AJOG editorial rejects the ethic that autonomy is a fundamental human right

Read it for yourself:  Planned Homebirth: the professional responsibility response

This article represents a serious attack on home birth and on patient centered care in the United States.  The attack is based on poor research and runs roughshod over established rights to bodily integrity.

This article was “Presented at European Congress of Perinatal Medicine, Paris, France, June 13, 2012.”  So not only does the article attack home birth, it also represents an attempt to “export” to the rest of the world a position that the obstetric profession, not mothers, should have the final decision on birth, at a time when that isn’t even legally defensible here in the United States.

The primary author, a Fellow of ACOG, faculty member at Cornell University Department of Obstetrics and Gynecology, should be aware of American jurisprudence supporting patient autonomy and right to informed consent.  We can also assume that he is aware that systems of midwife attended homebirth are well established and integrated into the health delivery systems of many European countries.  And yet, it is the decision of the 2010 European Court of Human Rights case that seems to have prompted this “critical evaluation”.  This was a case where obstetrician, Agnes Gereb, was imprisoned for attending home births in Hungary.  Her story is told in the movie “Freedom for Birth”, produced by One World Birth.

The authors’ conclusion is the height of hubris: “We urge obstetricians, other concerned physicians, midwives and other obstetric providers, and their professional associations to eschew rights-based reductionism in the ethics of planned home birth and replace rights-based reductionism with an ethics based on professional responsibility.”  In other words, reject the ethic that autonomy is a fundamental human right.

Who decides what is reasonable?

Fiduciary responsibility is, by definition, putting the needs of the patient first.  If fiduciary responsibility was the same as professional responsibility, this would not be an either/or proposition.  The author defines professional responsibility as a model of decision making where “the patient has the right to select from medically reasonable alternatives”.  Who gets to decide what is reasonable?  Why, the obstetrician, of course.  And if the patient opts for an alternative the obstetrician has not deemed reasonable, then the obstetrician is justified in placing the “rights of the fetus” ahead of the rights of the first patient (the mother), although what is actually being asserted is the obstetrician’s own agenda over the rights of his/her patient.

Buried in this article, and lost in the conclusion, is one very true statement: “The first professional responsibility of obstetricians is to ensure that hospital delivery is safe, respectful, and compassionate.” The author goes on to describe what that needs to look like, and in an easily overlooked fashion concedes that hospitals aren’t always safe places either.  In fact, both infant and maternal mortality are on the rise in the United States, at a time when hospitals have a near monopoly on birth.  This failing falls squarely at the feet of ACOG and the collective actions of its Fellows, which calls to mind this quote:

“ACOG no longer has the moral authority to set standards in maternity care…. It has made too many self-aggrandizing and self-protective recommendations (e.g. against home birth, videotaping birth, and VBAC) that limit the freedom of American women and families.” (M. Wagner, Born In The USA, 2006, University of California Press, p. 32)

Overlooking this reality completely, the author also overlooks the most reliable research on the safety of home birth, while noting that ACOG “accepts the findings of Wax et al”, a thoroughly discredited piece of published research that does not stand as prima fascia evidence against the safety of home birth.  Even Amy Tuteur (no friend to home birth) says this AJOG article is “poorly researched, relies on bad studies and is woefully paternalistic”.

One contradiction stands out as the authors call for “safe, respectful, and compassionate” hospital delivery.  No hospital birth can be truly respectful if the birth is happening in the hospital because the physician disrespects the woman’s right to an alternative and has rigged the system to eliminate access to all legal alternatives.

Illinois Friends of Midwives also responds to this article, calling it “paternalistic and misogynistic."
Wendy Gordon, LM, CPM, MPH, Midwives Alliance Division of Research, published an in-depth response on Science and Sensibility.

Another resource in any discussion on the safety of birth, and home birth in particular, can be found on Citizens for Midwifery website.

Yours in safe and respectful maternity care,
Willa Powell & the CfM Team

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Maternal-Fetal Conflict?

Mamatoto is a Swahili word meaning "motherbaby"--reflecting the concept that mother and infant are not two separate people, but an interrelated dyad. What impacts one impacts the other and what is good for one is good for the other. The midwifery and birth communities have used this concept for quite some time and more recently some maternal health researchers have also referenced the idea of the "maternal nest"--that even following birth, the mother is the baby's "habitat."

