Pediatrician Dr. Blair Duddy’s passion is keeping children healthy and following them as they grow up. Which is why he’s so passionately against most home birth as it’s performed in the US right now.
He sees the deaths and disability that result from poorly trained practitioners performing home deliveries. Now as we point out, different states have different licensing requirements for “direct-entry” midwives (the type of midwife he is concerned about) but here in Nevada, the training requirements are minimal, especially compare with nurse midwives and obstetricians. Watch this in-depth interview or read the transcript below, and if you want the 3 minute version, watch this.
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– Dr. Duddy, welcome back, son!
– Thank you so much. So I really appreciate the introduction. One of the things we talked about after I did the gifted piece is, you know my professional life is really one on one with patients in the office. And so it was really neat to reach out to people, outside of the one on one.
– He’s funny, like doctors came up to me when I was traveling, doing talks and they’re like, “You know that think you did with that Dr. Duddy guy, “that was so helpful, because now I have a way “of looking at my patients.” And I think that’s what we’re trying to do too, on the show, is amplify the voice of people who are actually connecting on these issues correctly with patients and with other health care professionals.
– So, I’m here because it’s a subject I feel passionate about. I do some medical leadership in town and sit on hospital boards, and so I’ve seen several cases of fairly bad outcomes for home deliveries. And there have been some deaths in town.
– [ZDoggMD] Right here in Vegas?
– Yeah, I’ve thought about this for a long time. I have an interesting origin story in that I was born at Stamford, I actually grew up in Sunnyvale.
– Wait, wait origin story, so were you bitten, be like bitten by a radioactive stroke patient and now you get hemiplegic when you get angry?
– But you know formative years were like the ’70s in San Francisco bay area, so my mom was a early child educator. She ran a laboratory pre-school staffed by high school and community college students. She was an early advocate of breastfeeding. We had an actual breast milk bank in our house.
– So with donor milk.
– So just like a bunch of bags of milk?
– Yeah, people would donate. People, you know there was no HIV, hepatitis testing, any of that stuff. Of course this was before HIV. And back then, if a baby had allergic colitis it could be very dangerous. They didn’t have these hydrolyzed formulas for them. And so donor milk could be incredible important.
– So we would have donor milk to give to, you know, one baby at a time that was in dire need of it.
– You know what, you know what, not to interrupt, well to interrupt ’cause that’s what I do, ’cause I have ADHD. I had a stool donor bank at my house. It was one of the earliest ones, and it was
– For C-diff yeah.
– largely unintentional, anyways go on.
– So she was an early breast feeding advocate and she was part of something called the Nursing Mother Council of Palo Alto, which actually pre-dated La Leche League. They didn’t have like lactation consultant certification back then, or at least she didn’t, but she was an early advocate. ‘Cause journey back circa 1970, the breastfeeding rate was like 20%. So that, in that context, one of our greatest family friends was a woman named Lester Hazel, who circa 1969 wrote a salient book, pushing back against the medicalization of birth, called Common Sense Childbirth.
– [ZDoggMD] Wow.
– So it’s weird for me to talk against home birth now when this great family friend, who was lovely, and bright, and caring, you know has this well known book about it. Now, to be honest, let’s travel back to 1969, it was a different experience, right? There was, dads weren’t involved in the delivery room at all.
– He would be outside smoking.
– Right,definitely. The postpartum women were put in this giant ward with six beds, sharing one post partum bathroom. And there was not breastfeeding advocacy or help. So, they didn’t have epidurals. Even in the caring for the baby side, they didn’t have routine ultrasound, the monitoring wasn’t the same. Neonatology was in its infancy, the first fellowship for neonatology was 1975. You know they didn’t all have baby ventilators, so not only could you diagnose and treat less, but the experience was horrible. Even though, you know I feel guilty sort of going against Lester, you know if we traveled back to 1969 I understand the push back. And so if it wasn’t maybe for her and that kind of discussion, maybe we wouldn’t have a much better birth experience today. Which is much better, it’s not exactly like home, but they try to, in the hospital room the dads all have fold out beds and they have lactation consultants typically full time to help moms with their nursing. So it’s a different experience. And the way I look at it is, you know, if it wasn’t for Lester maybe the hospital experience wouldn’t be better.
– That’s a wonderful history, because we actually lose sight of that, that it really was a miserable, clinical
– It was.
– detached experience.
– And it reminds me of like, you know the organic people. You know circa 1969, you know baby food had, literally table sugar in it. And if it wasn’t people pushing towards organics, maybe we’d still have you know sugar in baby food. Now it’s just, on the labeling, carrots and water and that’s all it is.
– [ZDoggMD] Right.
