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Monday
Jun272011

Disclosing Homebirth Plans to OB

On my Navelgazing Midwife Facebook Page, I asked:

If you had an OB and had/are having a homebirth, did you tell your OB? What did s/he have to say about it? Have any of you been fired from care for disclosing your homebirth plans?

I asked this because I’ve had a couple of recent inquiries about whether to share their upcoming homebirth plans with their doctor or not. My advice is to explore why you want to tell the doctor. Do you want him/her to be your back-up in case of an emergency? Do you feel that not telling is lying by omission? Do you honestly want to know what your OB thinks about your having a homebirth… whether you’re a safe candidate or not? Each woman has to answer those questions for themselves, but every single one of them also has to be prepared to be dismissed from care if their doctor isn’t too keen on the whole homebirth thing. It might not be fair, but that’s the way it is. For many doctors, even those who might be supportive (albeit, grudgingly), their malpractice insurance might not allow them to speak about their feelings, much less act upon them.

Here's how the women answered my question. No names given, of course.

C: No, I didn't want to deal with any comments my OB would have about my home birth plans. I saw the OB three times in my pregnancy for ultrasound and labs, and my midwife for all the other visits. This time I'm not planning to see an OB at all.

 J: I'm pretty upfront - my occupation is "homebirth midwife" after all. She didn't flinch one bit, although I know she personally is not a homebirth fan. But she gave me the consultation I needed. I like her a lot. She pulls no punches, just tells you what she thinks, no manipulation.

M: I hinted without saying my plans. She apparently never got the memo. After <my baby> was born (planned homebirth with a midwife turned unplanned UC [Unassisted Childbirth]), I called her to say the baby was born. She wanted me to come in right away and "get checked out". When I refused, she pretty much refused me ANY postpartum care (battled thrush, mastitis, depression); didn't matter. She was pissed and though she never dismissed me from her practice, she refused to see me and instead my appointments were with the [mean, nasty, devoid of feeling] CNM.

J: There is only one practice in our area, a family doc, who will knowingly do dual care for home birth women. Even the CNMs will kick you out of their practice if they find out you are having a home birth. Seriously! There is one group of CNMs who will do dual care on a "don't-ask-don't-tell" basis, but the others are openly hostile to home birthers, as are the OBs in our city. Any hint that a woman is considering a home birth and she'll get a discontinue care letter.

K: I sought care from the OB who performed my Cesarean for scar tissue issues, and since I was newly pregnant, but not her patient she wouldn't see me. A week later I got a letter dismissing me from her practice along with a tear-out of the increased-neonatal-death-with-planned-homebirth article. Had a beautiful healing HBAC three months ago. 

L: It was very much our intention to have an OB attended homebirth.

J: Recently, I had a client switch care to me for Out-of-Hospital birth. Then, she got cellulitis/mastitis on day four and her OB took her back, called stuff in, saw her in person when that didn't work and treated her beautifully. I really appreciate that. She didn't have to do that. She could have sentenced my client to the walk-in clinic of uncertain-care.

L: My OB took it pretty well, although he made sure to mention he wouldn't let his own wife or daughter do it, and he asked that I please call him after the birth to let him know that the baby and I both "survived." At a later GYN visit he was very excited to show me an article in some medical journal entitled "What If My Patient Wants a Homebirth?" and how, thanks to me, he has a better answer now if it comes up again. I found the whole experience amusing and I'll probably go back to him for shadow care when we have our next home birth. He delivered my first daughter in the hospital, so I did have a bit more history with him than just random prenatal visits along the way.

M: I was seeing an OB for fertility issues. When I completed the first trimester and was comfortably out of my personal "worry zone" for repeat miscarriage, I let her know that I was switching to a licensed midwife for a homebirth and she supported me completely. She is one of the local favorites for natural hospital birth and midwife backup. We are lucky to have her!

N: I'm seeing an OB but have UC plans, which I most definitely have not shared!