The Science and Sensibility blog is hosting their sixth blog carnival around the theme of mother-baby togetherness after birth, based on Lamaze's Healthy Birth Practice #6: Keep Mother and Baby Together – It’s Best for Mother, Baby, and Breastfeeding.

This carnival topic prompted me to revisit a post I made some time ago about maternal-fetal conflict:

Critiques of homebirth sometimes rest on a (flawed) assumption of maternal-fetal conflict (which is also invoked to describe situations with substance abuse or other risky behavior). In the Fall 2007 issue of CfM News, now President Willa Powell wrote about maternal-fetal conflict in response to an ABC segment on unassisted birth. She wrote:

[quoting the expert physician interviewed for the segment] "The few hours of labor are the most dangerous time during the entire lifetime of that soon to be born child. Because of this, I would argue, all soon to be born children have a right to access to immediate cesarean delivery, and women who insist on denying this right are irresponsible."

This was the only professional opinion in the program on unassisted birth, and he set up a typical expression of an obstetric community belief: the “maternal-fetal conflict.” The notion is that there are two “patients”, where the mother’s desires are sometimes in conflict with the well-being of the baby, and that the obstetrician has a moral/professional obligation to abandon the mother in favor of the baby.

I have to remind myself that Dr. Chervenak is setting up a false choice. In fact, this scenario is a “doctor-patient conflict”. The mother wants what’s best for herself and her child, but she disagrees with her doctor about what is, in fact, best. Women are making choices they believe are best for themselves and best for their babies, but those choices are often at odds with what doctors consider best for both, and certainly at odds with what is best for the obstetrician!

In the book Birth Tides, the author discusses maternal-fetal conflict:

According to obstetricians, the infant's need to be born in what they have defined as a safe environment, i.e. an obstetric unit, takes precedence over the mother's desire to give birth in what doctors have described as the comfort of her own home. It is a perspective that pits the baby's needs against those of the mother, setting 'overriding' physical needs against 'mere' psychological ones. It is rooted in the perception that the baby is a passenger in the carriage of its mother's body--the 'hard and soft passages,' as they are called. It is also rooted in the notion of the mind-body split, in the idea that the two are separate and function, somehow, independently of each other, just like the passenger and the passages. While women may speak about 'carrying' babies, they do not see themselves as 'carriers,' any more than they regard their babies as 'parasites' in the 'maternal environment.' If you see your baby as a part of you, there can be no conflicts on interests between you.

I previously linked to a book review that explores this concept of the more aptly described "obstetric conflict" in even more depth.

As we consider healthy birth practice six, I think it is fitting to remember that mother and baby dyads are NOT independent of each other. I have written before about the concept of mamatoto--or, motherbaby--the idea that mother and baby are a single psychobiological organism whose needs are in harmony (what's good for one is good for the other).

As Willa concluded in her CfM News article, "...we must reject the language that portrays a mother as hostile to her baby, just because she disagrees with her doctor."

--
Molly
CfM Blogger

Book Review: Birth Day

Book Review: Birth Day: A Pediatrician Explores the Science, the History, and the Wonder of Childbirth
By Mark Sloan, M.D.
Ballantine Books, 2009
ISBN 978-0-345-50286-5
370 pages, hardcover, $25

Reviewed by Molly Remer, MSW, ICCE
http://talkbirth.wordpress.com

Written in a fast-paced journalistic rather than academic style, Birth Day is a biological, historical, and sociocultural look at birth in our species, highlighting the experiences and skills of the fetus and newborn infant. The focus of Birth Day is on childbirth, but as a pediatrician, the emphasis of the journey in this book is on the baby and its development, skills, and remarkable adaptations to the womb and to life on earth. The book contains frequent references to evolution, which is not a concern to me, but may be to other readers.

The author’s personal experiences and observations are interwoven skillfully throughout the book lending an engaging “human” component—I loved his wry and occasionally self-deprecating honesty and realistic sharing. We read about the births of both of his children (one a very long labor eventually with an epidural and the second a scheduled cesarean due to placenta previa), his experiences as a medical student, and his observations as a hospital and clinic pediatrician. Dr. Sloan has been present at over 3000 births as a hospital pediatrician and 20 births as the baby “catcher” (medical school OB rotation). There is no real mention of homebirth, but occasional, supportive references to CNMs and to doulas.