– Now of course they go overboard and do things like frozen lemon juice for malignancy, which is obviously absurd. But, the way I look at it, because again I, you know when thinking about talking about this subject, I felt kind of guilty ’cause I’m throwing Lester under the bus a little bit because of, I disagree with home birth strongly, which is why I’m here. And there’s this natural, in other arenas, similarly it’s like, pregnancy is not a disease, don’t treat it as a disease, the natural birth community. And you know, the medicalization of a natural process, people have been delivering babies for a millennia without hospitals, why are we doing it? And so the um, the difficulty is the one balance of the experience of the mom, and the family being able to deliver at home in a more comfortable environment, versus what is the risk of delivering at home? So although it’s a normal, natural experience when it goes off the rails and there’s a problem we need the baby out and now. When I look at the whole situation I feel it comes strongly down in the, it’s safest to be delivering in the hospital.
– So, so okay. This is very, very helpful I think for a lot of people, a lot of mothers, a lot of parents, a lot of dads who are on the fence about this, like is this a good idea? I can tell you this, I’m with you on this. And the reason is, is that we see the complications of birth. So they talk about, like you said, medicalizing pregnancy, turning it into a disease is not a great idea, yes this is true. However, if you are, you know, I mean what… If you have a bad outcome at home that is a vastly different scenario than something like that happening in a hospital. And since we see that, you know my wife and I both times she delivered in the hospital, but both times we wanted to get the heck out of there as quickly as we could when were done. Because of what you say, it’s more comfortable at home. Home is really where, it’s a cliche, home is where the heart is. It’s where you feel the most connected in at home. And you have a new baby, you don’t want to be in a weird, clinical environment at the same time. We’re deeply grateful for the care that we got. And that, and I want to put one coat on that which is, we suck still in this country, at maternal care, compared to the rest of the developed world. And so we can do a lot better, we’re not perfect, we need to be very humble and continue to improve our quality. But that doesn’t mean you throw literally the baby out with the bath water on this.
– Yeah I agree, and there’s a lot of discussion of why our numbers are so poor for maternal mortality. But, you know I feel again, as a pediatrician there’s not the direct conflict of interest. You know I see babies whether they were born at home, c-section, vaginal delivery. And so my perspective is, I want a healthy baby and a healthy mom.
– [ZDoggMD] Your dog in the fight is healthy babies…
– not, you know you get
– [ZdoggMD] paid to deliver them by whatever means.
– Right, absolutely. And one of the things that the public doesn’t realize is I’m anti-home birth, I’m not anti-midwife.
– [ZDoggMD] Explain that.
– So midwives in the US, we have several classifications of them. In Europe and international standards for midwifery would be the equivalent of a certified nurse midwife here. So that’s, bachelors degree typically in science, or bachelors of science in nursing. So after RN, typically two years like they’re getting a masters in midwifery. They practice typically mostly at hospitals and birthing centers, they don’t do that many home deliveries. Most home deliveries are done by something a designation called certified professional midwives, or CPMs. And they used to be known as sort of lay, or direct entry midwives. And they actually, they don’t have in the same sphere of training, so it’s high school only. Plus, basically an apprenticeship with 60 deliveries total, 20 observational, they do some didactics. And they should be NRP certified. So they’re the ones doing a lot of these home births. And they’re really, they’re out of their depth by a mile. And,this is their life’s passion. When a delivery is at home and goes great, you know it’s magical. But there’s really out of their depth. And I know by criticizing their level of education, you know I’m throwing them under the bus and they’re gonna be defensive. And I just urge them to really look at these numbers and the process and just get trained, become a certified nurse midwife, that’s great. But they’re really not, they don’t have the training that I believe is really necessary to properly handle these babies.
– There’s a lot here and I think, and I’m learning this for the first time, so you’re teaching me about this. So it sounds to me like there’s a potential here for not knowing what you don’t know, for not being able to recognize problems at home that a more trained midwife, or an obstetrician would be able to recognize, and that leading to trouble. Now the question is, if you’re gonna make a statement like that, the question is, is there data to show that these home births have worse outcomes?
– Well yeah there is a lot. So the two things we worry about most, you know death in that’s significantly higher. And significantly higher is a debatable statistic and I’ll talk about that in a second. And then, hypoxic ischemic encephalopathy. So a hypoxic brain injury.
– So starve for oxygen, brain gets damaged.
– Yeah, and–
– [ZDoggMD] Cerebral palsy–
– They can have permanent brain damage. So the American Academy of Pediatrics and the American College of OB/GYN have a position statement on home delivery that they came out five years-ish ago. And basically, you know, we don’t want to be too paternal. One of the principle of ethics is patient choice and things, in their care. But we want to be very clear what we think is relatively safe delivery. It’s not as safe as a home delivery, I mean a home delivery’s not as safe as a hospital delivery, but, if you’re gonna do home delivery, we want these characteristics. We want a singleton, i.e not twins. Normal presentation, not breech. You need to have people able to resuscitate the baby, and so you need one for baby, one for mom. And–
– How do you do that at home?
