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Response to ACOG’s & the AMA’s Homebirth Resolution

The resolution says, en toto:

Whereas, Twenty-one states currently license midwives to attend home births, all using the certified professional midwife (CPM) credential (CPM or "lay midwives), not the certified midwives (CM) credential which both the American College of Obstetricians and Gynecologists (ACOG) and American College of Nurse Midwives (ACNM) recognize[1]; and

Whereas, There has been much attention in the media by celebrities having home deliveries, with recent Today Show headings such as Ricki Lake takes on baby birthing industry: Actress and former talk show host shares her at-home delivery in new film [2]; and

Whereas, An apparently uncomplicated pregnancy or delivery can quickly become very complicated in the setting of maternal hemorrhage, shoulder dystocia, eclampsia or other obstetric emergencies, necessitating the need for rigorous standards, appropriate oversight of obstetric providers, and the availability of emergency care, for the health of both the mother and the baby during a delivery; therefore be it

RESOLVED, That our American Medical Association support the recent American College of Obstetricians and Gynecologists (ACOG) statement that the safest setting for labor, delivery, and the immediate post-partum period is in the hospital, or a birthing center within a hospital complex, that meets standards jointly outlined by the American Academy of Pediatrics (AAP) and ACOG, or in a freestanding birthing center that meets the standards of the Accreditation Association for Ambulatory Health Care, The Joint Commission, or the American Association of Birth Centers [3] (New HOD Policy); and be it further

RESOLVED, That our AMA develop model legislation in support of the concept that the safest setting for labor, delivery, and the immediate post-partum period is in the hospital, or a birthing center within a hospital complex, that meets standards jointly outlined by the AAP and ACOG, or in a freestanding birthing center that meets the standards of the Accreditation Association for Ambulatory Health Care, The Joint Commission, or the American Association of Birth Centers. (Directive to Take Action)

Fiscal Note: Implement accordingly at estimated staff cost of $1,929.

Received: 04/28/08

[1] http://www.acog.org/departments/stateleg/MidwiferyYearinReview2007.pdf, accessed March 18, 2008

[2] www.today.msnbc.msn.com/id/22592397, accessed March 18, 2008

[3] www.acog.org/from_home/publications press_releases/nr02-06-06-2.cfm, accessed March 18, 2008

I respond:

It’s true. Hospitals are a safer place for mothers and babies to be during labor, delivery and postpartum. If unexpected emergencies appear, as they sometimes do, hospitals have more personnel, more medications and more opportunities to save a mother’s and baby’s life (cesarean deliveries, hysterectomies, ICU, etc.). Simply by virtue of being in the hospital, women have every medical, surgical or practical tool at their disposal; this spectrum of options cannot possibly be offered in the home.

When women having homebirths have complications, where do they run? To hospitals.

I can understand the thought process of doctors:

How come hospitals are so sucky as a rule, yet they are the gleaming white knights in an emergency? Why do we have to “clean up” the mess made at their beloved homebirths? Why do we legally risk ourselves when too many midwives don’t even have malpractice insurance? Why are we expected to accept patients whom we know nothing about in the middle of a life-threatening crisis and the midwife is able to release accountability and become the woman’s doula? Why, when a homebirth transport comes in, do the women still think they have a right to force us to adhere to an unrealistic and sometimes absurd birth plan? (I know you all certainly wonder) Why do women listen to midwives – women with far less education and experience than we have? How can women implicitly trust a woman with no license or a license that isn’t even nationally recognized or accepted? What do they say to get women to be so militant against doctors, hospitals and medicine?

The answer?


Hospitals and doctors make their own beds with their actions and words.

I understand there is very little to be gained on the economic front and that is not your motivation. I understand your heart-felt concern is for the life and health of the mother and baby. I understand that you feel any inconvenience should be tolerated and the “birth experience” is ancillary to the final outcome.

But, you see, the hospital “experience” is abhorrent to many women. When the experience includes procedures, medications and a dismissal of a woman’s individuality, the risk of being at home doesn’t seem so great after all. When women describe their hospital birth experiences in terms of “birth trauma,” “birth abuse,” and “birthrape,” something is terribly wrong with the system.

It is the hospital system itself that writes the homebirth script. If you want women to stop having homebirths, you are going to have to make some major changes in how you operate. I firmly believe if the hospital and physician care weren’t so egregiously offensive, cruel and inhumane, the Unassisted Childbirth (UC) movement wouldn’t be accelerating.

It is in the typical birthing experience in our country that sends women away from medical care and into the hands of homebirth midwives or planning UCs.

If I were on the committee to re-vamp the hospital system, being blunt with ACOG and the AMA, these would be my recommendations:

1. Stop de-personalizing women by putting them all in hideous hospital gowns.

I know you are probably rolling your eyes, but women HATE those gowns and understand that whatever they wear (of their own clothes) will be tossed into the garbage after the birth. Removing personal articles from women is tantamount to institutionalizing her. It’s vulgar.

2. Stop calling women “Momma,” “Mom,” “Mother,” and use her name.

It is rude at best to diminish a woman to a universally used word instead of acknowledging her individuality by remembering her name, not just the vagina, in front of you.

3. Since birth plans are so similar, perhaps listening to what the majority of them ask for would be prudent.

You know the drill… no continuous monitoring, encouraged (not just “allowed”) to ambulate in labor, encouraged to eat and drink in labor (and not assume every woman is headed to the operating room), no routine IV (most women are cool with a saline lock)… and how about bringing in birth balls, huge tubs and the accoutrements that homebirths and even in-hospital birth centers provide. If LMs, CPMs, CNMs and CMs can learn to maneuver around water labors, ambulating women and women on hands and knees, then surely educated physicians such as yourselves can.

4. Stop offering medications when women ask for them not to be mentioned.

We all know medications and epidurals are an inch away; we don’t need to be asked, “Where is your pain on a scale of 1 to 10?”. Women who want a natural birth work hard to not think of labor as pain. Again, if women in the hospital want something for pain, they darn well know they can ask for it. It is extremely disrespectful to a woman’s desire to re-frame her perception of pain in labor, all this Pain Scale stuff.

