N, Walsh D. Home-like versus conventional institutional settings for birth. Cochrane Database Syst Rev 2005; (1): CD000012. DOI: 10.1002/14651858.CD000012.pub2.

Major finding: Midwife care almost doubles risk of perinatal death (despite having obstetrics units nearby).

Gottvall K, Grunewald C, Waldenstrom U. Safety of birth centre care: perinatal mortality over a 10-year period. BJOG 2004; 111: 71-78


Risk of death doubled in primigravidae.

Risk of death trebled in those midwives who were independent.

Risk of death in labour multiplied almost 7 fold.

This is despite transfer of cases to the hospital when problems arise.

A link about a leading independent midwife.

Independent midwives are banned from the majority of London teaching hospitals following reviews of their "care". My own experience with them is that roughly half are good practitioners. The other half are despicable and I wouldn't let them look after a dog for the day.

By talking about Northwick park you show your ignorance. The governance of hospitals is a separate issue. There are numerous regulatory bodies involved that can take action and did. Are you aware that it was doctors blowing the whistle? Not your esteemed midwives. The main problem was closing down an adjacent unit without proper planning for the increased workload at Northwick. This exposed the weaknesses in staffing & accountability there.

Because of you and your politically correct friends, 60 maternity units will close to provide birth centres and home births. Many more midwives are needed and haven't been recruited. Inevitably the ones they get will be inexperienced.

Because of peoploe like you, Northwick-like problems will become common. There are potentially 60 Northwick's pending.

Independent midwives have one regulatory body, which only gets involved when there's a complaint. The next step is the criminal law which doesn't protect the fetus. Don't you know this? Women choosing indies are often "odd" and won't complain even if there's a disaster. 2 breeches died last year at homebirths in London. Did you hear anything about them? When indies go awry there is nothing to stop their practice short of a maternal death and the involvement of the police.

So do some proper research and start fighting for proper staffing in NHS hospitals. Indies are not worth anyone's time & effort. The good ones are needed in the NHS where they can look after many more women and pass on their skills. The rubbish should choose another career.

Drop the homebirth nonsense, get some savvy, and start protecting women and their babies from misinforation and potential death.

Antigonos said...

There can be no comparison between the professional State Registered Midwife, known as a Certified Nurse Midwife in the US, and the "independent" or "direct entry" midwife who simply does not have the same education as the professional midwife. In fact some "independent" or "direct entry" midwives have NO MEDICAL OR NURSING EDUCATION WHATSOEVER. Of course they are uninsured! They are practicing medicine without a license (which I thought was a crime).
As to the safety of home birth over hospital birth, there are a whole raft of variable factors, ranging from the type of patient, to the state of the hospital, the availability of emergency backup for home emergencies, distance to the hospital, whether the nearest hospital is a consultant unit, and so forth. The current situation isn't black and white. There is undoubtedly a category of women who cannot possibly deliver a live, healthy baby and survive the delivery at home. There are some women who could easily deliver at home unassisted and go hoe the garden an hour later. Most women, however, fall inbetween these two extremes, and what appears to be lacking is viable, medically acceptable, esthetically acceptable CHOICE. It's not just comfort, or high-tech, or lots of staff,or freshly painted units, etc. It is a combination of factors.

Anonymous said...

Oh, and those 2 studies quoted above are in LOW RISK women. God knows what the risk is in those having homebirths who aren't low risk.

Dr Aust said...

As a middle-aged biomedical scientist, husband of a doctor who used to do obstetric anaesthesia, mate thereby of sundry assorted doctors and heathcare types, and also father of a bouncing 3 yr-old, can I make a few points.

- I have never ever met a doctor (male or female) who would opt to have their baby at home. Not cultural hegemony, not anti-feminism, not techno-fascist anti-holism. The reason they all give can be paraphrased as: "not worth the risk just in case the shit hits the fan".

- all but one of the people I know who have had home births did it that way primarily out of ideological fervour.

- none of our acquaintances who wanted to have home births really understood the risks they were running, as far as Mrs Dr A and I could judge. They were making a choice, yes, but a choice based on a bedrock view that could be summarized as "But having a baby is completely safe, the doctors are just scaremongering"

To illustrate all three points, I knew one intelligent and highly alternative couple who had had one pre-eclamptic pregnancy and ended up in hospital. For their second baby they were utterly determined to have a home birth. Understandably given the high risk of a second pre-eclampsia (1 in 5 or maybe more), with possible threat in such event to lives of mother and baby, the Obs and Gyne people thought they were stark raving bonkers and flatly refused to sign off on it. Doctors are trained to be risk-averse, and quite right too. My alternative friends just didn't get it. They wanted a home birth because the hospital experience first time round had been miserable and frightening. Also quite understandable, but misguided from where I stand. Why would you take such an unnecessary risk?

My worry about Independent Midwives would be that some of them would encourage and enable a couple like this in their poorly thought-out risk-taking. You could call it choice. I would call it "rolling the dice".

As Dr Crippen has pointed out on his blog, and people have said here, giving birth is dangerous. Serious complications are thankfully rare (evolution is smart that way) BUT if it does goes really wrong it can happen in minutes. Unless you have full obstetric/paeds "flying squad" crash resuscitation team who can be with you within minutes, doing it at home is taking a risk you don't have to take. Saying "but if you're at home we can call an ambulance and rush you in" is something, but it is slower than being in the hospital. Also, your midwife can't call the doctor in for a quick opinion and a 2 min conference when they are just starting to worry. Again, might not matter. But it might.

Mrs Dr A and I opted to have our daughter in a midwife-led Delivery Unit at the local NHS hospital, BTW. Same excellent midwife all through, didn't see the doctor until junior was out and wailing. The point is that midwife-led care is great, but we were clear that we wanted to know there was full on-site medical back-up IN CASE IT WERE TO ALL GO PEAR-SHAPED.

Anonymous said...