C: My OB used to run a solo practice and is now partnered with two other doctors. He was wonderfully supportive of my unmedicated hospital births when he was the only OB there, but I wouldn't go back to them because I don't know and trust his partners. When I was pregnant with a miscarriage I called to see if I could get in for an ultrasound and was told I would have to schedule the full OB workup at ten weeks in order to be seen in their office at all.

E: With my second pregnancy (first home birth) I told my OB at around 16 weeks. Every visit included a diatribe about the risks of home birth. Finally, at 32 weeks I said 'please make a note in my chart that I don't wish to discuss it any further and if I have to keep going through this I will terminate my care'. It was not mentioned again. With my 3rd pregnancy, the practice already knew my history and was more relaxed about it. My 4th and 5th pregnancies I had no OB care.

P: LOL to the term "fired". Doctors do not pay their patients.

Navelgazing Midwife: I understand, P, but when you can be "dismissed" from their care, it isn't uncommon to consider that fired. It does seem like the only person who can fire should be the woman firing her provider, but The System is twisted enough that women ARE fired from care.

C: I've told my OB for both planned homebirths (the first of which transferred to the hospital). I was offered the same prenatal care as anyone else birthing with his practice (which was still not as wonderful as my homebirth midwife's prenatal care). 

The second time, only had prenatal care I didn't have access to with my homebirth midwife after my first visit to say, "I'm pregnant and having a homebirth, but would like to have a plan B option." The other two visits were for an ultrasound and Group B Strep screening. My OB wished me well and made sure to tell me to not to hesitate coming to the hospital if I need anything.

J: Yes. In 2001 in San Diego. It sucked.

A: My OBs obviously don't recommend it, but they give me care anyway. Though, I am convinced it isn't the same care since they know. I also am monitored by a midwife. So many other women I know that see the same OBs tell me such different stories about how their visits go. I guess maybe they think I get everything I need from the midwife, so don't monitor me as closely. I am convinced they just pick numbers to write in my chart as measurements.

E: I saw an ob a few times -- I specifically drove an hour each way to see the one homebirth friendly ob in my city. I told her and she was cool.

K: I didn't tell my OB face to face, but I did tell the front office I wanted copies of my records because I was considering a homebirth. They let me have them for $1 a page. At the next visit, the Dr. didn't ask me about it so I didn't volunteer anything. I didn't get fired; I quietly fired him. Called the office to cancel the next appointment; they were closed (weird, it wasn't a holiday), so left a voicemail saying I was canceling the next appointment because I has chosen to have a homebirth. I was 29 weeks. I never heard from them at all after that.

C: I saw an OB a few times to do genetic counseling (I was paranoid being Advanced Maternal Age) and never told him my plans to UC.

R: I didn't share with the OB my plans of a UC!

A: It was important to me to co-care, and also to not be lectured. So I did not feel obliged to divulge my birth plans.

J: My former OB has two CNMs in his practice. I mentioned, on the first visit, that I was considering a homebirth. (First pregnancy but had been to him for well visits.) He mentioned that with his practice, I could have a, "home-style birth in the hospital" but otherwise didn't push. At 20 weeks, I switched care to my homebirth midwife. Everyone at his practice was cooperative and I never looked back.

C: I was fired from the practice.

S: I'm from the United Kingdom and I was under OB care, when I told her I was going to have a homebirth she went completely mad! Told me I would have a heart attack if I didn't come into hospital as I had Pregnancy Induced Hypertension. I spoke to the head of midwifery and she was great! In the end, our baby arrived unassisted in our living room. If i would of gone to hospital she would of been born in the car! 

R: Nope she never knew. 

L: It is interesting to read everyone's comments. I have an OB and decided not to see him for prenatal care because I didn't want to risk being ousted OR putting him in an awkward position with the Clinic he's with. So when I needed a script for tests, I saw a local DO who provides parallel care for others as well.