5. Educate nurses and yourselves about the importance of reverence in labor and birth.

Speak softly, knock before entering the room, look in a woman’s eyes, SLOW DOWN, listen when she speaks and THINK before you do; stop when she asks you to stop (touching her, the vaginal exam, lying to her, etc.). While this might be the 20th baby you’ve “delivered” today, it is that woman’s ONLY birth that day… perhaps the only baby she will ever have.

On the same note, when you are the surgeons during cesareans, SHUT UP about day-to-day topics and remember where you are – standing at the birth of a human being. Imagine the doctors and nurses yacking about the best sushi restaurant of the moment while your daughter (or spouse or mother) is taking her last breaths on earth. That is exactly what it feels like to many women when you act like you are cutting on an anesthetized woman. This woman lying there feels – perhaps not the skin incision; her heart and spirit are not numbed. The same respect and consideration are due humans joining the earth as humans leaving the earth.

6. Stop using your status as a means to manipulate or lie to women when they ask you questions.

Educated women are so tired of “the dead baby card.” There are times when life and death occur, but there is an enormous leap between, “We need to rupture your membranes so we can put an electrode on the baby or your baby might die,” and an abruption. Your exaggerations and attempts at –or out and out manifestations of- risks must stop. I believe the manipulations are one of the major reasons women ignore what obstetricians (and many nurses) say. If you always spoke the truth, your word would stand stronger. Crying wolf takes on a whole new meaning with physicians in the baby business. Nowhere else in medicine can you find this level of untruth streaming towards patients.

Just today a woman told me about her two mild decelerations in an eight-hour period that caused a doctor to take the husband outside and say the over-used phrase, “If she were my wife….” The doctor insisted on an “emergency cesarean,” yet the woman didn’t find herself in the operating room for another 4.5 hours. Interestingly, her surgery was at 5:00 pm. Coincidence? We are sure not. How can you wonder why she wants an out-of-hospital birth this time? Such absurd scenarios pepper your medical records; we see it all the time. Stop it.

7. Find a way to open your hearts to the pain and sadness in women whose births don’t go the way they expected.

Of course women “shouldn’t” have a cement-set vision of their births, but many women do have desires and wishes and it is deeply sad for them when things turn out differently. Try and talk to her like a human being in pain, not just a physical body that can be repaired with staples and numbed with Vicodin.

I understand your belief in the impossibility of seeing each woman as a human being. I understand you think if you hear every woman’s fears, pains and concerns you will surely commit suicide from all the pain foisted upon you. I understand that you think you just don’t have the time for all that emotional stuff. I understand that you believe listening is for a therapist, not a technician like a doctor. I understand you are busy, busy and just can’t possibly have any more time to offer women so they can whine and cry about this or that.

But, you are wrong.

The best and most beloved of doctors touch their clients… if not physically (although many do this as well), then emotionally. They take a few extra moments to listen to women, not just hear them. Re-frame your own perceptions of women speaking about sad, painful or difficult topics. It isn’t whining; she is speaking from her heart.

The great part of all of this, though, is that when you open yourself to a woman’s pain, you also have given her the space to share her joys, laughter and triumphs. It isn’t all negative “energy” that comes from pregnant, birthing and postpartum women. It is a mix of emotions, just as life is a mix of joy and sadness.

Through exquisite sadness comes exquisite joy.

8. Demand more (compassionately-trained) nursing staff in Labor & Delivery units.

Women know one reason they are encouraged to have epidurals is to keep them immobilized and quiet. (Did you know that?) It is much easier to staff a unit with women who don’t wander the halls or moan with each contraction. We know it can be disconcerting to watch women give birth without medication, especially when you believe women are suffering needlessly. But, one reason women choose midwives is we are able to BE with women in their transitory state of labor towards becoming a mother (or mother again). Being able to not just tolerate, but embrace an unmedicated woman’s labor is a wonderful gift of understanding and kindness to women. It’s okay if she’s loud. If she “scares the other women,” take the lead and explain the wonder of an unmedicated labor and birth to the frightened patient. People reflect the emotion you express, so express goodness instead of disgust or dismay when speaking to other patients regarding unmedicated laboring women. And really, if it’s so distressing to everyone, sound-proof the rooms; technology abounds.

Have nursing staff attend doula trainings to develop the compassion necessary for work in L&D units. Seeing birth from another angle can do nothing but expand her capabilities with unmedicated and medicated women alike.

9. Institute doulas in all L&Ds.

When the above goals are met, doulas become the physical and emotional augmentation for nurses in the unit. If the woman no longer has to hire a doula to fend off the medical interventions, she becomes what she was designed to be… the loving support person for the laboring couple.

10. Remember that birth is unpredictable.

You chose to be obstetricians. Birth happens during the entire 24 hour day and night. If you are one of the many that “nudges” women to birth during the daylight hours, whether with pitocin or cesareans, shame on you! If you are tired, either suck it up or find more help in your practice. If you are on-call, sit yourself at the hospital for your call time. Coming and going, wooshing in at the last second of birth, discussing a woman’s care via telephone and forcing women to stop pushing until you arrive are incredibly insensitive and sometimes cruel ways to treat a woman birthing a human being. Probably the number one complaint I hear about obstetricians is their absence in birth. Women are shocked at how little they see their doctor – any doctor - once in labor. A major reason women hire midwives is because they are physically present for labor, birth and postpartum. A nurse is not a replacement for your care. If you feel labor sitting is beneath your skills and a waste of your time, perhaps losing the OB portion of your title is called for. Women pay for your care. Isn’t it time you care?

11. Accept that as long as the System remains the way it is, women will continue having home and unassisted births.

There will always be a segment of society that desires homebirths and it behooves the medical world to do what it can to make the emergency transition from home to hospital palatable. While hearing “We want you to see we aren’t monsters in the hospital” when a woman moves from home to your L&D units is less than comforting, the sentiment behind it offers a moment of understanding in why some people choose homebirths in the first place. If all of you really want us homebirth advocates to not see you as monsters, quit acting like ones!