Original anom here. Just getting back to you regarding home vs hospital births safety. It's been interesting to look into this. Again I stress that I'm not pro or against home or hospital birth. My main point is that hospital births should and could be a lot safer if properly supported. I found some interesting links: and Basically no evidence there that hospital births are safer. It would be good if you could provide information to that effect. It would benefit the debate. Indeed women and their families need to know what is best and safest as proven by decent research. In response to another comment from another anon. If you read my comments properly you'll see that I do campaign for better care and resources on the NHS. I feel very strongly about this. Having haemorrhaged in my own living room following substandard NHS midwife based care in a supposedly good teaching HOSPITAL, I feel that criminalising independent midwives via PII won't help the current crisis. Better management and resourcing will. Independent midwives are governed by the same supervision as NHS midwives.
This is my last posting so to conclude:
Pregnancy and childbirth carry an inherent risk which sadly cannot be completely eliminated.
One-to-one continuous care has been shown as the gold standard of maternity care. With a couple of exceptions this, is only available across all regions via independent midwives.
There is no sinister terrifying risk reason why independent midwives cannot currently get insurance. This is due to the fact that they are a small group and the potential payout in an obstetrics claim is extremely high - it does make sense financially for insurers for this small group. NHS can get insurance due to economies of scale.
In terms of research, most of the studies suggest that home births are just as safe if not safer than hospital births for low risk pregnancies.
In terms of independent midwives only being for rich or 'middle class' women. This isn't actually the case. Many independent midwives take on cases free of charge for people who can't afford to pay. Indeed I know one IM who as a general rule does not get paid for her work. If someone is attended by an IM it lightens NHS midwives' caseload - benefitting other women.

I hope ultimately independent midwives will get insurance. This is looking quite likely. For anyone who wants to see the 'gold standard' of one-to-one care available on the NHS, then please sign the one mother one midwife petition.

For women, men and babies let's all work to make sure that better care is made available to all.

Canker said...

Amazing hot air. I thought that the home-birth issue (as against the independent midwife issue) was sorted out years ago!
There is good international evidence (including an earlier Cochrane review) that managed home births by qualified midwives have lower perinatal mortality.
The reason is obvious. It's medical risk-aversion which leads to over-enthusiastic intervention.
Medics and lawyers never seem to get this idea. No matter how many times I've tried to patiently explain that interventions carry their own risks and if they are made too frequently/lightly the balance of risk will favour the `non-intervened against, they say silly things like the earlier commenters on this post like `in case it were all to go pear-shaped'. To which the answer is `if you have been assessed as low-risk, then the most likely source of pear-shapiness is a medic with itchy fingers'.

Now, if you really care to take this issue seriously, you might, for example, look at the the Northern Region Perinatal Mortality Survey published in the BMJ.
Of the (1986-1993)
3466 home births, the perinatal mortality was 134!
At first sight this confirms the wisdom of hospitalisation.However,
131 of these deaths were in cases where the birth was not planned to be at home or where there was no plan for delivery at all (i.e. the pregnancy had either been concealed or not diagnosed)!
The remaining rate for planned home births was far better than the average in the low-risk group.

You might also look at the NBTF enquiry, which attempted (but failed) to form matched (by risk factors) pairs of low risk (planned) hospital and home births. Probably the most important conclusion of the enquiry (apart from the lower rates of infant mortality and morbidity and of caesareans and other interventions in the home group) was that `home births will probably increase to 4 or 5% of all maternities in the UK over the next decade and this needs preparatory planning’!

Anonymous said...


Sterling efforts. But there is not point in trying rational argument with independent madwives. They do not understand. "Negligence does not apply to them"

Ho Ho

The truth of the matter is:

"When an independent madwife comes in at the door, science goes out of the window"


Martin said...


Of course home births are more dangerous than hospital births. And not smoking is safer than smoking.

My point was and remains that if a woman wishes to give birth at home, she should be free to do so. I am also in favour of her right to choose to terminate a pregnancy within a humane timeline. I believe this is consistent with mainstream libertarian thinking in the US; I see no reason why it should be inconsistent with libertarianism in the UK.

I also advocate legalisation of all drugs, including Class A narcotics, which could again be used by a pregnant mother to the detriment of her unborn child. I think you must trust people to make their own determination of acceptable risk. Treat people like adults instead of infantilising the populace as the Tories, Labour, Democrats, and, to a lesser extent, Republicans do.

The involvement of a minor (baby) is neither here nor there, as the mother is co-responsible for all decisions potentially affecting the child's welfare until he or she is 18, including whether or not to have immunisations and other possibly life-or-death medical treatment.

I would not advocate home delivery in a high-risk pregnancy, but most births are routine and pose no risk to mother or child. If a mother wishes to deliver at home, I see no reason to empower anybody to de facto prohibit it, least of all the fucking government.

Spirit of 1976 said...

Anyone who thinks independent midwives are a good idea should have a look at this case:

A few extracts:


A NEW age midwife has been cleared of hindering paramedics trying resuscitate a baby during a home water birth in Edinburgh.

Ambulance staff claimed Beatrice Carla, 55, massaged the infant's feet with olive oil and administered herbal remedies while they tried to perform life-saving CPR. The baby, which was not breathing when born, survived but suffered brain damage.

The conduct and competency hearing in Edinburgh yesterday found it was not proved that Ms Carla had got in the way of paramedics

However, the qualified midwife admitted nine counts of failing to keep adequate notes and could yet be struck off.


However, the ambulance staff have evidence described her care as "inappropriate". They claimed she did not use the standard bag and mask device midwives are trained to use. Ms Carla said she had tried to use the device but was unable to create a vacuum around the baby's face.

Paramedic Ross Edwards told the hearing he saw Ms Carla stick her finger in the baby's mouth and apply a powder to it's gums while he was trying to resuscitate it.

And the two other ambulance staff told how they witnessed Ms Carla massaging olive oil into the baby's feet while they were battling to save its life.

Mr Edwards told the hearing his team successfully managed to "bag and mask" the infant, who he said almost immediately turned a much healthier pink colour.