– How do you–
– Well the midwives will do that. They’ll get NRP certification, but remember they’re not nurses. They can bag babies, so 90% of the time or more, if you have a baby that’s not breathing, you can use bag valve mask, on room air and get them moving and resuscitated. However, sometimes you’re gonna need a volume expander or epinephrine. And they can’t do that at home, they’re not nurses. So they’re not really able to resuscitate a baby in the way that we could in the hospital. So if you look at admits to hospital with hypoxic ischemic encephalopathy, there’s a 44 times chance more that they’re born at home versus a hospital. So that the–
– Wow, 44 times.
– It’s yeah.
– And, the increase, even under these low risk criteria the mortality rate’s gonna be about one in a thousand higher for home versus hospital delivery.
– So let me see if I understand this statistically. ‘Cause this is an elephant rider thing, so my rider’s trying to process this rationally and my elephant is feeling emotion around it. So, for every home delivery you do an extra baby per one thousand births will die.
– Yup, so what’s interesting when the AAAP, ACOG came out with this, there was flay more in the journals. And someone’s like, “Are you guys crazy?” And the authors were like, “Well with, “yes it’s higher, but it’s not that high “and we want to let them choose,” we’ll just present the data. So for hospital delivery there’s a 99.95% survival rate, for home delivery, it’s 99.85%. See that’s good, but yeah that’s still one in a thousand. So if you applied that to four million delivery cohort every year in the US, that would be 4,000 extra deaths. Which is, by the way, two times total US childhood cancer deaths. If you take all childhood cancer deaths, zero to 18, you know leukemia, brain, lymphoma, you know blastoma osteocarcoma, blah, blah, blah, add those up, multiply it by two, that’s how many deaths there would be if everyone was born at home, under low risk.
– You know let’s really put a, put a point on that too. So you’re saying 4,000 extra babies are dying every year because,
– Would die if,
– would die.
– Would die if every one was born at home.
– If born at home, got you.
– That’s the one in a thousand statistic.
– That’s extrapolated.
– Extrapolated, yeah. So, I don’t think it’s worth it versus the experience of home birth.
– And, the home birth advocates will say, well there’s medical, complications that happen.
– [ZDoggMD] Right the hospital’s a dangerous place.
– Excessive rate of c-sections and other, you know, infections, et cetera. You know I’m here in the end to say I don’t think it’s worth it,
– for any family.
– Yeah, yeah. Well you know what’s interesting is that one of the problems, we did a show on maternal mortality earlier last year. And one of the problems is we were sending women home without good followup, without close checking, and so as a result it’s the home that was really a part of the problem. And also we don’t have good protocols to actually keep an eye on mom. We tend to focus on baby, a million different reasons. But again, there are dangers in the hospital, but it sounds like the dangers at home, especially if you’re in the hands of a practitioner who maybe doesn’t have the higher level of training as a nurse midwife, or an obstetrician, is more dangerous.
– Yeah and they do, they do home midwife deliveries in Europe, but they’re with the higher level trained. Some countries up to 20% are delivered at home. Now again my point is you’re gonna at best, WHO says, like a 10% c-section rate is appropriate. Meaning if you’re doing less than 10%, you’re gonna have deaths or, you know morbidity, encephalopathy. So that’s at best, so transfer rate ends up being you know, 10 to 20%. The survival data is pretty close to the hospital. In Europe, they have seamless systems, you have to make sure you’re not too far away from medical care, and able to transport the baby. You know I see that and I should listen to that, but I just, you know if I just look at one, again looking at extrapolating data, if you look at one complication that can happen, which is cord prolapse. So if the umbilical cord, basically loops out and pops out like between the baby’s shoulder and the mom’s symphysis pubis. It’s just basically the blood vessels are compressed. And as soon as that happens, the time clock starts to hypoxia and ultimately death. You need the baby out in minutes to half hour. And, that’s gonna happen not commonly, .2%, something like that, but again, if .2% of formulan US deliveries that occurs, out of hospital mortality in that situation is something like 40%. So if again you looked at large statistics that would be again like 3,000 deaths. Like 1.5 times total US childhood cancer deaths. Just for that complication of cord prolapse. Cord prolapse in the hospital is a scary thing. They often put mom in a different position where someone has to, you know glove and basically reach in and push the baby’s head up to try to take the pressure off and then they wheel them to the OR and do a stat emergency c-section.
– Right, right. A great indication for c-section
– Right, right.
– in that case. So, you know this has an emotional heft to it, because I remember when I started doing ZDoggMD stuff, one of the first groups of fans that started following us were a group of mothers, all of whom had had, they had been really the sort of crunchy granola types and the natural types and they had had a home birth, or attempted home birth. And then had bad outcomes.