None of the above requests include anything about the prenatal and postpartum period. Often, your prenatal demeanor belittles a woman’s questions and concerns. It isn’t uncommon for your appointments to last mere moments after the multi-hour’d waits in the waiting and exam rooms. Calling a woman by her name and looking her in the eyes as you speak goes miles towards building trust and goodwill. Women who trust sue less. If there is no other motivation to humanize your demeanor, consider that studied fact; women who know their doctor well typically do not take them to court.

One reason midwives are rarely sued by the client, much to your bafflement, is exactly because communication between midwife and client is so extensive. Communication builds trust and trust allows the care provider to say, “We really need to do a cesarean,” and the client/patient saying, “Okay.” I know it sounds simplistic… and it is really that simple.

Risk is a part of life and those that choose homebirth are accepting that risk. Women don’t just want an “experience,” they want compassion, respect, some semblance of autonomy and the knowledge they are being seen as an individual, obtaining individualized care. It might seem selfish or bizarre that someone would take that risk, but it seems a risk to step into the hospital and be put on the production line that includes unwanted (and often unneeded) medications that are used to speed up the production line, being pressured to immobilize and be silenced and strong-arming that all too often ends in a cesarean.

While it seems I am only focusing on what you all need to do, I also know homebirth midwives could always use more education. The schools work hard, and are working harder, to include the vital information that keeps a woman safe at home and to know when a transfer/transport are necessary long before it gets to the critical stage. Midwives don’t wait until the last second; we understand the time element that can be crucial in life and death.

A glaring error in your Resolution says that CPMs are “lay midwives.” That is incorrect. A lay midwife has no formal education in midwifery, but only learns through apprenticeship or even on her own, rarely studies birth as is done now. It is rare to find a lay midwife, even in states where there is no licensing. In California, the National Association of Registered Midwives (NARM) exam (which, if passed, creates a CPM credential) is accepted by the Medical Board of California as the bar women must leap over in order to be licensed in the state. The same can be said for other states that have adopted the NARM exam as acceptable for licensing. Licensed and Certified Professional Midwives are not lay midwives. Using that sort of inflammatory language leaves the homebirth/natural birth advocates shaking their heads knowing you still don’t understand even the basics of what women want or need. I am the first to say licensed and CPM midwives’ education doesn’t equal a certified nurse midwives’, but we do have book learning, CPMs now graduating from accredited schools. We also have experience in natural birth and in knowing normal birth, we are hyper-aware of when birth deviates from the norm.

Another issue I have with your Resolution is your acceptance of out-of-hospital births with CNMs. Do you not know we carry the same equipment and medications (except for sedatives and an isolette) as what sits inside a free-standing birth center? Once again, having all the correct information before writing public pronouncements would help your image amongst those that have issues with you.

Instead of bashing midwives, wanting to outlaw homebirth and perpetuate half-(or un-) truths, understand we aren’t going anywhere and it might better serve women and babies if you supervised us (as CA law requires) or at least collaborated with us. Talk to your insurance carrier, create a resolution that you cannot be sued when patients transfer care from a midwife without taking that fact into account, find a way to tolerate (at least!) midwives so the relationship doesn’t have to be so antagonistic. We’ll also do our part in continuing to educate ourselves, create increased opportunities to practice vital skills and work towards licensing in all 50 states.

I know this is long, but I hope it’s been at least somewhat enlightening. Please consider the requests above. They will fast forward the goals you desire - to have more women birth in the hospital; the location we all know is the absolute physically safest place to have a baby. Physiologically, probably not. Interpreting the difference is paramount.

References (3)

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Reader Comments (66)

Brava! That's all I can say.

June 20, 2008 | Unregistered CommenterAnne

Bravo! Such a great summing up of not only what is wrong with the medical birth paradigm, but what can be done to change it. It is terribly saddening to see ACOG continually using scare tactics to push people away from the legitimacy of midwives and homebirth.

Thanks you!

June 20, 2008 | Unregistered CommenterKate

Nice blog to accidentally stumble upon. Ditto Kate.

My L&D nurse actually said, "I'm not used to this one-on-one nursing. Most women just shut up & get an epidural." (For the record, I asked to labor in the shower, to drink water, and to be left alone as much as possible.)

My MD was actually a "midwife in disguise" and I got the best hospital birth I could have. However, it was such a combative experience to get to that point, which was more exhausting than the birth. I am so glad I chose homebirth subsequently.

June 20, 2008 | Unregistered CommenterAnonymous

Perfect! Excellent! I have been considering writing a similar piece myself but I can add nothing to what you've said here. Bravo! Peace....

June 20, 2008 | Unregistered CommenterKneelingwoman

I think I lurve you! Well, and perfectly said!!

My first was hospital born, and the second was not. The third will not be either, unless there is horrible horribleness (which there won't be :P), and my partner is well aware of why I won't go. :P

June 20, 2008 | Unregistered CommenterAmanda

Perfectly put.

I had a homebirth for my first baby 2 months ago (wonderful CPM-attended waterbirth); I knew enough about the current climate in hospitals that I would simply not be able to have the kind of birth that I wanted to have in a hospital.

I don't object to being in a hospital when it's called for - I felt driven away from them as an acceptable place for my baby's birth due to exactly the kinds of policies and attitudes you describe.

If I felt that I would be respected, truly cared for, and treated as an intelligent human being during my labor, frankly, I would have felt okay with being in a hospital. But I know that the chances of the above are slim to nil, and if you ARE able to have a no- or even low-intervention birth in a hospital, even in the best case scenario you have to spend every moment of your labor fighting with strangers for it - many of whom may be downright hostile to your choices - in order to do so, and that's just not how I wanted to spend my childbirth.

I could go on, but why, when you've done it so eloquently? This should be seen by as many involved parties as possible. Send it out! Everywhere!

June 20, 2008 | Unregistered CommenterAnne Tegtmeier

Brilliant, beautiful post! Thank you!

June 20, 2008 | Unregistered CommenterWendy

Amen Sister!

