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Wednesday
May172006

Co-Care Thoughts

So, what to do about women who feel they need to see a doctor as well as a midwife (Licensed or not)... is the midwife comfortable with that? Does the midwife find conflict between OB and midwifery information/advice? And how does she work with that conflict?

Around these parts, we have no physician back-up. The licensing board knows this, our clients know this and the doctors know this. For a variety of reasons, some women still choose to do doctor visits as well as midwifery visits. With HMOs, labs are covered if the client also sees a doctor, so some women choose to go for OB prenatal visits at least until all the labs are completed. Other women find it important to have a doctor in case they end up in the hospital... the doctor unknowingly being the back-up plan even as s/he is most certainly not the back-up for the midwife.

Conflict between what a midwife and an OB says arises at nearly every visit. I am continually told, "But my doctor said - what do you think?" And I will offer the midwifery standard of care answer. Many times, the client comes back exasperated with the fear-mongering and doomsday predictions of the medical world.

Oh, your HAVE to have an AFP screen... what if your baby is DEFORMED? (a true comment to a client)

You HAVE to have the glucose tolerance test - ALL the women do it and your baby can DIE if you don't. (true exposition of the test)

I spend inordinate amounts of time explaining tests, screens, and procedures with as many pros and cons as I know about. I send women to the Net and the library so they come away with their own opinions and desires - and I honor them to the best of my ability. I know that docs typically "don't have the time to go into all that" and sigh audibly when a woman says she read something on the Internet and asks if they can't discuss the issue. Sure, it's easier to have everyone comply without asking (being a sheeple), but these really are choices - even when the law states otherwise. When women come to me and tell me their doctor said they HAD to do this or that because it is the law and they can't opt out of it, I tell them that if that were true, the government wouldn't have created refusal forms that can be signed and put in their charts.

Women ALWAYS have the right to refuse procedures. It doesn't always mean it will be heard or (not) acted upon, but they do have the right to refuse.

And then the issue arises about whether to tell the OB or not about upcoming homebirth plans. Women risk being "fired" from their docs if the doctor is rabidly against homebirth. Some doctors will give extensive speeches and make a woman sign frightening consents before they continue their care, but most doctors (and even some CNMs) will refuse to see a woman after her homebirth disclosure. I've known military docs to call a service member's commanding officer and "report" the service member's intentions to birth at home.

(The military has a stand against homebirth if the service member herself is birthing. In more than one occasion, the service member was threatened with no postpartum leave if a homebirth occured. The military "owns" the service member and can dictate where she delivers her babies. I would love to hear about some service members who delivered at home, especially if their commanders knew about it. I'd love to see this belief/attitude change.)

Recently, I did a birth where the doctor began asking me questions about physician back-up and how could the language of the law be changed in order to allow docs a safety valve (of responsibility) while still offering midwives the benefit of their knowledge and experience. I told him that if the word "collaborative" could replace "supervisory," a whole lot of issues would become moot and the winner would be the women themselves. It was then that the doctor told me he was on a task force discussing this very issue and he really appreciated my input. Boy, was I glad I had my answer rehearsed and clear!

I rarely ever speak to a physician in a collaborative sense. I mostly utilize the slew of CNMs I know around the country to help me figure out if a woman needs to move towards more medicalized care or if what I am seeing is an outside variation on the norm. I am blessed to have these women. With some of the local hospitals, I'll call and ask what the temperature is (how warm or cold will the reception/doctor be if we come into that hospital) and make a decision about where I am going to take a transfer based on their information. (A transport is different; an ambulance makes that decision, typically.)

When a mom asks me if she should get co-care or not, I ask her what her goal is... to get labs paid for? to keep in touch with a doctor she believes she would see in labor or during the birth if we transfer to the hospital? because family members (partner) insist on it? I remind women they rarely see "their" doctors during their births, so if it is for some continuity in that respect, I encourage finding a more valid reason.

Some women need on-going or occasional meds during the pregnancy (meds that don't rule out a homebirth - thyroid meds, antibiotics, for example) or benefit from services I am unable to offer (obtaining diabetic supplies, insurance-paid-for nutrition counseling beyond what I am able to provide, etc.). For these women, it makes perfect sense to continue an on-going relationship with their physician. Some women would choose to do so; others would not.

When I've needed a medication (antibiotic for a UTI, for example) and the mom doesn't have anywhere to go, I have turned to CNM friends to write them for the client. I do this extremely rarely (I don't want to over-use my resources nor do I want them to get in trouble) and most often, I send them to the CNM for a cursory visit.

I also have a supplier for Diflucan and Acyclovir for the women who need those meds during or after their pregnancies.

I wish it wasn't so. I'd certainly much rather be able to turn to physicians so they are able to utilize their privileges (and skills) for our clients, but they are held hostage by administrations, insurance companies and peers. They have to say: "Either see me and never utter the words homebirth or you can't have anything I could provide."

Sucky lack of alternatives if you ask me.

Reader Comments (4)

I'm continually amazed at the number of women who take what their doctor says over what they are feeling physically and emotionally...and with the number of people (men and women) who do not become active participants in their own care. Perhaps we simply need to help people understand what their rights are and then to choose the appropriate care-giver for their needs. That's not to say that needs can't change, and therefore caregivers. But, you're right, it's a sucky lack of options, especially if you need to have some things medically monitored but still want the midwifery model of care.

May 17, 2006 | Unregistered CommenterAnonymous

What an informative post for me. It's somewhat different here, but I need to know this stuff.

If I could do it all over again myself...

Hh

so I usually warn them ahead of time what they are in for give them the Penny Simkin card of questions - recommend they take someone to go be an advocate- I also really think about/evaluate commitment these folks may just barely be into homebirth- if all the cards are just perfect- if they have an op baby or acynclitic and labor is taking a long time- maybe they are going to be ready to transfer sooner and be angry with me if I try to play it out longer--- even if the baby is ok

another comment --- even though we are not part of the HMO the labs are still covered via an order sent by us and we get the results.

May 20, 2006 | Unregistered CommenterAnonymous

Wow, how nice the HMOs will pick up the lab tab. Here (at least as far as I know), that isn't possible. BUT, you have given me pause for thought. Perhaps if I sent them to the lab itself? I'll have to try that out and see if it works.

Everyone's comments are really helpful and yes, it can be telling how married a woman is to co-care, but I also know that some women need to for reasons I might not understand or be privy to (a spouse that insists, etc.).

Aside: It constantly amazes me that I will spend a pregnancy with someone and then, in the transport, will learn details of their medical history they never shared with me. Why didn't they say anything? Were they afraid I would risk them out? Judge them? They forgot? How come they blurt out intimate information to complete strangers wearing white coats or scrubs? An interesting phenomenon.

May 21, 2006 | Unregistered CommenterNavelgazing Midwife

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