– [Blair] Right.
– And their mission was to raise awareness about how under regulated and under trained some of the home delivery–
– [Blair] Right.
– You were talking about the lower level–
– [Blair] The CPNs, yeah.
– And how they would tell the stories and there was a picture of the mother postpartum, holding a dead baby. And I remember, I remember actually crying reading this message. It was the first time I opened a Facebook message and I started crying and I thought, you know what? What am I missing in this? Because it seems natural. I’m actually an anti-interventionist. I often say on the show that we do things TO people instead of FOR them in medicine and that we are part of the problem, and we need to get better. However, however, I’m also a rationalist and believe in evidence and when I see this and I hear the evidence. It has both an emotional motivation and a rational motivation. But what you said about Europe, we might be able to get there eventually, so it doesn’t mean we throw it out.
– Right. So, one of the things that’s come to foreign OB world in the last 10 years is a laborist. So a physician that’s just doing the night shift to help deliver babies that need to in the middle of the night. And the downside is it’s not your regular OB that you knew for nine months. The up side is it’s someone that’s there, ready on the spot. And so, all the hospitals, one of the metrics they follow is unintended deliveries. So they’d be able to deliver without an OB/GYN or midwife and the numbers have gone to essentially zero. So, what we need to do is make the hospitals more, and more and more comfortable.
– [ZDoggMD] Yeah, comfortable.
– And it feels like home as best as possible. And you have certified nurse midwives doing a ton of deliveries and there’s a hospitalist there. ‘Cause if we need that baby out they’re there to do the surgery to get the baby out.
– Obviously I’m biased, I’m a big fan of hospitalists in general, because I feel like the hospital’s gotten so complex, it’s very hard to be a primary care doc and a hospitalist and nail both of those things. However, there is that continuity issue. So it means that hospitalist has to be in close cahoots with your primary, ideally. But I think that’s doable and I’m with you on that. And I’m a big fan of trying to improve, both quality and comfort in the hospital. When we gave birth, I remember because we were quote, unquote, VIPs, something bad was gonna happen.
– Right? Two doctors, me and my wife, both work at Stanford, both delivering at Stanford, everything’s gonna go wrong. Luckily we went in with this attitude of, we’re gonna stand to the radar, we’re not gonna request anything. And it worked great, because people were in their routines. And what I found was it was comfortable, but not as comfortable as home.
– [Blair] Right.
– Both me and my wife were dying to get home. We went home a little early. And that may have not been the best idea, because the kid wasn’t breast feeding quite right. And we realized when we ended up having to give formula, she was like, brr! Just drank the whole bottle and my wife was just racked with guilt for not being to feed, and was sort of lactation shamed and all that.
– So, yeah I mean it might be time to talk about that we’re two men talking about the birth process.
– We’re mansplaining.
– Right, well you know, we are compassionate and empathetic and we both have an N of 2 of kids and have been through that. And we can’t know what it’s like to grow a human being inside. So this birth experience thing is a big thing out there. And my point is that yes, I can’t experience it, but you know I’m more comfortable on talking about this, ’cause I’ve been a pediatrician now for 5 years, so I’ve been to thousands of deliveries, many more thousand in the first 24 hours of life. And I’ve seen the arc of kid’s lives. And I, you know, I want everyone’s birth experience to be great, but it’s one day out of the next 20,000 you’re gonna be the parent. And I just want a healthy baby, right. That’s the important thing. You know when, when we took my daughter to kindergarten the first day and Mrs. Parks had, was sitting down with all the kids on the ground in front of her, and then the parents were standing in the back. And she was reading The Kissing Hand. Do you know that one?
– Yeah, so, she’s reading The Kissing Hand about the first day experience of the raccoon family.
– It’s pronounced “ruhCOON”, by the way.
– And all the parents were trying to prevent themselves going from a mild cry to an open weep. When you looked at them you couldn’t tell which ones were born at home, versus c-sections, versus vaginal, versus adopted. They all love their kids, right. So the idea that you have to have this perfect birth experience, or the long term relationship isn’t gonna be right, is just in my view not true at all. I think there’s a lot of women that have that, you know the famous mommy wars things, that they have to do it the right way. They have to do it naturally, or this way. Or if they don’t breastfeed they’re worried, you know, that they’re a terrible mom. And I see a lot of that. And, it can trigger post partum depression. You know I think about that birth experience. I was just thinking I had like epiphany that it’s a little bit like Paris Syndrome, have you heard of Paris Syndrome?
– I haven’t, teach me.
– So it’s not a DSM5 diagnosis, but circa the 1980s there was some psychologists that described these people that were traveling to Paris. They were a high amount of Japanese tourists. And they had such great expectations, oh my gosh, I’m going to Paris. And when they got there there was this disappointment. And for some of them it triggered like psychiatric symptoms delusions, et cetera.