The author has a healthy respect for the process of birth, noting in his conclusion that “…the most striking thing to me after all these years is how often such a complicated process goes right.” As a breastfeeding counselor, an element that I loved in this book was the author’s complete acceptance and integration of the importance and normalcy of the birth-breastfeeding continuum as well as the assumption of breastfeeding present throughout (bottles and formula do not make a single appearance throughout the 370 pages). This presentation was both very refreshing and completely appropriate.

The content of Birth Day was reminiscent of Birth by Tina Cassidy, with the primary difference being the emphasis on the infant’s experiences. There were occasional instances of questionable data such as, “An unattended breech birth, for example, is nearly always fatal to mother and child.” (?!)

Fast paced and often very funny, the author of Birth Day has a knack for explaining complicated concepts in simple terms and using effective analogies. I learned some new facts about the history of birth and was pretty captivated by the whole ride.

--
Disclosure: I received a complimentary copy of this book for review purposes.

Medical Care is a Consumer Issue

From the book Women and Doctors some good reminders that medical care is a consumer issue (and a business!):

"Keep in mind that health care is a business. Doctors would like to have you see them as thorough professionals, unsullied by such crass considerations as income and market share. Don't believe it! Not only are genuinely unethical and mercenary doctors actively marketing their operations, but well-intentioned doctors are doing it as well. In fact, the health-care system as a whole is actively pursuing you as a patient through the same techniques that everyone with a product is using to get you to be a customer. The danger lies in your failing to understand that. Be a smart and wary consumer, and keep the entire health-care system in the same perspective that you probably already have placed car dealers, insurance salesmen, and makers of food products."

And on a related note, here are some stats from the recent US Maternity Care Facts from Childbirth Connection:

In 2006, combined facility charges billed for "mother's pregnancy and delivery" and "newborn infants" ($86 billion) far exceeded charges for any other hospital condition in the United States.

In 2006, 42% of all maternal childbirth-related hospital stays were billed to Medicaid. The two most common conditions billed to Medicaid as the primary payer in 2007 were pregnancy and childbirth (28%) and newborns (26%), which together comprised 53% of discharges billed to Medicaid.

"Mother's pregnancy and delivery" and "newborn infants" were the first and third most expensive conditions billed to private insurance in 2006, involving 14% of hospital charges to private insurers, or $41 billion.

--
Molly
CfM Blogger

Cardiology & Birth Analogy

I'm sorting through my large stacks of books containing pages I've marked with quotes/ideas I'd like to share via various blogs. The pile has become very overwhelming and I've decided I need to pare it down...decide what to post about and what to put back on my shelf. Some time ago, I shared a birth analogy from the book Mother's Intention about health clubs needing to be staffed with cardiologists (just in case one of the patrons had a heart problem while exercising).

Later in the book, the author employs another helpful analogy, again using cardiology as an example to make a point about inappropriately applied maternity care interventions:

What if...

You went to the doctor complaining of chest pain...not bad pain, but bothersome. To rule out a heart problem, the caregiver listens to your heart. He scowls, then excuses himself to make a phone call. He comes back in and tells you that you need to be admitted to the hospital for a test that requires the use of a drug. The drug has a low risk of serious complications, which is why you must be in the hospital, but he feels confident in taking that risk.

You go, and within minutes of having the drug administered, you have a heart attack. You are rushed into emergency open-heart surgery. Complications arise, but they are dealt with. You nearly bleed to death, but with a blood replacement you recover.

The repair doesn't go well, which may mean you will need further surgery later...maybe even a heart transplant. You definitely will need to change your previously active lifestyle.

Later, you discover the call your care provider places wasn't to a specialist, but an HMO lawyer who advised him not to let you walk out the door, just in case the routine examination missed a serious problem. You also learn there were less dangerous ways to determine if there could be a minor problem.

It turns out, you really did have a minor case of heartburn. All you have been through was unavoidable, but "As long as everyone's ok now...that's all that matters"...right?

A comment like that, to a mother who has suffered unnecessarily, when she would have--or could have had--the result of a live, healthy baby without such sacrifice, disregards her feelings of loss.

Parents should be expecting more!