Lousy record-keeping, inability to use basic CPR equipment, and to top it all she gets in the way of paramedics who are resuscitating the baby properly to apply quack complimentary therapies.

This is pretty much the kind of worst-case scenario that Katy Newton is predicting. A bad permanently brain-damaged by an incompetent madwife, and no insurance for the family to claim compensation to pay for the lifelong care package that this child will now need.

Katy Newton said...


If you look at the IMA's website on saving independent midwives, you'll see that one of the reasons they say independent midwives are good is precisely because they offer a "normal birth" (which, as most hospitals will not permit independent midwives to deliver in them, means home birth in the vast majority of cases) to women who are classed as high-risk.

Anonymous said...

Spirit - Geoffrey Hodgkins died in a psychiatric ward after being restrained by staff for 25 minutes The Independent report that followed made for grim reading.
Hodgkins, a heavy smoker and an obese man, was held face down until he suffered an arrest.

The lessons of the Bennett inquiry clearly had not been learned and as you know none of the RMNs involved in the restraint of Rocky Bennet faced prosecution for his death.

NICE recommend RMNs who administer rapid tranquillisation should be ILS approved [Immediate Life Support], to Resus Council UK standards. Those performing restraint should have received BLS [Basic Life Support] training.
I wonder how widely these recommendations have been implemented ?

I can remember being terrified of the 'crash box' when I was in charge of the psychiatric ward.
I would look at the laryngascope, ET tubes and bag & valve mask in much the same that the Incas must have done when they first came across the conquistadors.
Back then I knew very little about the difference between a VF or EMD arrest.

So, a question, is it fair to lambast ALL of the independents due to the gross negligence of one muppet ?
It would certainly be worthwhile to know how they compare to their NHS counterparts when it comes to paed or adult resuscitation skills.

But, until mothers decide to stop birthing at home we still have to rely on midwives when things go wrong [because they undoubtably will sometimes].

As I mention above CEMACH did not suggest that independents pose any additional risk, neither was there any reference to them being inadequately trained [as a group] when it came to resuscitation [unlike the RMNs in the cases cited above].

Anyway, if midwives are so crap perhaps the docs would like to take over homebirthing, either that or the job of dragging hordes of protesting, and heavily pregnant women to the nearest maternity unit [providing there is a bed available to admit them, of course].

the A&E Charge Nurse.

Katy Newton said...

A&E Charge Nurse, from reading what the docs say above I don't think they want to take over home birthing at all; I think they would prefer it not to happen, because it is far riskier than birth in a hospital. I don't actually think that's in serious dispute, to be honest. And I have to say, I don't think most women choose home birthing anyway, as the statistics you quoted (I think it was you, but I am losing track) show. Also, if you'll forgive me for going anecdotal, not one pregnant woman I have met in the last 30 years has considered giving birth at home. They all wanted to give birth in hospital so that there's proper support if it goes wrong. I don't know who these radical home birth activists are, to be honest, because I haven't met any.

Anyway, to reiterate my main point. The fact is that I personally don't have a huge amount of faith in independent midwifery, because to me encouraging/enabling women classed as high-risk to give birth at home under the guise of "women's choice" demonstrates huge arrogance and lack of responsibility. But that's by the by, really. It isn't about "if the midwives are so crap", and it's driving me nuts that people are conflating insurance and competence. They are completely separate issues (well, not for an insurer, but certainly for the purposes of this topic). Insurance isn't there to protect crap people who shouldn't be practising in the first place. It's there because we're all human and everyone makes mistakes or loses concentration at work. It's natural. The problem is that if you happen to be in a profession where pretty much everything we do involves someone trusting you with their life, their health, their children or their income, then any mistake you make, no matter how understandable - as negligence frequently is, objectively - can have serious and expensive consequences.



is where the insurance comes in.

Anonymous said...

Thanks Katy - I'm a bit lost, OK I'm probably a bit dim as well, BUT, I don't think anyone is advocating that midwives practice without insurance ....are they ?

As you know insurance arrangements for the indies changed in '94, when the RCM pulled the carpet, which meant they had to find a firm willing to underwrite the risk, they did, to the tune of approx £15k pa.

Now the indies are to lose this one and only insurance source, making it impossible for them to idemnify their practice.

So, what will change, a small group of very experienced midwives will not be able to offer home births.
Remember there 18,862 registered midwives [2006 figures] although this number is falling as well, of these around 200 are indies.

Great, shout the docs, 'when an independent madwife comes in at the door, science goes out of the door'.
A corollary being mothers wouldn't consider birthing at home at all if wasn't for these mad bints, such is the capriciousness nature of these gullible women, it seems.

Well, maybe, but until that day arises, and it seems unlikely it will soon given that 'choice' is enshrined in official policy, I ask again how does taking the indies out of the equation improve services ? [assuming we are talking about home births].

the A&E Charge Nurse

Katy Newton said...

No no no no - they HAVE lost cover. They lost it in 2002. Independent midwives have been practising without insurance since 2002 and the Government now plans to make insurance a condition of practice for several professions, including midwives.

Martin said...


Then we are in agreement. Any mother classed as high-risk who chooses to deliver at home is making a poor decision. I wouldn't go so far as to deny her that choice, but I'd strongly advocate against it.

Anonymous said...

Katy, thanks for the clarification, my understanding was that the change was ABOUT to occur.

Practising without insurance is indefensible, period - maybe an independent midwife could comment if this is actually the case or not.

I'm an Emergency Nurse Practitioner [as well as an opinioned C/N], the Trust accepts vicarious liabilty for my work, although I have a personal policy with the MDU [sorry, docs, even they can't resist the ENP shilling].

I suppose some of the commentators on this thread will be glad to see the back of the independents, whether or not this actually makes homebirth any safer is another matter entirely.

the A&E Charge Nurse.

Anonymous said...

Independent midwives cannot get insurance because they are such a small group, not because they are dangerous. They fully inform women of this and the implications. They are all qualified, registered midwives.