I believe midwives should attend most births in the hospital. If you want to catch a baby vaginally, you should at least be a midwife or an OB with midwife training. I really think the OB side of things should be only when surgery is needed OR when a woman is truly high risk and not just AMA or a grand mulipara. I believe nurses should be freed up more by midwives who do sit and stay in the room with the patient. The nurse role in birth should change.

It's never the OB who sets the tone of a birth, it's that nurse. When I've felt great after birth emotionally (and noticed I recovered quickly) it's been the great nurses. When I've stressed out, it's been either incompetent nurses or the just plain mean nurse I had last time (I wonder if she felt angry or felt she was an adversary to me).

Treat a woman having a baby like a woman, not like a child who has to be tricked into things. Be honest. Oh, honesty goes a long way. I'd consent to interventions if I believed you when you said I needed them because you gave me some freedom when I didn't need the interventions. If a woman is on oxygen and on a monitor and wants to move...give her longer cords and tubes. If she wants to go to the bathroom and you're afraid she'll pop that baby out, think...bed pans or chux pads that are disposible can be used. Telling her she cannot go to the bathroom is demeaning (especially when she has to pee for four hours straight and ends up peeing on your precious sterile plain you created in the bed you won't let her leave).

If a woman doesn't have an epidural, remember she can feel your fingers in her vagina when you think you're helping by holding the "lip back" during multiple contractions. A woman feels violated often if you just keep your finger in there so you don't have to switch gloves (again, all that stretching and poking and four hours later we finally deliver without your help because of an OB who said let her move).

Okay, off of my late night rambling.

Dawn again...

June 20, 2008 | Unregistered CommenterAnonymous

Wonderful! I wouldn't have nearly so much trepidation about doctors and hospital births if they followed the recommendations you laid out.

They're reaping what they've sown, is all.

June 21, 2008 | Unregistered CommenterCappuccinoLife


That's all I can say about this brilliant, beautifully and intelligently written post. Bravo!

June 21, 2008 | Unregistered CommenterNoble Savage

Excellent post. My only criticism is that you seem to be suggesting that home birth is a response to the problems with the hospital system, and that if the hospital system just changed practices and attitudes women would stop having home births. "It is the hospital system itself that writes the homebirth script. If you want women to stop having homebirths, you are going to have to make some major changes in how you operate."

Not the case. I have had a wonderful, midwife-attended hospital birth with respectful treatment and no interventions, and I have had five home births. I would never choose to go to the hospital for labor or birth without a specific indication for medical intervention that could not be accomplished at home.

I would make this choice even if I believed that there was a 0.1% increased risk of adverse outcomes from my lack of proximity to immediate c/section. I think that one tenth of one percent is a risk I'm willing to take to give birth in my own home rather than in even the best and more respectful and accommodating of institutions. And there will always be women who feel this way, no matter how the hospital system is improved.

The College of Midwives of British Columbia's position statement on home birth states: "Even where home birth numbers are small, it has been observed that it is at home that birth is most likely to remain normal.Home birth provides midwives with an opportunity to observe normal birth without intervention, which can in turn lead to a reduction in interventions in hospital." For this reason, Canadian midwives are *required* to maintain a minimum number of home births as well as minimum number of hospital births as a requirement of registration. In a system where doctors rather than midwives are the lead maternity caregivers, it would not be a bad thing for them to be mandated to attend a home birth every year as a continuing education requirement.

June 21, 2008 | Unregistered CommenterSora


I'm just a post-partum nurse (for the past year) and have become a frequent reader. (I had hospital midwife deliveries in the 80s - hence the interest in midwifery.)

Regarding the pain scale you mentioned:
I have to use the pain scale frequently post C-section, post vaginal birth, and thanks to JACHO, the pain must be assessed, must have an intervention offered, must be re-assessed before one hour. The hospital is fined (I think) if this is not done AND documented that it was done.

I know it can be tiresome to my patients - being asked "and what is your pain on a scale of 1 to 10" and then being re-assessed later on this same subjective scale. At times, I blame my question on the government. : - )

June 21, 2008 | Unregistered Commenterbookwoman


I understand what you are saying and I *do* say that there will always be women who choose homebirth... even if the hospital were fabulous and wonderful.

However, many MANY women come to homebirth after terrible hospital births. I believe the number who do FAR outweigh those that choose homebirth because their first birth was wonderful.

There are also first-time moms (primips) who come to homebirth and often it is because of the control factor... they have heard the "horror stories" about hospitals from friends and just know intuitively they would do MUCH better at home.

I appreciate your writing. Great things to share.

And while I'm poking my head in the comments...

I really, REALLY appreciate the kind words. I worked really hard on this and am very proud of it. It made me shake with anticipation when I hit PUBLISH... I just knew it would resonate with many of my readers. Thank you all so, so much.

June 21, 2008 | Unregistered CommenterNavelgazing Midwife

I knew that JCAHO (Joint Commission on Accreditation of Healthcare Organizations) was the culprit of the pain scale - and it's annoying that nurses are required to use it. I knew exactly when it went down... nurses apologized for asking every 4 hours even when women asked, over and over, to not be asked that again.

I have my own issues with JCAHO. Grrrrr.

June 21, 2008 | Unregistered CommenterNavelgazing Midwife

I wish this post was a press release in response to these organizations.

June 21, 2008 | Unregistered CommenterJennifer

One of the reasons I am considering moving to Canada (yes! and my entire family!) is precisely for the reasons you noted. Midwive's should not have to serve women in this birth hating environment, women should not have to sacrifice their safety nor the safety of their babies to have "good" births (though of course a UC with a bad outcome would be an equally aweful birth). Midwives (CNMs vs CPMs) should not be pitted against one another nor have to fight for territory. It's such a frustrating situation.

June 21, 2008 | Unregistered CommenterRed Pomegranate

Please see motherfriendly.org for ten steps to a mother-friendly hospital. The steps have been ratified by more or less everyone and the data supporting them is also posted.

June 21, 2008 | Unregistered CommenterAnonymous

thank you for your brave and wise words. thanks also for editing the part about supervision & collaboration, (either you edited or I read incorrectly in a post-birth stupor) to say supervision is required in California. because personally I would prefer OB consultation and collaboration, not supervision. That strikes me as too hierarchical and disrespectful of midwives' education & experience. Why not a collaborative relationship where we can learn from each other (in an ideal world...)?