A: In my area, your general practitioner cares for you until around 20 weeks at which point you are transferred to OB care until the end of your pregnancy (New Brunswick, Canada). In a small percentage of cases GPs do deliveries and only transfer care or consult if needed. For my second pregnancy, I advised my GP that I'd hired a midwife for a homebirth, but that I still wanted to see an OB/GYN to introduce myself. I went for one visit with the OB and told him our plans. He reviewed my charts from my previous birth, asked if I was confident our midwife had enough training and told me there was a 99% chance that I wouldn't need him or the hospital. I was totally flabbergasted. He suggested I send in my charts from the midwife after 36 weeks in case I needed to transfer. I wish I could call this OB wonderful on all counts but, I've since worked with him for a few doula clients, he's got some good and bad points, is all I'll say. He also supports placentophagy... go figure!  

L: I planned on having a homebirth; then we ended up seeing OBs. My husband mentioned my wanting to homebirth and the OB said basically "Oh no, you don't want that." Never said anything about it to him again but, tried to find out if there was a practising midwife around - nothing. If I'd said something at nanowrimo write-ins though, I'd have had a better idea (as I found out a year later).

While I didn't homebirth, I really wish I had done what I wanted in the first place - my husband finally ended up talking to his midwife-friend who he'd kept telling me I should contact from that first anti-homebirth sentiment we got; she was there for us and was a whole lot better than the L&D staff - suggested helpful things before they even thought of them. If I were pregnant again, I'd be planning on a homebirth again.

R: I was planning a homebirth w/a CNM (with family doctor back-up) until 27 weeks when an ultrasound revealed twins. I switched to a hospital-based OB group with CNMs and tried to avoid revealing my PRIOR plans -- even though I was no longer considering a homebirth, I feared being treated as a "nutso" and disrespected for my original choice. The doctors already seemed annoyed enough at my lack of early-pregnancy ultrasounds and switching to their practice so late in pregnancy. I needed them to take me seriously and be partners in my care and didn't want to alienate anyone. I didn't even want the nurses in the hospital to know. When we arrived at the hospital at 39w5d with me in VERY active labor and the nurses rushing around, my mom mentioned it and I got upset, even though it clearly didn't matter at that point (the babies were born an hour after I arrived, I don't think anyone even had time to read my birth plan). For reference, my care providers are in the area described by J. above, so the fear of bias wasn't just in my head!

J: I live in Washington State where CNM are licensed to do home births, so when I told my OBs, they were supportive and fine with it. In their practice they employed two CNMs that delivered babies in the hospital. They also told me if I needed to transfer to the hospital to have the nurses page them and they would cover my birth. So I really did have the best of both worlds. I realize that I am in a minority!

Me again.

I had concurrent care with my second baby, my UC baby. I certainly didn't tell the OBs I saw at the military hospital. I got enough crap from them after she was born. They even sent Child Protective Services out to the house to make sure we weren't neglectful parents. No, just really, really hands-off. (Much more so then than I am now!) With my third baby, my military CNMs did know of my homebirth plans with a legal hebamme (German midwife) and were wonderful about it. When my plans changed because my membranes had been ruptured longer than the hebamme could legally keep me as a client, the midwives embraced me as a hospital-birthing mama, promising to make the birth as peaceful as possible. I ended up delivering in the car with a CNM and an OB; I wouldn't consider it "peaceful." Hilarious was more like it.

In a perfect world, we'd all be able to share our whole stories... care would be seamless, whoever we were sitting in front of. It makes me sigh with frustration that women are often forced to either lie or omit information because they might lose an important link in their pregnancy care. I applaud the providers that withstand the enormous pressure to punish and ignore women who are choosing to birth at home. Thank you for your tenacity! I also applaud the women who walk the thin line of another form of Don't Ask, Don't Tell... the kind that can get you kicked out, just as readily as when it was gays in the military. Both are just wrong.