– [ZDoggMD] Wow.
– And so, I mean postpartum psychosis is well known, and certainly depression. But there’s whole vibe that you have to have this perfect delivery. You know if I don’t deliver this perfect way, or if I don’t breastfeed, plan on community college, not Harvard. And you know I support breastfeeding, of course. But for women that can’t, or don’t, or don’t want to, there’s no reason to give them a big guilt trip. You know especially in term babies. The preterms, the 32 weekers, needed like a Dr. Duddy milk bank.
– But uh, but you know–
– By the way that doesn’t sound creepy at all.
– It sounds so creepy. Can you cut this part out?
– No that’s staying in. So actually what you’re bringing up now is interesting. ‘Cause I get a lot of messages from moms who are sitting on these Facebook groups. And they are obsessing and other mothers are shaming them. And then they go to the hospital and then maybe there’s an aggressive lactation consultant, who doesn’t, maybe the bedside manner’s a little different and they’re not really acknowledging the sense of insecurity and really. You know if you don’t breastfeed you’re a bad mother and this kind of thing. And you know to some degree I think my wife experienced a little of that.
– Oh yeah.
– You know just some degree I think Tom might have gone through some of it. Tom directly ’cause he produces man milk which is very high in no nutrients. It’s high in pork rinds. And so, this idea that, what you just said I think is so important, I almost want to clip that out and put it out as its own clip. Because there’s so much shame. And you say it’s not without consequence. You can trigger worse–
– Was it Paris Syndrome?
– Paris Syndrome, yeah for the city of Paris.
– It’s just the expectation.
– It’s pronounced “pareeee”, just in case, you know the two communists in the back there like to pronounce it correctly. They would actually kill me if I said Pari, because they would think that I would I like the French. So but, one thing you were telling me before we even started this, why this matters, are death statistics. People don’t understand statistics.
– [Blair] Right.
– The causes of death for children are actually rather surprising.
– Right it’s interesting. Again it enters the space that you guys have talked about which is that for a lot of people, and they truthfully tend to be high SES types that–
– [ZDoggMD] What’s SES? Sorry I’m dumb.
– Oh social economic status.
– Oh, I’ve never abbreviated it like that. Excellent.
– Yeah so they–
– Logan is low SES, just so you know.
– So they are, you know pushing back against medicine, that food is medicine and that, that medical intervention is, you know unnecessary, and overdone and so that gets to the, I’ll just have, you know a healthy kid and not worry about vaccinating because my kids are healthy.
– [ZDoggMD] Right.
– And that they’re, you know they’re immune to infection. And as you’ve talked a lot, that’s just not the truth. And what happens, of course in the 1950s when the Polio vaccine came out and everyone went to school with kids with Polio, the line to get the vaccine was like, you know, you know huge. Someone got in line because they were around kids with Polio. Now that we’ve been successful with the vaccines, there’s not as many.
– You don’t see it.
– People have a neighbor that’s sick. I mean I talked about that when I did the anti-vaccine piece that, you know we’ve eliminated bacterial meningitis in the under five crowd. And you just don’t see kids with hearing aids anymore, very often because you know one of the top three causes is eliminated. 10% of kids that got meningitis, it destroyed their eighth cranial nerve and they were left hearing impaired. So you just, in middle schools, and elementary schools and high schools, you don’t see kids with hearing aids anymore.
– You know and when we had Paul Offit on the show, he was talking about even just varicella, chickenpox.
– We have 10,000 admissions a year, chickenpox related complications. And now we’re dropping that with the vaccine.
– Yeah I mean the benefit of officially being old is I’ve seen–
– Is there an official cut off?
– Yeah. Is I’ve seen kids die of bacterial meningitis. I’ve seen a bunch of chickenpox. In the early ’90s there was a measles outbreak in LA, so I’ve seen like
– You’re a UCLA grad.
– nine or 10, yeah. Seen nine or 10 cases of measles.
– Did you ever see Koplik spots?
– No, they didn’t have Koplik spots the ones I saw.
– But I saw one in a pregnant mom that almost died, she was in the ICU.
– [ZDoggMD] Wow.
– But anyway these–
– Measles kills 110,000 kids a year, people a year, still worldwide, yeah.
– Yeah, right. I don’t know if we’re gonna show the graphic or not.
– [ZDoggMD] It came with you today. There it is!
– [Blair] In 2015 I came across an article in the pediatrics journal. It was about morbidity and mortality of trauma worldwide and so they had World Health Organization data. This is circa 2008, on causes of death of children, this is Planet Earth, so that’s gonna be 20% developed world.
– [Blair] Number one is perinatal causes, so that’s basically home births. So that’s prematurity, asphyxia and sepsis. Number two, diarrheal diseases.