W/regards to treating the laboring woman with respect: I'd add that care providers should sit down as much as possible in the birth room. I am acutely aware of a power differential when everyone in the room is standing and the laboring woman is lying or sitting in bed, & often she is somewhat to completely exposed. What would it feel like if she were the tallest person in the room instead?

June 21, 2008 | Unregistered CommenterAbundant B'earth

No content editing was done... my guess is the birth-fatigue. :)

I did change the name of the title because it is apparent, after reading SEVERAL times, the resolution; it is NOT about enacting laws to outlaw homebirth. I think that's an odd misunderstanding from a variety of sources.

But, I did not change the content of the text.

June 21, 2008 | Unregistered CommenterNavelgazing Midwife

Please don't tell JCAHO on us, but at my hospital if we have a client laboring who prefers not to have pain meds, we make up the pain scales - and we make it up a fair bit for other women as well. We are required to document a pain scale EVERY HOUR in active labor, and document a response to that pain level and nobody seems to enjoy trying to "rate their pain" every hour. My hospital still provides one to one nursing care for every laboring woman, and we pride ourselves on providing excellent labor support, so it's certainly not that women's comfort is not being addressed, just that we have found that JCAHO's idea of addressing it is pretty useless and annoying to many women.
I am a hospital based birth attendant and try hard to do everything on your list. I attend my clients throughout active labor. The secret to being able to do this is that I'm a family doc and do about 60-70 births a year. It is an inconvenience to reschedule my office hours (although since I don't practice "daylight obstetrics" I have a lot of middle of the night births) and to miss things in my personal life, I tell my clients that one of the benefits of going to a lower tech birth attendant who isn't a busy surgeon is that I can attend my own clients.
OBs who are also doing gyne surgeries, trying to cram 30 patients a day through their office, and attending hundreds of births a year probably can't provide labor support and need to limit their time spent at births.
That's why I feel that maternity care ought to be provided by us lower tech providers - midwives and maybe family docs, and leave the surgeries to the surgeons

June 21, 2008 | Unregistered Commenterdoctorjen

Good goddess, Dr. Jen... I love you! From your practice to practices around the United States.

You are the best. Thanks for telling/reminding us how wonderful you are.

June 21, 2008 | Unregistered CommenterNavelgazing Midwife

wonderful post.

June 22, 2008 | Unregistered Commentermidwife

I will make up numbers for the pain scale to put into my required documentation, on my natural birthing women, because I know that *I* would not want to be asked to "rate your pain on a scale of 1-10" while I'm trying to deal with a contraction!

June 22, 2008 | Unregistered CommenterAtYourCervix

Know any family physicians in the Johnson County Kansas area like Dr.Jen? I want one who would stay there during my labor, what a treat to have one like that!


June 22, 2008 | Unregistered CommenterAnonymous

Great post. I agree with Abundant B'earth that supervision implies disrespect and mistrust in midwife education and skill. I am very pro-collaboration and consultation, and referral when things are out of scope of the midwife.

Like another commenter, I do think nurses can make or break the experience. I've seen it with my own eyes and am appalled at how some of my nursing peers treat women.

It's also good to see other providers (nurses and docs) make up numbers on the stupid pain scale. So glad I am not the only one. My nursing education makes me feel guilty about doing that.

Again, great post!

June 23, 2008 | Unregistered CommenterLabor Nurse

This is such an excellent post, and so well written.

When I sent a scathing letter via email to my former OB/Gyn asking for my medical records and telling them I was leaving the practice, I got a call from the director of the practice herself asking me to elaborate on my experiences and apologizing for being such a disappointment.

She kept saying, "Mmm hmm. Mmm hmm. I totally agree with you. You're right, this is not the way it should be." So I stopped talking for a minute and asked, "If you agree that things should be different, then why aren't they?" She couldn't answer.

It's so frustrating to me that people don't understand that in this, pregnancy and birth, as in life, there has to be balance. Certainly the mother's birth experience does not and should not trump the result of a healthy baby, but is it necessary to COMPLETELY discount women's experiences, and make us feel like birthing pods on an assembly line?

And how on earth can people compare getting your appendix removed to giving birth? As in, "If you were getting your appendix removed, would you ask the doctor to dim the lights? Put your appendix on your chest immediately following the extraction? Play mood music?"

Are these people kidding? I guess herein lies the difference between seeing birth as a medical event and a physiological one, with different requirements from doctors regarding sensitivity, compassion, and respect. Honestly, are those things too much to ask for?

And shouldn't ALL doctors, not just obstetricians, be held to these same standards? If someone was having a leg amputated and was awake for the procedure, would the doctors talk about what they did that weekend, or would it be a somber event? Shouldn't it be the same for the sobbing mother who hoped for a natural birth but is now getting cut open?

I wish there was some way to know that someone from ACOG and the AMA is reading what you write.

June 23, 2008 | Unregistered CommenterMommy Dearest

I've seen in a couple places folks make the comment that the AMA/ACOG is not meaning to outlaw homebirth. I see that their statement does not in fact say anything about criminalizing homebirth. My question, though, is what exactly do we think they mean by "RESOLVED, That our AMA develop model legislation in support of the concept that the safest setting for labor, delivery, and the immediate post-partum period is in the hospital, or a birthing center within a hospital complex, that meets standards jointly outlined by the AAP and ACOG, or in a freestanding birthing center that meets the standards of the Accreditation Association for Ambulatory Health Care, The Joint Commission, or the American Association of Birth Centers. (Directive to Take Action)
What is this model legislation supposed to do exactly? How do you develop legislation is support of a concept exactly? (Please note I am not asking this rhetorically or with sarcastic bent, I really don't understand what is meant by this.)

June 23, 2008 | Unregistered Commenterdoctorjen

I too make up my patient's pain scores most of the time...if they want pain meds (for real) they know to ask me, that's one of the first questions I ask them and I let them know, if/when you decide you need it, let me know. JCAHO needs to get their head out of their you-know-what!