You give an anecdote about a tragic case involving an Indie and we are supposed to listen. I could quote the MRSA case recently where a baby died unecessarily or talk about Jessica Palmer, the young mum who died tragically through lack of care in the NHS or about the midwife who was struck off last week (again NHS) for assaulting a woman.

But anecdotes as we know are "bad science". It is fine for Crippen et al to quote sensationalist articles from newspapers in outrage against the "mad-wives" and in the same breath say that science goes out of the window when an indie walks through the door.

Competing interests:

Used an excellent IM for last 2 births
1st birth so appalling and dangerous that no amount of insurance cover offered by the NHS would ever convince me or my partner (also a lawyer) to go back there.

Spirit of 1976 said...

You give an anecdote about a tragic case involving an Indie and we are supposed to listen.

Of course! The issue isn't whether or not it's a typical anecdote. The issue is what happens when such cases arise. Hence the "bad science" comment completely misses the point. But then those defending independent midwives here seem to be missing the point completely over the course of this thread.

The point IS when such a case arises, THEY AREN'T INSURED! That's the dfrdifference between an independent midwife and any other clinician who behaves incompetently.

How many times does this point have to be made before the IM-defenders actually grasp what the problem is? They! Aren't! Insured! How about if I repeat it backwards? Insured Aren't They. In pig-Latin? ey-they n't-areay sured-inay.


Anonymous said...

We KNOW they are not insured yet women like me (a lawyer) still choose IMs over the appalling, disastrous care in the NHS. I feel safer with an uninsured midwife by my side than an insured institution which leaves me ALONE in labour with a 1st year petrified STUDENT midwife delivering my first baby without ANY supervision.

I will repeat for you.


Anonymous said...

Anonymous at 08:49,

Perhaps we can all agree that insurance should be a MANDATORY device to protect patients - we all know mistakes happen whenever there is scope for human error [or negligence, etc].
Labour, as you know, poses particularly dangerous risks.

I have no doubt that none of the indies would argue otherwise. The problem is they are being shut out of the market, despite being around for many years - and despite the lack of substantial evidence that NHS midwives are any better when it comes to homebirth.

If we simply ask should ALL health professionals be insured, there would be a resounding 'YES', but this would make for a very short [and dull] blog.

No, I suspect what we are really getting excited about is home verses hospital births, and the inevitable polemic that follows in its wake.

On the one hand we have the hospital lobby armed with evidence to prove that they offer the safest care STATISTICALLY - of course, this is no guarantee that your baby will not be the one in 1/2 million to contract and die from MRSA [if we accept recent media reports]. There are no guaranteed safe options, as all prospective parents know, when it comes to birth.

Even so, a percentage of mothers have always birthed at home, and while it is legal, some still prefer this environment to hospital.

Maybe the anti-home birth lobby fear that the indies are misleading mothers, and are rather pleased that another door is being shut when it comes to maternal choice [because of their convictions that statistically hospital is the safest place to have a baby].

The activities of a few fringe loonies has been used to demonstrate what an unrealistic and unreliable bunch these indies are, the problem is, we then hear diametrically opposed accounts, such as yours, about how brilliant the independent midwife was [although it is impossible to condone practising without insurance].

I'll bet if the RCM wanted to sort this insurance mess out they could - either stand by the indies or prove the anti-homebirthers correct to characterise them as dangerous liabilities.

the A&E Charge Nurse.

Canker said...

Why do you think the `home birth is far more dangerous than hospital birth thing' is `not in serious dispute'. Speaking as a statistician who has given talks about this very issue, it's very much in dispute. The medical profession has been trying to shut that dispute down for 70 years using exactly the same tactics as you have just deployed and it's disgusting and highly reprehensible.

Did you, by any chance check up on the papers I recommended above? Did you check on the Dutch experience (where 40-50% of births are still at home and the perinatal mortality statistics are better than in the UK)?
Like hell you did. You just advanced the same old tired crap that the medics have been using since the 1930s.
Get with it! Doctors kill and maim by unnecessary intervention. And that's sad but inevitable. The questions is, `how much'? And I don't mean `what damages can you get'.

I know nothing about the competence of independent midwives, but you interleave your complaints about them with highly dubious attacks on all home births and that's the worst form of political manipulation. As such, your remarks really don't belong on this blog. Or have I completely midunderstood its spirit?

Katy Newton said...

Canker, my post is about is about





My opinions about the competence of midwives are backed up by research and I do not think you will find any study which says that in this country home birth is safer than hospital birth. But that is by the by because we are talking about


which is a different issue from competence.

The spirit of this blog is libertarian. Until Mr Kitchen decides to take my post down, it's staying. He won't, because as a libertarian he believes in freedom of speech. Clearly you do not, or you wouldn't have said anything as asinine as "your remarks don't belong on this blog". But do feel free to make any representations to him that you want.

Canker said...

You misunderstand me. Or misrepresent me. I intended to imply that the style of your post was not in the spirit of this blog but no matter.
How many times do you have to be told about research which shows exactly what you have, yet again denied?
I've pointed you at two studies which show exactly that `home births are safer than hospital births' for low risk births.
Surely that's the issue as far as the risk of home births is concerned? Yet you say again that you `do not think you will find any study which says that in this country home birth is safer than hospital birth.'
Incidentally, I was unaware that insurance was a prime libertarian issue, at least in those bald terms.
You also choose to completely ignore my comment about apparently deliberately interleaving two distinct issues. You conflated the issues yet, when I attempt to address the second, you claim that you're only talking about the first.

Chairwoman of the bored said...

Canker - What's the matter, not enough swearing?

Katy Newton said...

I've pointed you at two studies which show exactly that `home births are safer than hospital births' for low risk births. Surely that's the issue as far as the risk of home births is concerned?

1. I have also been pointed to studies which show the opposite by other people in this comments box, so you'll forgive me for not accepting your statistics as intrinsically better than anyone else's.