 

Monday
Jun282010

Why Doctors Don't Care

So, a couple of weeks ago, Abi Cotler O’Roarty wrote a piece for the Huffington Post called “Why I’m Protesting for My Natural-Birth Friendly OB.” In there, she shared the plight of Dr. Robert Biter, an OB/GYN here in San Diego and his suspension and reinstatement from Scripps Encinitas Hospital. During the suspension, hundreds of women came out and protested in front of Scripps Encinitas, even Ricki Lake joining us one day. If there was ever any question about Dr. Biter’s magnetism, these demonstrations took care of that. For those that’ve read my blog for any length of time, you know I’ve written about “Dr. Wonderful” for years now. (The first birth I did with him was three years ago last week!) While I knew I wasn’t alone in admiring the man, it was stunning to see the outpouring of compassion for his situation. 

Abi’s article spoke eloquently about her birth experience with Dr. Biter and how different it was from her first birth where she’d been given a mangling episiotomy from a resident at UCSD. Dr. Biter repaired her severe damage and then guided Abi, during a tumultuous labor, as she birthed her baby over an intact perineum. All sorts of legalities are going on regarding Dr. Biter and six lawsuits pending (all GYN), but hoards of us continue supporting him in his calling to help women. 

Then, Abi wrote a follow-up piece asking “Are Today’s OBs Giving Women What They Really Want?” Much of the article continued with Dr. Biter’s ordeal, sharing why women will sit for hours in his waiting room or holding placards in the street, all the while being nine months pregnant! It wasn’t until the last paragraph that she says: 

“But I wonder, if more doctors were willing to stay present with a woman in birth and allow her labor to move at its own pace, would they too have a packed waiting room and hundreds of picketers clambering to support their mission? If word of mouth has any place in medicine today, then Dr. Biter's success might just be a lesson to OB's everywhere: start respecting a woman's right to choose the kind of birth that's right for her, or lose your business to someone who will.” 

I wanted more of that meat, the flesh I expected the article to explore. So, I decided I would explore it myself. 

Over these last three years, I’ve watched woman after woman abandon their doctors and traipse over to Dr. Biter’s practice. Once I learned what he was about, his style (if you will), I totally understood the draw. Others make snide comments about Hero Worship or deifying him. I chuckle knowing those that throw the epithets around are seriously jealous and/or don’t have any other way to explain the loyalty Dr. Biter enjoys. Women don’t throw themselves at his feet, don’t keep their husbands from going to prenatal appointments so they could have him for themselves and certainly don’t see him as anything but a kind and giving man who happens to be an OB. Why is it so strange for a man to be loving to another human being? Why are his motives questioned by those that don’t know him? What is so hard about believing someone really can perform an act of kindness without expecting something in return? Amusingly, his tactile motives have been called into question, again by those who don’t know what they are talking about… that he must be hitting on the women, that he must be being sexually inappropriate with them. What’s so funny about that is the ongoing speculation that he must be gay to be able to be so kind to women in labor and birth! For crying in a bucket, who gives a whit about his sexuality! (None of the women I know do.) He just is

So, why don’t doctors offer care like Dr. Biter does? Office visits that linger, company to women during long labors, gentle hugs of encouragement, standing back and holding the space as women wander around in their own clothes during their rites of passage… and cooing over a mother’s success and the perfection of the new baby she just brought into the world… why don’t they mimic these behaviors? 

I know there are a myriad of reasons that, collectively, create the doctor’s attitudes. Talking to doctors, nurses and nurse midwives over the last couple of decades, this is one of the questions I’ve often asked. 

Over and over, one remark kept coming up: It is too painful to make such a deep emotional investment in a client. Apparently, caring (not just attending) for a patient sucks the life out of the doctor, so it’s easier to put up walls and treat everyone as a thing instead of a living being. Even as a midwife, we are taught not to cry with our clients. Well, I break that rule, probably with each woman. Of course, there is the importance of not sobbing on a client, not turning the tables so she is soothing you, but showing compassion through tears, in my opinion, is never a bad thing. (Probably because I do it, right?) Dr. Biter typically cries at each birth. I am sure other doctors are equally horrified and disgusted by his behavior. Patients, on the other hand, find his empathy validating of their triumphant experiences. 