June 24, 2008 | Unregistered CommenterAnonymous

Thank you doctorjen. My question exactly. Not rhetorical either.

June 24, 2008 | Unregistered CommenterJudit

NGM, you know how that has played out in California, why put that into your otherwise helpful post?

June 24, 2008 | Unregistered CommenterAndie

Re: Supervision.

It was meant as a "could you at least attempt to do what the law requires of us?" Not that I want to be supervised by obstetricians. Collaboration is my own desire and goal.

I can see where people would have an issue with how I wrote it, though.

June 24, 2008 | Unregistered CommenterNavelgazing Midwife

Dr. Jen:

I think the word "legislation" is where the confusion/distress comes in.

How I read it is that the AMA/ACOG themselves want to create language *in their own rules and regulations* regarding how they feel about homebirth. I believe they want to have very strong language, speaking in the positive about hospital and birth center birth as opposed to in the negative against homebirth, but language loud enough to be heard by the media and women who might be on the fence about where to birth.

Anyone else hear it this way? To me, legislation doesn't mean legal/the law, but their own inner legislation.

June 24, 2008 | Unregistered CommenterNavelgazing Midwife

It's not a doctor's job to be compassionate. It's a doctor's job to be a doctor. Some are compassionate, some are not. You can't dictate their behavior anymore than they can dictate yours!

Boo-hoo if your birth plan didn't go exactly as planned. None do, even at home. Be happy you have a healthy baby and quit whining that you had to wear a hospital gown. Is it really that big of an issue? Is you life and your baby's life ruined because a doctor called you "Mom" instead of calling you by name?

Giving birth is a big, important event... but it doesn't mean you get whatever you want. Have a home birth or don't - it doesn't change the statistics that prove hospitals are safer. If you think that the risk is worth it, give birth at home! No one is stopping you. Just quit complaining about it!

June 24, 2008 | Unregistered CommenterAnonymous

What a tender heart you have... filled with compassion and empathy.

*rolling eyes*

So, women should be treated like meat on hooks and accept that? It's okay that ALL humanity is removed in the name of being medical? Why do women speak about "bedside manner" being so vital when picking a doctor? All a person has to go on initially IS bedside manner/compassion/kindness/connection to another human being.

Your reasoning is EXACTLY why doctors should ONLY be tackling the complicated cases. Your attitude is vulgar when it comes to normally birthing women. If you are a "care provider," I pray you work only in surgery with anesthetized people. I'm sure I would spit on a nurse like you.

June 24, 2008 | Unregistered CommenterNavelgazing Midwife

Probably not spit for real, but I'd sure want to.

*shaking head and baffled at some people's lack of humanity*

June 24, 2008 | Unregistered CommenterNavelgazing Midwife

You know, as a physician, I used to think that the only thing that mattered was "competence" by which I meant skills and knowledge, and that a good bedside manner was all fluff in addition. After practicing 7 years, I no longer believe that. Being compassionate, being a good listener, being willing to not be an authority figure but a partner in health, and not having my personal mental health tied up in being obeyed - these things all make me a better doctor. All of those so-called extra, or touchy-feely things I feel are fairly essential to good practice. The grand majority of decision making I do is based on what my clients tell me, and fostering excellent communication makes it far more likely that my clients will tell me the truth, will be comfortable sharing uncomfortable facts with me, and will not be distracted by emotional distress at my behavior and unable to accurately share their true concerns and issues with me. Also, building that open communication and trust with my clients means when push comes to shove, we trust each other and can make decisions quickly without either myself or the client having to wonder if either one of us is being untruthful, or manipulative, or whatever.
I've heard this argument before - who cares about wearing a gown, or being called by your name, or whatever, that isn't what competence is about - but I challenge any healthcare provider to truly ask themselves why it is so important to them to insist on things that matter so little. If the gown is no big deal, than neither is wearing an old t-shirt from home. In all areas of medicine, I feel it is vitally important to provide good evidence informed care and let go of all those things that have no basis in evidence (and not just in maternity care, as a family doc, I find many areas of medicine where we do things because "them's the rules" and I'm still working on letting go of them one by one.)
I would argue for partnering with our clients to make decisions together and for healthcare professionals to not feel they have to be so controlling in areas that just don't matter. These small steps go a long way in promoting trust, establishing a willingness to listen, and paving the way for the best working relationship with our clients - and I fully believe that those skills demonstrate a provider's competence.
I'm not arguing that it's better to have good bedside manner than competence, but that the two cannot be adequately separated, and that the physician or other provider who cannot even acknowledge the emotional needs of their clients is in far more danger of making decisions not fully informed, wasting precious time arguing with "difficult" patients, and generating mistrust when they need to be building trust.

June 24, 2008 | Unregistered Commenterdoctorjen

Thanks for your post and your blog, I am a long time lurker, and love the wisdom and wit that I find here. I am a relatively new L&D nurse, taking the first steps towards getting my CNM. I love my job when I am able to connect with my patient, provide labor support (not just pit and epidural management) and attend deliveries where both mother and child are respected and treated gently. I hate it when I see OBs doing things like making women push when they aren't having a ctx just because the ballgame is on in the breakroom, or cutting episiotomies so they can make it out the door by dinner time, or starting a repair and forgetting that their patient is unblocked. There is nothing, except maybe a wicked case of PIH, that could convince me to give birth in the hospital environment when I have children someday. It is heart breaking to me that most of the nurses I work with would only let 2 or 3 of the 20 or so OB GYNS that we work with actually deliver them. The process by which physicians are reprimanded for their bad, non-evidence based practice is completely laughable. I am trying to hang in there, and every now and then I have a fun precipitous delivery or lovely howling woman to keep me coming back.

June 24, 2008 | Unregistered Commentermemilie

Thank you navelgazer for an excellent response. As someone in self-imposed exile from L&D nursing, and a rabid homebirth advocate I find your words so refreshing.

Thanks to you to Dr. Jen. Your words are a healing balm.

Dawn, there is a DO in Olathe that practices at Olathe Medical Center with a CNM that can provide a good hospital-based experience.