2. How many of the home births to which you refer were conducted by independent midwives as opposed to NHS midwives?

3. You appear to have missed the point that independent midwives encourage women classified as high risk to birth at home. I notice you don't provide any statistics for that.

4. Do you suggest that your Dutch study is representative of the situation in England?

5. Am I right in thinking that your statistics do not include analysis of problems in birthing resulting in non-fatal injuries for mother and/or baby?

Katy Newton said...

Incidentally, I was unaware that insurance was a prime libertarian issue, at least in those bald terms.

I have no idea what that sentence is supposed to mean. Seriously.

Libertarians can't talk about insurance?

Insurance is intrinsically unlibertarian?

Anonymous said...

Katy - when you say your post is about *sigh* insurance.

Is this simply a reference to the undesirability of clinical practice without it ?
Because if that's all you are interested in then I'm sure we can we can ALL agree that, yes, practising without insurance is unacceptable, and finally put the matter to bed.

On the other hand if you are alluding to the motives underpining this draconian change, such as the thesis that indies are baby eating incompetents, then Canker is absolutely right to comment on the wider cultural and historical context - personally I have found his/her contributions very enlightening.

Sorry if thats inconvenient, but I suspect these associated issues are the main reason for most of the interest on this thread.

yours, as ever, the A&E Charge Nurse

Canker said...

1. It's not about voting (`my stats are as good as yours' is the argument of the playground-read the papers and consult a professional statistician if necessary) it's about the quality (and in particular the quantity)of the stats. Moreover, they are not `my statistics'. You won't find much that's bigger (in the UK) than the Northern Region Perinatal Mortality Survey. Of course if you really want big and convincing you need to turn to a country which hasn't tried to eliminate home births, like the Netherlands.

2.As I've repeatedly said, I know nothing about independent midwives and if you'll stick to that topic alone, I'll shut up. But you haven't.

3. See 2. I agree 100% with your implication. Encouraging high-risk births at home is insane. You're right, you're right, you are absolutely, 100%, right.

4. I do not suggest that `my Dutch study' is representative of the situtaion in England. In several ways it clearly isn't. However, there is equally no evidence that similar benefits would not be enjoyed if the UK switched to encouraging low-risk home births and significant evidence that it would. It's a bit hard to tell because the medial profession is still doing it's damndest to make sure that a minimal number of low-risk home births happen.

5. No, you are wrong.
Mortality is what I quoted but the studies show markedly decreased rates of perinatal morbidity for babies and mothers.

6. Of course libertarians can talk about insurance as much as they like. I'm all for it. Carry on. It just didn't seem to me to be a libertarian issue like, say, being allowed to pay for private medical care.

Anonymous said...

I know that you've said you haven't yet had kids yourself,but do you know any women who have recently (last 3 years approx) given birth in a UK hospital? Even if you don't know anyone who has can you please give us all your perception of what a hospital birth would be like? I know this sounds slightly odd, but we all have expectations/preconceptions, so if you were going to give birth soon, what would you expect to happen in terms of care?
Also let us know how much antenatal care you would expect on the NHS and postnatal care both in hosptial and once you are back home?

Katy Newton said...

Well this is purely anecdotal, and therefore not statistically relevant, but I know twenty three people who have given birth in the last three years, of different backgrounds and economic means. They all gave birth in NHS hospitals and they were all satisfied with the care that they received.

I don't suggest that this means that no one ever had an unsatisfactory experience in hospital, mind. But I don't know anyone who wanted to give birth at home.

Amy Tuteur, MD said...

First of all, there is not a single paper that shows homebirth to be as safe as hospital birth. Sure, there are papers that CLAIM to show that homebirth is as safe as hospital birth but that's not what they show. They rely on invalid and deceptive comparisons. So, for example, the Johnson and Daviss study in BMJ 2005 that claims to show that homebirth is as safe as hospital birth actually has a rate of preventable neonatal death at home that is more than 3 times HIGHER than a comparable group of women giving birth in the hospital that same year.

You can't find that anywhere in the paper, though, can you? That's because the authors knew that their findings showed that the neonatal death rate at homebirth in 2000 was 2.6/1000 (including congenital anomalies) and the neonatal death rate in the hospital for low risk white women at term in 2000 was 0.7/1000. Therefore, the authors blithely (and inappropriately) compared the neonatal death rate at homebirth in 2000 to the control group death rate in a series of out of date homebirth studies, some more than 20 years old.

Read the actual studies, do the calculations and you will see what I mean. There are no studies that show homebirth to be as safe as hospital birth. That's what NICE pointed out in their recent report on antepartum care. According to NICE:

"Our best broad estimate of the risk is an excess of between 1 death in a 1000 and 1 death in 5000 births. We would not have expected to see this, given that in some of the studies the planned hospital groups were a higher risk population."

As regards the reason why independent midwives cannot get malpractice insurance, their own statistics demonstrate why they are considered too much of a risk.

Let's look at their most recently published neonatal mortality statistics:

In 2003-2004, they cared for 337 women who gave birth to a total of 347 babies. Both the stillbirth rate and the neonatal death rate were quite high.

There were 4 stillbirths, 2 were intrauterine fetal demises of unknown cause, one was the result of rupture of a C-section scar and the fourth was due to hypoxia. The overall stillbirth rate was 11.5/1000.

There were 4 neonatal deaths among 343 livebirths. Of the 4 deaths, 2 were due to respiratory distress, 1 to hypoxia and 1 to genetic anomalies. The overall neonatal death rate was 11.7/1000.

The stillbirth neonatal death rates were very high. What is most interesting is that half the stillbirths and 3/4 of the neonatal deaths were due to potentially preventable causes.

This data is valuable, but the dataset is so small that it is difficult to draw conclusions. However, it is yet another homebirth dataset that shows that homebirth has an excess of preventable neonatal death.

Anonymous said...

A= A

Whatever the home vs hospital argument, she is NOT to be taken seriously. The woman is a crazy! She is an EX doctor (not practised for many years) who is utterly, totally, unhealthily obsessed with homebirth. She is a dire statistician to boot and needs to get a life.