– Pull it back, Logan.
– Yeah I need to look at it.
– [Blair] Diarrheal diseases, so you know, that includes rotavirus. I don’t off it didn’t talk about that there’s 100,000 kids a year die in India of rotavirus. To this day.
– Yeah they don’t, 100,000 they don’t give the vaccine, ’cause it’s too expensive,evidently. It might be that, I forget whether it needs to be refrigerated, whether there’s some logical issue, yeah but.
– There’s some legal, yeah.
– So, you know, by comparison again for morbidity, if you look at total childhood cancer deaths in the US, all cancers in children, about 2,000 a year. So that’s 50 times the number of childhood cancer deaths in the US, those kids die of just rotavirus. Before the vaccine I would put like three, four kids a year in the hospital with it, now we don’t see it anymore.
– But you know this is the best part. The anti-vaccine industrial complex with the professional anti-vaxers who I don’t give a pass to, because they’re delusional and they’re dangerous to children. I give a pass to parents who are struggling with the issue and are legitimately concerned and emotionally reacting. I don’t give a pass to these people because they will attack someone like Paul Offit for making a vaccine that saves untold lives. And they’ll besmirch his reputation and this and that. And that’s fine he can take it, he’s a tough guy. He was on the show, people were banging on the wall. Right?
– Right, I remember that.
– And prepare for that Blair because it’s fun, it’s a badge of honor when that starts happening. We just can’t tolerate it anymore.
– Right I mean I feel like, you know, I can talk about this again, ’cause I’m a pediatrician and if an OB does, they have a conflict of interest, it really felt important. The other cause of death, so lower respiratory tract infection, that’s pneumonia, prevented by HIM and Prevnar vaccine, Malaria, in certain malaria areas. What’s the next one?
– Congenital anomalies.
– Yeah and so, obviously that’s birth defects, but even prenatally now there’s sometimes prenatal surgery. If a kid has diaphragmatic hernia and they’re born in the hospital, you can have immediate intervention and decrease mortality of that. So even that is helpful to be born in the hospital. Then, what’s next?
– [ZDoggMD] Yeah, so pretty much all the vaccine stuff, pertussis.
– [ZDoggMD] HIV/AIDS which is interesting.
– Yeah that’s test moms, treat them, give babies ACT when they’re born, so that’s preventable.
– [ZDoggMD] Then you have meningitis, which is preventable.
– [Blair] So it’s like six of those top 10s are vaccine preventable infections.
– [ZDoggMD] Go the next slide, Logan. Child mortality age 15 to 19.
– [Blair] So this is teenagers. So number one and two, similar to the US is motor vehicle accidents and suicide. Some communities it’s homicide for number two.
– [ZDoggMD] Right, right.
– [Blair] But number 11 cause of death of adolescence on Planet Earth is maternal hemorrhage.
– [ZDoggMD] So adolescents giving birth and–
– Yeah and obviously only half can die of maternal hemorrhage.
– Right, right.
– Right, I mean so that’s incredible I mean. If you want to go back to the olden days, 1% of women used to die in childbirth, right?
– So this is what I love, you know. We need to be natural, we need to live like our ancestors did. Well then you’re gonna have a short, brutish, and painful life, and a pretty quick death, because that’s how most of our ancestors lived.
– Yes, my daughter, my eighth grader was doing a project or a paper on Mozart. And, like if you look at his family history like he was, he and a sibling are two of eight that survived. And then he had like five kids and two of them survived. And these were mainly, you know perinatal stuff and then vaccine preventable infections. So I mean on Earth there’s still like a dozen countries where 1% of women die in childbirth. And then what was it? The other graphic that’s interesting whether you–
– [ZDoggMD] Abortion.
– Yeah whether you’re pro or against or whatever, it’s number 14 cause of death.
– Is like, what like on, the supervisor–
– Right they have someone, you know they’re in the developed world and they’re worried that Dad’s gonna literally kill them if they have an abortion or are pregnant. And so they get someone else to do it who’s non-medical, or they throw themselves down stairs, or something terrible like that.
– Oh wow.
– Yeah. And so anyway–
– This is a real, this episode is a real, feel good hit of the summer, Blair.
– Well the– Well the um, the feel good part of it is, neonatology is incredible. Like in my career I’ve seen these micro preemies have so much less morbidity. So in 1960 if your one kilogram baby in a 90% mortality rate. In 2000 you had a 90% survival.
– That’s amazing.
– It is, it is.
– And again, it’s the medical advances and we should celebrate them.
– One thing that, you know again, if you look at midwife data in Europe, their numbers, I mention their numbers are fairly close to, the hospital babies. So they do home delivery relatively successfully.
– [ZDoggMD] Right.