June 25, 2008 | Unregistered CommenterLaborpayne

Now I want to get pregnant, seriously. I would love to TRUST my care provider for freaking once!

I will have to email you to find out who. I will have to get my stuff changed so my yearly can be switched.


June 25, 2008 | Unregistered CommenterAnonymous

Great points in (almost all) of the comments/discussion.
JACHO is right on the $ when it comes to the pain scale, assessment, treatment and reassessment....but I do NOT believe that pain from L&D is the same kind of pain as from a broken bone, PO recovery or having something removed from your body. They make the mistake of lumping *all* pain into the same category because of their medical approach to L&D.

Labor pain is the ONLY pain that indicates something is going RIGHT within our bodies. All other pain indicates that there is a problem.
I do not believe that "forcing" women to be a part of the JACHO pain assessment is a healthy way to support laboring women.

All of this boils down to the "mentality" of birth. The hospital mentality (by procedures, protocols, SOC, etc) all indicate that birth is a medical emergency in waiting. (and if they have to wait too long, then they'll help it along with medical conveniences and poor attitudes of patience).

That's the way they are trained and indoctinated. Everything is wrong until proven otherwise.

In my personal birthing experiences (as well as doula for 87 births), most midwifery care is everything is right and unfolding perfectly until proven otherwise. (I also believe that many times, you get what you focus on but that is another post)

What that we could modify and began to change the way that women view labor and birth? People like the anonymous poster who ordered us to shut up and stop whining are the very attitudes who keep us out of the hospital birthing arena.

Different women want different things from their birth experiences and anyone who would suggest that we put those things over the health of our babies just doesn't understand that the health of our baby is often the VERY reason we make the choices that we do.

To the medical model of birth - stop being so territorial and threatened and open your friggin eyes/ears/hands to what we are saying and learn to provide what women want (on both sides of the river)and perhaps you'll get more of what you want (women to birth in hospitals)

I had an emergency section (& it really was an emergency) wtih my first birth, a VBAC in a birthing center with a CNM for my 2nd, a water/home birth with my 3rd with a CPM and then had her come back wtih me for my 4th birth. I can CLEARLY define why I made the choices that I made and would do them again in a heartbeat.

The hospital cannot give me what I want in the case of a normal, uncomplicated labor and delivery.

June 26, 2008 | Unregistered CommenterDora

Your post implies that you have a problem with home birth. I can understand your opposition UC, but home birth?

And I must disagree that the hospital is the safest place for labor, birth, and post partum. What about staph infections? What about unnecessary C-sections? What about routines that slow labor and actually cause fetal distress? What about, as you mentioned in your post, birth trauma. As Penny Simkin would say, safety is more than just coming out alive.

June 26, 2008 | Unregistered CommenterJenni

um... I am a homebirth midwife! I do not have "issues" with homebirth. Interesting way to read what I wrote, though.

When discussing safety, the general understanding means: What is available should ANY *birth-related* complication appear. In that context, hospital IS, indeed, safer. BUT, as you bring up, there are other, more peripheral issues that can and do come into play when taking home versus hospital birth into consideration.

It is why some women choose homebirth even when it seems so obvious to others why they should be choosing to birth in the hospital. We all have our limitations and what we will put up with. With home and hospital birthers, they are usually very different standards, indeed.

June 26, 2008 | Unregistered CommenterNavelgazing Midwife

I know you're a homebirth midwife. But here are a few quotes from your post:

"If you want women to stop having homebirths, you are going to have to make some major changes in how you operate."

"It is in the typical birthing experience in our country that sends women away from medical care and into the hands of homebirth midwives . . . "

"Accept that as long as the System remains the way it is, women will continue having home . . . births."

Don't get me wrong; I liked the majority of your post. It just seems like you're trying to appeal to OB/GYNs by advising them on how to make home birth even less popular. That troubles me.

June 26, 2008 | Unregistered CommenterJenni

It was a great and thoughtful post!
I too may have been thinking along the same lines as Jenni when I first read, but I have read much of your blog, and was aware of what you were saying. It is a trade off and any midwife/mom who has had a 3 minute shoulder dystocia or had a client walk into a birth center and birth a very asphyxiated baby within 60 seconds of arrival understands the trade off all to well.
Honestly it is the lies and lack of true informed consent that really gets me, the deliberate shit that doctors and nurses say to clients to get their way.
I loved the bit-o-truth about how our not so wonderful medical pros write the book for home birth! So true!
Great post!

June 27, 2008 | Unregistered Commenternadahfmidwife

I *am* speaking to doctors and I *am* trying to tell them how to make hospital birth more appealing. There are a significant number of women who would deliver in the hospital if they were humane, but choose homebirth because of the climate in hospitals.

There will always be women who want homebirths no matter how wonderful hospitals make it for women, but just because YOU wouldn't want to have a normal birth in the hospital doesn't mean the hospital shouldn't civilize births there.

There are also a load of women who waffle between home and hospital birthing, but choose hospitals for insurance reasons. They, too, deserve to have beautiful births.

All those women who deliver in the hospital should have the births I describe (and more!)... and I do believe that hospitals cause enough women to leave their walls that they really do need to get it together.

Perhaps we should agree to disagree?

June 27, 2008 | Unregistered CommenterNavelgazing Midwife

This... this.

"There will always be women who want homebirths no matter how wonderful hospitals make it for women, but just because YOU wouldn't want to have a normal birth in the hospital doesn't mean the hospital shouldn't civilize births there.

There are also a load of women who waffle between home and hospital birthing, but choose hospitals for insurance reasons. They, too, deserve to have beautiful births.

All those women who deliver in the hospital should have the births I describe (and more!)... and I do believe that hospitals cause enough women to leave their walls that they really do need to get it together. "

This is what i try to explain to some maniacal and fanatic homebirth advocates in my internet circles. I deserve to have a normal, natural birth in a hospital. I deserve to be treated like a human being and not a number on a page. This is what I wish for all women, for our future.

It should not be a choice between "hospital=birth rape/some other traumatic. horrible experience" or "homebirth/UC." That is a large leap for some women.