Anonymous said...


Interesting points Amy, much appreciated. I also take your point about the IM sample size being too small to draw valid conclusions.

Katy you haven't actually answered my question as to what you would expect for yourself.

I'll share some of my experiences with you and Amy. I've had both my kids in the last 3-4 years in NHS hospitals. For my 1st baby I would say the antenatal care was good, appointments quite short and sweet, but I was low risk - happy with this. NHS antenatal classes also good. The only thing was at this stage it seems that as soon as you are pregnant, regardless of what you've done or achieved etc, you are treated like a 'brain donor'. A minor point though. Once I went beyond my due date and my care was transferred to hospital things changed. I came under loads of pressure was talked down to and in the end I agreed to be induced. There were no problems for me healthwise or for my baby. Basically, the whole induction thing was mismanaged, the unit was short staffed, I wasn't listened too at all. Postnatally, I felt really unwell and sought help on 8 occasions and my concerns were dismissed. To cut a long story short I nearly died as a result of the negligent care and my complications reached crisis point at home following discharge from hospital and I had be re-admitted to hospital, where the rubbish care continued. I decided not to sue the hospital.

For my second baby, I did my homework, took advice and decided I would book at a highly regarded hospital specialising in high risk pregnancies further from my home. Although my GP told me my pregnancy was not high risk. GP offered to get me a C section on the NHS - didn't fancy this. I identified the main problem with my first delivery was lack of continuity of care on the midwifery side and the fact I got all students or newly qualifieds. I wanted to avoid this again. In fact I couldn't bear the thought of having this type of care. I read that continuity of care IMs offered this. I checked their website, but didn't fancy a home birth. It just didn't feel right for me. I then found one IM who also did hospital births in my area. I felt if I was going to go outwith the NHS with an IM, I had responsibility to make sure I was going to under the care of someone competent. I did my homework on her - checked out brilliantly. I met with her and I was extremely impressed. She did my entire antenatal, labour and postnatal care (delivering my baby in hospital). The birth WAS insured via the hospital. This service is now under threat and I cannot understand why. It was an eyeopener to have good midwifery care. She arranged a number of additional checks/tests for me which I know I wouldn't have had if I had had an NHS midwife.

Whilst I had a bad experience on the NHS with my first child, I needed an IM with me to enable me to go back to hospital. I personally understand why women feel they cannot go back to hospital. In many cases IMs are providing care for women who would actually avoid care all together and yes many of these women will be high risk. IM care for these women is safer than them avoiding care all together. .

Amy Tuteur, MD said...

Anonymous 10:16,

People tend to get confused on this point. Hospital birth is SAFER than homebirth (especially for the baby). That does not mean that hospital birth is perfect. It does mean, though, that even when you include incompetent hospital care and even when you include malpractice in the hospital, the hospital is still safer than home.

There is no reason to believe that incompetence and malpractice are any less common among midwives than among physicians. Indeed, the claim by an independent midwife that negligence is not a problem for them shows that it must be a very big problem. If you are in such denial about the fact that midwives are simply human beings like everyone else, you cannot possibly recognize or acknowledge negligence when you see it.

As I said above, the statistics offered by the independent midwives themselves do not represent a large enough group to draw firm conclusions. However, it is important to understand that the neonatal death rate indicated by the midwives' own data is 5-10 times higher than the neonatal death rate in the hospital for low risk white women at term.

I, too, can understand why women don't want to go to the hospital. What I cannot understand is why they do not go anyway. Over 96% of women in the UK put the safety of the baby over their concerns about how personably and supportively they will be treated.

The bottom line for this discussion though is that independent midwives cannot get insurance at a price they cannot actually pay because the insurance company cannot make a profit that way. The risk of death at homebirth, the risk of subsequently being sued, the risk of losing that lawsuit, and the risk of a large financial judgment arising from the loss are all so high, that the midwives literally cannot afford to pay the price that is necessary for the insurance company to compensate for the financial losses they incur.

Insurance companies will ensure anything. You just have to pay them enough to cover their losses. Independent midwives cannot do that because their financial losses are so great that they cannot afford the payments required to cover them.

Anonymous said...


I think you've identified this issue regarding the safety of the child. Those women who are avoiding hospital do so because they believe they are safer at home. They are putting the safety of their baby first. No one actually has more to lose in the situation than the mother - really think about that. However they do believe they and their baby are safer at home. That's the nub of it. Now whether you agree with this or understand this, then that's different. Now I haven't had a home birth and I'm not sure I would intentionally have one, but I think there are conflicting data on home vs hospital some favour home and some favour hospital, so who are we to dictate to other women? Indeed the UK government wants to give all low risk women the option of a home birth on the NHS and they are prepared to insure this. Why? They must be going with the research which backs homebirth for low risk women.

What I would like to see happen isthe following:
Clean maternity units
Proper staffing levels (doctors and midwives)
Abolition of the new NICE guidelines on antenatal care which has cut the number of check ups for women by almost 50%
Proper post natal care
If women want to - the option of a home birth if appropriate for them.

What is probably going to happen. Worst case scenario. Women pushed into homebirths because they are cheaper. These homebirths won't be propery supported because.. there aren't enough midwives and the independents are no longer available. When panic ensues, guess what not enough Obstetricans either!

Katy Newton said...

I have lost track of the anonymouses here, but I would have no objection to independent midwives delivering babies in hospitals where they are covered by insurance and where obstetric support is more easily available if things become complicated. I understand that most hospitals do not permit independent midwives to do that.

Anonymous said...

A new anonymous coward speaks...

I had a home birth. I wouldnt quite describe myself as a raving lunatic, or as some kind of radical. My decision was made after much consideration. Some of the factors I took into account were as follows:

1. I was having a low risk pregnancy (if I had not been low risk, you couldn't have kept me away from the hospital).

2. I wanted to, as far as possible, allow the birth to progress naturally.

As I understand it, stress inhibits the production of birth hormones. As I was classed as a low risk (I'll stress that again, low risk) pregnancy, I felt that for me, it would be less stressful to at least start my labour at home, with the option of heading to hospital if I (being fairly bright, reasonably well informed and accompanied by at least one qualified NHS midwife) felt at any time that I needed to do so.