– So I think that’s important to look at. And I mentioned why, you know, that still makes me a little uncomfortable. In the US, nurse midwife mortality rate is actually less than OB/GYN. But that’s because of selection bias, right.
– They are not doing–
– Oh so healthier moms.
– Right, well they’re not doing the high risk, they’re not doing c-sections, right? And so you’ll see like in the lynch people comparing things all the time, like, “Oh their numbers are better, “so we should have them do it.” Well they’re not delivering a 500 gram, 24 week preemie that has 50 mls of blood in their whole body.
– And then isn’t a slide against midwives, it’s saying, that’s how you explain that statistic.
– Right, right, ’cause otherwise people say like, “Well you know, the mortality rate “in the operative theater or hospitals, “is much better than surgical center. “So we should like do our valve replacements “in surgery centers, ’cause they have less deaths.” Right.
– They select for the better, safe provision. Here’s a question, The Business of Being Born, by Ricki Lake, I haven’t seen it personally. What are your thoughts on the documentary about the OB industrial complex.
– Right, I mean it’s frankly annoying to me. No, if you want to argue that, again, the benefits of the experience, and that versus like, are we over medicalizing, what’s the c-section rate? You know, but the whole business that the premise that it’s just greedy doctors and hospitals, just ticks me off, right? Because the truth is, an OB gets about as much for their global fee for care as a midwife. And so like my son, my baby boy, who’s now 18, it was $2,500 for the global fee when he was born. So that’s nine months of care, plus the delivery, plus rounding in the hospital, you know one or two days. And the whole delivery, two to four days c-section. Plus the six week followup. Typically they don’t get paid more for c-sections, so that’s a fallacy. Like, oh they just want to do c-sections ’cause they make more. They’d rather not, ’cause they have fewer days to round, there’s no postop followup.
– [ZDoggMD] Right.
– So you can call them medically wrong, but to call them greedy is just–
– [ZDoggMD] Just wrong.
– Yeah, absolutely.
– Just straight wrong.
– They’re following their passion. And by the way you know, let’s compare the certified professional midwives with their high school plus 60 deliveries versus OB/GYN. As you know is 12 years after high school to be a board certified, you know, OB/GYN. The medical years should count as like dog years, ’cause they’re working 80, 100 hours a week anyway.
– Right, right.
– And so the amount of training is not even
– Vastly different.
– And a nurse midwife is on that spectrum closer to the OB.
– Right, exactly.
– Yeah, yeah. And so yeah, ’cause I got a lot of people sent me messages about that documentary. They were either pro or con. To me, here’s a thought that’s a little provocative. Isn’t it the height of narcissism to want to value the experience of birth over the safety of the child and the mother?
– Yeah I believe that’s true, the extension of that is this phenomenon called free birth. Do you know about that?
– Yeah, tell me about this.
– So free birth is, you know–
– Hey is that free birth? Turn it up man! ♪ Lord I was born a rambling man ♪ Anyways I remember those old, remember those old K-Tel Records?
– Yeah, yeah.
– Yeah, greatest hits of the ’60s man, Free Bird.
– Yeah I think there’s a ZDogg parody about free birth, right?
– [ZDoggMD] There will be.
– So um, yeah free birth is you know, don’t put, delivery is not a medical condition, pregnancy’s not a medical condition. It’s really sacred, and it’s, you know our, it’s the most important day of our life, bring a new family member in. And we want to do it by ourselves. So they are born with just the mom and the partner, without any medical intervention, no midwife there. With the advent of the internet there’s been, they have of course, a support group for them. And you know, they’ll be like, trust the process, you know. They’ll be egging them on even when, they’ll sometimes live blog that, you know, it’s been five days, ruptured membrane. There’s meconium staining. So meconium is the nine months of build up, that’s baby poop, it’s really just sloughed cells. It’s that early stuff that looks like tar. So if there’s meconium what that means is they’ve been hypoxic enough to loose anal sphincter tone.
– Again like Logan, yeah. I like to throw him under the bus, ’cause he can’t really respond, he’s not mic’d there’s no camera on him.
– Yeah, so it’s super sad. That’s the pinnacle of about the experience. I just want a healthy mom and a healthy baby.
– Words of advice for people who are considering home birth, or getting ready to deliver, they’re trying to come up with a birth plan. What would you tell them?