Lately, I’ve noticed a difference in my care at Kaiser (an HMO… a damn good one, as far as I’m concerned). My weight isn’t the primary issue discussed, the triage nurses have been offering to take my blood pressure on my lower arm so the cuff isn’t so tight, the doctors have begun sitting on the stool (lower than the patient on the table?!? Horrors!), looking me in the eye and not standing with my chart in one hand and the door handle in the other. Might compassion be becoming fashionable? (I haven’t heard there’s any change to the gross care of women in L&D, unfortunately.) 

Compassion takes time. For most doctors, there is never enough time. The things that must be done are crammed together so the things they want to do get the bulk of the day/week/month/year/career. Compassion requires listening to women and seeing each one as an individual. It might require remembering her name or, at the very least, her face. Compassion puts the others’ feelings and experiences above your own. Convenience is not a hallmark of compassion. 

It’s distressing hearing how prenatal visits are with pregnant women’s doctors (and even some nurse midwives)… how they wait and wait and wait, then go pee and wait some more, sometimes undressed on the exam table. The nurse does the vitals and once the doctor comes in, s/he is there for maybe five minutes, seeing the woman as a batch of numbers: blood pressure, weight, weeks pregnant, fundal height and fetal heart rate. Psych-social issues are to be addressed elsewhere; if the woman is lucky, she might even get a piece of paper with referrals on it. The doctor doesn’t have time for chitty-chatting (I’ve heard that phrase on several occasions), so assembly line-ing patients doesn’t begin in the delivery room, but here, in the doctor’s office. Chitty-chatting would not only mean taking time, but getting emotionally invested in the woman. If he’s emotionally invested, he will think about her after she’s gone. He might worry about her when he should be listening to the next lady’s baby. He might find concern disconcerting as his concern for woman after woman piles into a giant heap of hardships, difficulties, happy thoughts, worries, joy and pain. It’s far easier to blankly stand before every woman, giving her equal care, adding a few more tests for this patient or sending that one in to be induced. 

What’s baffling to me is how women put up with this! This is care?!? 

Doctors continue this practice because it works for them. In and out, both in the office and in L&D. Herd them in and spit them out; the faster the better. And we are well-trained patients, following the un-written rules created by a society of men. 

I have a distinct feeling that care in labor isn’t going to change until we change the care we receive as prenatal patients (clients!). Those who want a natural birth in the hospital often choose a CNM for their care. CNMs are wont to spend, if not buckets more time, at least spoonfuls more than most doctors. And that time spent is reflected in the labor process. CNMs spend much more time (typically) with moms in labor than an OB would. Doctors, however, breeze in for prenatals and breeze in to catch the baby, deliver a placenta and sew up a mom… before zipping out once again. 

We homebirth midwives spend loads of time with our clients. If we only see them for their regularly scheduled appointments (rare for me), we’ve spend a whole lot more time with them than the doctors or CNMs would. The average CPM prenatal (from what I know around the country) is one hour and then, factoring in the labor, birth and postpartum visits, we really do get to know the nuances of our clients and their families. We see them as those numbers the doctors do, PLUS as spiritual, emotional and integrated human beings that have thoughts, wishes, hopes, dreams and fears. In our time with women, we address these aspects that, while not directly affecting the baby as, say, GBS might, do affect the entire family, including the baby. 

Women share with us things they would never share with their doctors –because the doctors not only have a wall for themselves, but that wall also keeps women at arm’s length. We’re able to hear that a woman’s husband might be having an affair or that her dietary habits aren’t what she tells the OB they are. Women will ask us about sex, saying, “I can’t talk about this with my doctor.” If a woman can’t talk about the very act that created the reason for the doctor appointment itself, there is something very wrong with that system. 

There are some notable exceptions to the status quo of the OB in America today. But, it is sad that they can be called out by name and city. It should be the other way around! The yucky ones should be pushpins on the map to avoid and the great OBs everywhere else. 

I haven’t come up with the “cure” for the crappy prenatal care/crappy birth care situation. And as stupid as it is that we have to figure out a solution, no one else is going to. I know that, until doctors take the time to see women as whole human beings, they will never be able to respect the choices she makes in birth. One cannot happen without the other.

Where do we start?