For what it is worth, at one point, I very nearly did head in. This was after we had called the NHS midwife with the news that my contractions were stronger and closer together and she hadn't materialised after an hour. She knocked on the door just as my other half started talking to the hospital (I was almost 5cm dilated by the time she showed up..but I digress...)

As it happened, the birth went well, and my daughter arrived safely at home with no medical intervention at all until the third stage. (I really wasn't interested in delivering a placenta naturally or otherwise.) But the whole thing progressed rather faster than the midwife was expecting, so I wasn't even able to take up the option of gas and air.

As for independent vs. NHS midwifery, I can't comment. My care was NHS all the way, and I have no real complaints. Continuity was not what it could have been, but I moved house half way through so at least some of that is my own fault.

I was also very lucky, and the midwife who had been looking after me after my house move was able to be there to deliver my baby. I realise this is not always the case.

I suspect that when you are in transition, you could have Atilla the Hun delivering your baby and not care all that much. But it was nice to see a familiar face.

If I was to do this again, and was again classed as low risk, I think I would (if I could) employ an independent midwife to work alongside the NHS, for prenatal care as much as for the birth.

But if I was rated anything other than low risk, I'd happily transfer myself to the care of a full, doctor led obstetrics team. Although i couldn't promise to be a model patient.

Not sure what that adds to it all, but I thought it might be of interest to all and sundry anyway.

Anonymously yours...etc.

Amy Tuteur, MD said...

Anonymous 1:54,

"Those women who are avoiding hospital do so because they believe they are safer at home."

That is a very serious problem with homebirth advocacy. Homebirth advocacy is based in large part of mistruths, half truths and outright deceptions. That's why it is sadly ironic that homebirth advocates like to claim that they are more "educated" then other women. They are not more educated. Indeed, what they believe they know about childbirth isn't even true.

That's why the insurance issue is so revealing. For better or worse, the insurance industry is only interested in making a profit. They could not care less about what homebirth advocates or homebirth midwives believe. They have elaborate mathematical models of the INHERENT risks of childbirth. They know how the availability of technology modifies those risks, and their models tell them that homebirth is so dangerous as to require very large premiums to cover the losses.

It is important to understand that the issue is NOT that insurance companies won't cover midwives. The issue is that midwives cannot AFFORD to buy the coverage that is necessary to pay for their losses. The willingness to practice without insurance is an ethical issue. Insurance benefits the patient. The decision to practice without insurance means that independent midwives take something away from the patient (insurance protection) in order to preserve profitability for themselves.

Anonymous said...

In the UK, Independent midwives CANNOt get insurance. They want it but cannot get it anywhere. It is not a case that they weigh up the finances and decide it is not worth it for them.It is the IM that risks getting sued personally if something goes wrong. They definately dont want that! When IMs could get insured they paid £20,000 a year for it. After 9/11, the insurance market went haywire and IMs did not even have the £20K option anymore.

Amy Tuteur, MD said...

Anonymous 5:04,

"They want it but cannot get it anywhere."

That's misleading. The midwives are have not said they will pay any price for insurance. They want insurance that they can afford. Insurance companies are no longer writing policies for independent midwives because independent midwives cannot afford the premiums. Either way, the cause is the same. The point is that homebirth is too DANGEROUS for insurance companies to insure at an affordable price.

Anonymous said...

UK IMs CANNOT get PII, at ANY price. this has nothing to do with the safety of homebirth. The NHSLA insures midwives in the NHS to do homebirths. The RCM insures midwives who are employed by the NHS via vicarious liability to do homebirths. Homebirths are perfectly legal in the UK and are considered a safe choice for healthy low risk women. Insurance companies will not insure IMs as there are too few of them to make it financially worthwhile, not because they are dangerous (all are qualified, trained in the NHS and have supervisors of midwives and are registered with the NMC).
Insurance companies could not care less about danger or safety or politics. They are about profit and loss and are businesses at the end of the day.

Amy Tuteur, MD said...

Anonymous 11:11,

"They are about profit and loss and are businesses at the end of the day."

Right. Due to the dangers of homebirth and questions about the compentency of homebirth midwives, insurance companies feel they cannot make a profit insuring them. The midwives cannot pay the premiums that are required so that the insurance company will have money left over after paying out claims incurred by midwives. Moreover, as the statistics from independent midwives shows, to date, the perinatal death rate at homebirth with independent midwives is 5-10 higher than it is for low risk women in the hospital. That is a very serious problem.

You keep claiming that homebirth is safe, but the risk of neonatal death at homebirth is several times higher than at hospital birth. That's what the scientific evidence shows, that's what NICE has concluded, that's what the independent midwives statistics show and that's what the insurance companies have concluded from their own data. There is NOTHING that shows homebirth to be comparably safe to hospital birth, regardless of what other homebirth advocates have told you.

Now you, or other homebirth advocates, may conclude that the excess risk of preventable neonatal death (on the order of 1-2/1000) is acceptable for you. That's your right. However, it is factually false to claim that homebirth is as safe as hospital birth.

Anonymous said...

I am NOT a homebirth advocate, far from it!
I am just an interested bloke (wife had an IM for 2 hospital..she was not insured)

Not getting PII is not because of IMs practice rather the economics of the payouts.Nothing to do with safety! More to do with maternity payouts being always the biggest of all litigation claims as it represents the beginning of life and lifelong care for the damage done. This is well demonstrated in the NHS as Maternity payouts gobble up the most money in litigation cases.

Anonymous said...

You're drawing conclusions from the recent IM stats. This is inappropriate. The sample size is too small. You've said this yourself in your earlier postings and cautioned against drawing conclusions. Why are are you doing this? It makes you look bad and unconvincing. Mmmm, maybe I should have a homebirth!