In another book waiting in my pile (Open Season), I was amused to see a quote marked in which OBGYN care is referred to as "gynogadgetry."

And in another book, The Doula Guide to Birth, I marked another quote that feels very relevant to the others above: [a March 2006 study in the American Journal of Obstetrics & Gynecology] "reviewed all fifty-five of ACOG's current practice bulletins, calling these articles 'perhaps the most influential publications for clinicians involved with obstetric and gynecological care.' The study concluded that 'among the 438 recommendations made by ACOG, less than one third [23 percent] are based on good and consistent scientific evidence.'"

Enough said.

--
Molly
CfM Blogger

Grassroots Network: OB supports delayed cord clamping

Dear Friends,

As we try to change the way childbirth is conducted, the question of when the cord is clamped affects both mothers and babies. While immediate cord clamping is habitual in hospital-based obstetrics, midwives, especially out-of-hospital, typically delay cord clamping at least until the cord has stopped pulsing.

Now Nicholas Fogelson (an OB?) has written an excellent commentary on the need for this OB practice to change, including references:

http://academicobgyn.com/2009/12/03/delayed-cord-clamping-should-be-standard-practice-in-obstetrics/

Delayed Cord Clamping Should Be Standard Practice in Obstetrics
December 3, 2009

For anyone working to achieve this change in practice, this will be a good resource. And there are good comments to which Fogelson has promptly written thoughtful responses.

Yet another instance of midwives being ahead of the game!

Sincerely,
Susan Hodges "gatekeeper"

Book Review: Permission to Mother

Permission to Mother
By Denise Punger, MD, IBCLC
OutskirtsPress 2007
Softcover, 257 pages
ISBN: 978-1-4327-0385-1
www.twofloridadocs.com

Reviewed by Molly Remer, MSW, ICCE
http://talkbirth.wordpress.com

Written by a doctor and mother of three sons, Permission to Mother is a series of short, autobiographical vignettes about various natural mothering topics. The style is both a strength and weakness of the book. The bite-sized stories are perfect for a busy mother to read in between household tasks or while nursing her baby. However, the brevity precludes depth and most topics lacked full exploration. Many of the “chapters” are only one page in length (sometimes only half a page). The longest are 3-4 pages. This is not sufficient space to really examine a topic—instead the sections are more like short anecdotes/snippets from the author’s life and experiences, often ending almost as soon as they began.

The book is organized into four parts. The stories in Part One cover a variety of topics beginning with Dr. Punger’s experiences with birth in medical school, then moving into her own birth experiences, her experiences working with a doula, and homebirth observations. The highlight of the whole book is the birth story of her third son—an undiagnosed double footling breech birth at home.

The second section of the book address “The Breastfeeding Years” and includes a wide variety of stories about nursing during pregnancy, tandem nursing, working and breastfeeding, becoming an IBCLC, breastfeeding through anesthesia, and also segments about the family bed, cloth diapering, homeschooling, and unschooling. A surprising story in this section called “My Spiritual Journey as a Physician, Mother and IBCLC,” is actually a story about her sons’ circumcisions. Depending on your personal feelings about circumcision, this section may sadden or disappoint you or it my provide reassurance about your own decisions.

Part Three addresses “Breastfeeding Medicine” and explores some case examples from the author’s medical practice with nursing mothers. Again, the segments are so brief that they contain little of clinical value to other practitioners.

Part Four is a brief section about “Why I Do the Work I Do” and consists of letters to the author from satisfied clients.

As I read this book, I had the persistent feeling that much of the content had been written for other sources—perhaps a magazine or a blog. There was a choppiness to the writing that conveyed this sense. And, as previously referenced, the extremely short, vignette format lent an unsatisfying incompleteness to many of the stories. I also noted a higher-than-average number of minor errors in the text contributing an amateur quality to the book.

Despite these critiques, it was refreshing to read about natural mothering from a physician’s perspective and I enjoyed her insights about breastfeeding medicine. (Can you imagine how the world might look if more physicians practiced with this background and experience?!) If you are looking for short, personal narrative experiences of natural mothering, you may enjoy the simple style and friendly stories in Permission to Mother.

--
Originally published in The CAPPA Quarterly, October 2008.

Disclosure: I received a complimentary copy of this book for review purposes.