– I’m not in favor of it, but you really need to look at the risk. I’d prefer you to deliver in a birth center with a certified nurse midwife, or a hospital with a midwife. I think the future is, let’s just kind of really work on making hospitals more comfortable. Bugging moms less, like really coordinating, if someone’s gonna go change out the trash, let’s do it in one visit. You know my wife is very, a personal space kind of girl, not like anyone like looks forward to, you know cervical exams. But, you know in the hospital they’re like my, you know work brothers and sisters and stuff, and they’re very dedicated and kind. But they do it every day and they may not realize some, some moms are just more sensitive. And so, you know during the, during her pregnancy they would, you know come in episodically and check her cervix. And they would say they were doing it. But like she wants to know why and how. So minimizing interventions. You know, it’s a process. And there’s been lots of improvements both in the neonatal side and also in the OB side. So like they don’t do routine episiotomies. They found that that’s not that helpful to prevent, you know grade four tears. I remember when they started doing delayed cord clamping. So now they wait until the pulse before they clamp the cord. They wait until it stops pulsating. And as a pediatrician I was kind of worried, because it’s a lot easier to deal with a anemic baby than a, uh, polycythemic baby.
– Over poly–
– Yeah after a crit of 65, you go from linear to nonlinear viscosity. And so you can have stroke like syndromes and you can have hypoglycemia and worse, and worse jaundice, but it turned out to be better. That’s the whole point. You know stuff we did, you know when anti medical establishment talks about DES or–
– Yeah or, you know, some of the things that went off the rails, yeah we learned and we moved on. Science is a process, not an ideology. And that our goal is to get better and better. You know making the birth process, you know having maybe a hospital floor that is just totally different than the others and really makes it as comfortable as possible. Right now it’s, I’m used to the hospital, so to me it was not a big deal. You know my wife had one vaginal, one c-section. Our son was early and came out, he had a cord around his neck, which is common that they can kind of pull it off, but he got a little asphyxiated, lower APGARs, needed resuscitation, was in the NICU the first week. So bonding was not, possible, they couldn’t do skin to skin, and nursing was hard. You know if someone suggested to my wife that she loves our baby boy any less than anyone else who had the home delivery and had, you know had the skin to skin, there’s gonna be a mom fight, right?
– Mom Fights was a reality show on, on TLC for awhile.
– So I don’t want to totally blow off the experience, but again, if the kid has brain damage due to hypoxia, unnecessarily, that’s a tragedy.
– That’s the bottom line. One thing I’m gonna say in parting here is that these groups online, they’re wonderful and they can be supportive, but at the same time they can create stress, anxiety, shame, guilt, depression. And I’m gonna make a really stupid mansplaining analogy here on our way out and it’s this. In 2003 or ’04 when I first became an attending, I finally had an income that qualified me to buy a car that didn’t suck. So what did I do? I bought an Acura TL, the 2004 Acura TL, which was like $30,000. And it was like the entry level luxury car. And I was obsessed with this car, why? Because I Googled the car and there were these support groups online of mostly dudes going, “Bro, bro, bro, did you get the 18 inch rims, bro? “Oh, did you hear that sound that the engine “sometimes makes, you should take it back to the dealer. “Because if it makes this, any time makes a click noise “once, they sold you a lemon.” And I started getting this paranoid anxiety about this car and I’d go to the dealer and I’d be like, “You know the leather has a tiny little “imperfection right here and I read online, “someone else said that’s a problem “in your Ohio manufacturing plant.” And I became insane about a thing that gets me from point A to point B. And I started obsessing about this thing until I finally let it go. I forgot what happened, I got a ding. My first ding I’m like, “I’m out, I no longer care.”
– For some reason it doesn’t surprise me that you have a little OCD.
– A little?
– Yeah, it was, oh man. I would wax, ’cause you know you’re not supposed to trust anyone washing your car. Just like you don’t trust an OB to check your cervix, you know you do it at home. You don’t trust someone else to wash your car, because they might put a scratch on it. And they’re gonna want to intervene then, they’re gonna use the buffer and that’s gonna cause more harm. And the parallels are astounding.
– I’m speechless.
– So is most of the audience at this point. Any parting words, ’cause I think we did about 45 minutes, which is perfect.
– Well again you know, I’m really throwing negativity on these women that are doing the certified professional midwives. And you know it’s hard because I know their heart is in the right place. They think they’re doing the right thing. But it’s just, it’s not enough, they’re beyond their depth. I urge them that they want, if that’s their passion, to get the training, so that they can train to the level that it’s safer for babies and families.
– Guys, I want you to do me a favor. Leave comments, leave suggestions, share this with people who are trying to learn about this. You can get the CME once we get it approved. I’ll leave a link for supporters on Patreon and on Facebook to do that. Dr. Duddy, I have learned a lot today from this. Because this is something that, again, it’s been on my radar for a long time, but I haven’t directly spent a lot of time researching, because we had our births in the hospital. Hearing it from you, someone who’s been in the business for 25 years, not as an obstetrician, but as someone who cares about babies, someone who I personally trust, and someone who takes care of my friends and their babies. And I would trust with my child’s life. I want to thank you for being on the show and I hope you come on again.
– Thank you so much.
– [ZDoggMD] Thanks brother, we out.
– So what I didn’t tell you about.