Amy Tuteur, MD said...

Anoymous 5:04,

"You're drawing conclusions from the recent IM stats."

I'm not drawing conclusions; I am simply pointing out what they are. While it could be a fluke that the perinatal death rate is so high for IM attended births, it is just as likely that IM attended births are even more dangerous than what their current statistics show.

The most important point is that all the existing data are consistent. Scientific studies show homebirth to have an excess rate of neonatal death; NICE has concluded that homebirth has an excess rate of neonatal death; the IM midwives own statistics show an excess rate of neonatal death; insurance companies have concluded that IM midwives cannot profitably be insured because they cannot afford the premiums needed to cover their losses.

No one has yet presented ANY scientific data to show that homebirth is as safe as hospital birth.

Interestingly, the Midwives Alliance of North America (MANA) has been collecting statistics on all CPM attended homebirths in North America since 2000. The statistics for the year 2000 were the ones used for the BMJ paper and they do NOT show homebirth to be as safe as hospital birth.

MANA will not publicly release the statistics for years 2001-2006. They can be obtained by people who demonstrate that they will use them "for the benefit of midwifery" and who also sign a confidentiality agreement not to share the statistics with the rest of us. So MANA is withholding the results of almost 30,000 CPM births. That suggests to me that those statistics show homebirth to be even more dangerous than existing published data.

Anonymous said...

Amy, whatever the rights and wrongs of the insurance issue, please get the facts right. IMs cannot get PII because of being such a small and unprofitable group for insurance companies. The insurance companies are not making judgment calls re danger here, it is just not worth their while business wise. It maybe the case in some states in your country but not here. Remember, insurance companies here cover for homebirths for the 1000`s of midwives who work in the NHS. IMs are not dangerous here, you always get a bad apple in every profession but our IMs are viewed very highly in the UK (except by Dr Crippen but most people dont take his sanctimonious holier than thou blog particularily seriously).
Many IMs are eminent speakers, writers and lecturers, one even has an MBE from Buckingham palace for services to midwifery! They are not all homebirth advocates and many work in hospitals too and are 100% legal all over the UK. They are not like USA "lay midwives"!

Anonymous said...

Concisely and well expressed Anonymous 10:07 - here, here!

midwifemuse said...

As a community midwife, working within the NHS, I would just like to make a couple of observations:-
ANY woman, however high risk, can elect to have a homebirth, no obstetrician, manager, midwife, G.P can prevent that, it is her right. Legally any Trust who has a high risk woman proceeding with a homebirth is required to supply at least one, preferably two midwives to attend the birth. A midwife cannot refuse to attend however concerned she/he may be about the eventual outcome, there is no such requirement on Doctors. On occassions Trusts have been known to employ independant midwives when high-risk women are insisting upon home birth, these would generally be breech births. Why do they do this, because NHS midwives, and doctors no longer have the skills in this type of birth, Indies do.
Continuity of care is often the reason why women choose to employ an IM. 15 years ago all women were given huge promises in Changing Childbirth, one of which was that would have a named midwife. Most women now have a named midwife, but this is semantics as this only means that a midwife has her name on the notes, not that she/he will provide all the care or be there for the birth. For this to happen the number of midwives, in the Trust I work for, would have to increase by 50%, this is a pipe dream, it will never happen. Who is to 'blame' then for the increasing popularity of Independant Midwives amongst women who really want choice, I believe it is lack of funding within the NHS for maternity services, both for staffing and environment. One of the essentials instilled during training is that being a midwife means that you become the womans advocate, I'm not going to comment on whether that is adhered to by some of my colleagues but I do think that many IMs believe that leaving the NHS is the only way they can really support a woman's choice.

Julia said...

Hello debaters,

the issue of homebirth vs. hospital birth persistenty comes up in this debate, and numerous people have stated something like "Hospital is safer. That's a fact."

Wouldn't it be interesting to see what the Royal College of Obstetricians and Gynaecologists says about homebirth for women categorized as low-risk (prior to onset of labor)? As it happens, they very recently produced a joint statement with the Royal College of Midwives. The summary says:

"The Royal College of Midwives (RCM) and the Royal College of Obstetricians and Gynaecologists (RCOG) support home birth for women with uncomplicated pregnancies. There is no reason why home birth should not be offered to women at low risk of complications and it may confer considerable benefits for them and their families. There is ample evidence showing that labouring at home increases a woman’s likelihood of a birth that is both satisfying and safe, with implications for her health and that of her baby.1–3"

RCOG and Royal College of Midwives Joint Statement No.2.
April 2007

The full report is available as html and pdf at the RCOG's website under:
(or just use their search engine for "home birth")

prochoice said...

According to Amy Tuteur what I know about childbirth is not true! So, can I assume I must be a Doctor to be permited to decide where I give birth and who to have at my side?

I will be planning to have my baby in the comfort and safety of my own home unless there are complications, in which case, I live accross the road from our hospital so a "tansfer" would take minutes (bearing in mind if there are complications during a hospital birth it can take much longer than this for someone to take notice of you anyway!).

I am a sane woman who is as fully informed about labour and birthing as I can be without having given birth yet.

I would also like to point out that for most people no amount of money could ease the pain of losing a child or a spouse!

This whole argument is a load of crap! It is each woman's choice where and how to give birth and no amount of arguing over it will make any difference!

As soon as one of you "men" can say that you fully understand the mental and physical torture many women go through in pregnancy, labour and birth then you can make informed arguments but until then your arguments are just statistical and are of no value no matter how many letters you have after your name or how educated you are!

As for the women, each to their own - but when you have a child exercise YOUR OWN right to choose but remember that if you have the right to choose a hospital birth then I have the right to choose a homebirth.

Anonymous said... one of many studies. Please remember the morbidity associated with intervention, stress incontinence being the mildest ailment. Your opinions are just that and based on very little fact. Try google scholar, look for RECENT articles and you will find yourself on here later retracting your flawed views.

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