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Friday
Jun202008

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?

Nothing.

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.

Thursday
May102007

"How Women Become Mothers"

A magnificent article/review of Ricki Lake's The Business of Being Born can be found here.

Please spread the link around!!