You are an advocate for ALL women, not only those who choose the path you think they should. I so appreciate your blog. gzt

June 27, 2008 | Unregistered CommenterMommy Dearest

i liked what you said here, although i personally have the opinion that it is physically safer during a normal birth and some slightly off from normal births to be home than in the hospital.
infection rates alone are worth staying home for if there are no life threatening reasons to transfer.
if AMA succeeds in making homebirth illegal in america, i will be moving far far away.
i really dont think they have a chance in hell though.

your recommendations to the hospitals is great, although i think the problem is that all the improvements would cost too much money, and after all isnt that what hospitals are all about? making money?

June 27, 2008 | Unregistered CommenterJackieD


You have said a lot of really great things about how hospitals might vastly improve their maternity services, but you totally stunned me with a couple of your key (to me) comments. My responses here are not placed necessarily in order of their appearance in your post.

Response to key comment #1:No, hospitals DON'T dictate or in any way create the homebirth 'movement'. Sure, it's true that there are women who are 'driven' to homebirth out of fear/anger/disgust with hospital birth. BUT--Home is the original, natural (given by nature/God/dess) and most lengthy tradition of safe birth. If birth, and birth at home (and even 'unassisted birth') were not inherently safe enough, then we would certainly not be enjoying the high human population this Earth bears--a population whose foundation numbers were created well BEFORE hospital birth (or even doctor- attended at home) became 'fashionable, trendy, a cause celebre' (yes....it was DOCS who first leaned on the cause celebre to disseminate the new fashion of doctor-attended and eventually, hospital birth. Please read your childbirth history....). Doctors and hospitals created the hospital birth experience through extensive and tireless propaganda and political campaigning. Women now are waking up and reclaiming, not newly creating, a homebirth tradition.

Response to key comment #2: Uh, so what if homebirthing women run to the hospital for emergencies/problems??? Why should this be a problem for anyone? First of all, 'doctors' are for 'medical problems'--duh. Docs can whine all they want about having to cover an emergency for previously unknown clients--but I am not fooled by this rationalization. They simply (in general, with exceptions) resent that anyone would choose homebirth and a midwife's care instead of their own from the outset; they simply resent the lack of control they have in such situations, esp where parents arrive with an expectation of True Informed Consent (which by the way IS THE LAW).

SEcondly, if AMA and ACOG would just accept the natural primacy of homebirth, they would be helping make better med. services available at home so that many families wouldn't even have to transport for some med. assistance. There are LOTS of things that could be provided/done at home by properly trained personnel having a properly outfitted ambulance. Why is this not the norm?

Thirdly, some families go to the hospital when homebirth seems to be 'going wrong' (or really is) only because they feel they must cover their tails legally...some feel powerless to allow nature/god/dess to take it's course even when they might want to, because of the legal issues that might land them in very hot water. Hot water, by the way, that has been largely created by the AMA who does very much have influence on legislation and the courts.

Response to key comment #3: I think anyone who tries to put a benign spin on the AMA's 'legislation intentions' must be simply and totally in the dark about that group's long history of political and legislative mechinations. YES, they intend to outlaw homebirth if/where at all possible! YES, they will certainly participate in the creation of laws that criminilize homebirth--they ALREADY HAVE, they ALREADY ARE. Do you really have no idea of the influence of the AMA on the personnel and policies of your state's med. board??? Just for instance.

Response to key comment #4: Where on Earth do you get the notion that hospital birth is actually safer than homebirth? How can anyone versed in birth and places of birth possibly believe that, as a general statement? I can't even say more about that. I'm sorry--this is an entirely untrue statement and I'm shocked that a homebirth midwife would say it.

Sure--hospitals could do a far better job of providing birth services--and you have done a good job of naming the changes needed. They could be far more heartful and humane, and might be causing far fewer medical and emotional problems than they currently are. But I can't really understand why you bother to focus on this--instead of paying attention instead to homebirthing women and midwives, and making our lives better. I can't help but wonder why, instead, you are not using your energy to help motivate large scale protests by women/families against the AMA's resolution (and power in our lives) and in support of LESS AMA control and MORE constitutionally-based personal control in these matters.

June 29, 2008 | Unregistered CommenterMaggie

I decided to focus on a different aspect of this issue than nearly every other blog/website/message board.

I rally for civilized hospital births because I have clients that might NEED to birth in the hospital! Shouldn't SOMEONE speak about the issues that alienate and frighten our homebirth contingency? How can you NOT speak up about the horrid hospital birthing environment?!

I am more than just a homebirth midwife. I am a woman who lives in this society and a woman who assists and attends births in the hospital - in the midwife-as-doula capacity as well as monitrice-as-doula capacity. I am also sister/friend/neighbor to MANY more hospital birthers than homebirthers. Shouldn't I make this issue my own since I feel I have something to add to the discussion?

I understand the politics of the AMA.

I understand COMPLETELY the history of birth.

I encourage you to look elsewhere in our world to see what birth used to be like before antibiotics and cesareans.

How you can even remotely think homebirth is *completely, 100% safer* than hospital birth shows me you haven't been to enough births to see the tenuousness, the unpredictability and the depth of drama birth can create.

I witness the beauty and amazingness and wonder of birth far, far more than the drama, yet I *move* when nature leaps out of bounds.

I might not be the midwife for you... your possibly thinking I live in dread and fear of what birth can do, but I am not that kind of midwife.

I am the kind of midwife who RESPECTS birth and in that respect, I permit her to unfold in her own precious way. I have been blessed with a lot of knowledge about birth and I hold it lovingly and use it wisely.

I am the kind of midwife I would want at my own births.

June 29, 2008 | Unregistered CommenterNavelgazing Midwife

Thank you for this post.

I risk out of homebirth. The hospital birth of my first child was such a profoundly disempowering experience that, given my lack of other reasonable options, my partner and I have decided not to have any more children. I will not go through that again.

I truly believe that humanizing hospital birth is part and parcel of advancing all of women's choices in birth, including homebirth.

June 29, 2008 | Unregistered CommenterM.O.

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