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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GRN: ACOG Is Not Qualified to Evaluate the Practice of Midwives

Grassroots News Message 2011-03-16 "ACOG Is Not Qualified to Evaluate the Practice of Midwives" March 11, 2011 Grassroots Network Message ACOG Releases Opinion on Homebirth Hello Friends, After a January press release announcement, the American Congress of Obstetricians and Gynecologists (ACOG) officially issued its current statement on the safety of homebirth in February (ACOG, 2011.). The numerous challenges posed by a physician’s trade organization releasing an opinion about homebirths (which most obstetricians do not attend), based on unsound research, will be explored below. In the statement, ACOG acknowledges that they “respect the rights of a woman to make a medically informed decision about delivery,” but again asserts its long-held belief that hospitals and birth centers are the safest settings for birth. ACOG’s opinion on homebirth is based largely on results from a poorly conducted, scientifically weak meta-analytic review (Wax et al., 2010). This paper has been roundly criticized for its methodological flaws and shortcomings, rendering its conclusions inaccurate at best. You can check out these links for critiques: The Big Push Science and Sensibility Our Bodies Our Blog Midwifery Today Scribd That ACOG would use poor quality science is a testament to the fact that ACOG is a private trade organization, not a scientific organization, whose primary goal is to support the interests of its members (for more on this). Perhaps even more important, ACOG, as a group, lacks any comprehensive knowledge of or experience with midwifery practice. ACOG is not qualified to evaluate the practices of midwives given the vast differences between modern obstetric practice and midwifery practice. Most obstetricians have never observed a single woman labor and give birth without any medical intervention, let alone in her own home. It is essential to keep these considerations in mind when evaluating recommendations from a trade organization such as ACOG. While ACOG’s opinion on homebirth is not surprising, it is important to consider the potential negative impact it could have on the future of women’s access to homebirth. Some may recall the 1999 ACOG practice bulletin recommending that VBACs (vaginal birth after cesarean) only be attempted in hospitals with immediately available emergency surgical teams. This recommendation had an immediate (and long lasting) chilling effect on the number of VBACs occurring in the United States (see the figure below, reprinted from Roberts et al., 2007.). If ACOG’s statement on homebirth is used to set policies in the same way that the VBAC opinion was, access to homebirth could be jeopardized for many women for a long time to come. In the statement, ACOG asserts that several of the current, well-conducted empirical studies illustrating the safety of homebirth cannot be generalized to the United States, given that they were conducted in countries in which midwifery is well integrated into the health care system. In light of this assertion, we call on ACOG as well as national and state medical societies to understand that criticism and to begin to support (rather than obstruct) efforts to license and integrate well-trained professional midwives into main stream health care delivery in the United States. Sincerely, Lauren Korfine, PhD for CfM References: American College of Obstetricians and Gynecologists, Committee on Obstetric Practice (2011). Committee Opinion: Planned Home Birth, Obstetrics and Gynecology, 117(2), 1-4 Roberts, R. G., Deutchman, M., King, V. J., Fryer, G. E., & Miyoshi, T. J. (2007). Changing policies on vaginal birth after cesarean: impact on access. Birth, 34, 316-322 Wax, J.R., Lucas, F.L., Lamont, M., Pinette, M.G., Cartin, A., Blackstone, J. (2010). Maternal and newborn outcomes in planned homebirth vs. planned hospital births: A metaanalysis. American Journal of Obstetrics and Gynecology, 243, e1-8.) From Roberts et al., 2007. Number of births by cesarean section over time. Note the sharp decline in VBACs after 1999, the year ACOG issued its VBAC practice bulletin that lead to VBAC bans in many hospitals.

LEARN MORE ABOUT CFM SIGN UP HERE TO RECEIVE GRASSROOTS NEWS MESSAGES! SHARE WITH OTHERS IN YOUR AREA! Feel free to forward and share on facebook with friends, family and colleagues SEND US NEWS! If you find news, resources, or other valuable information that you think should be posted on the Grassroots Network, please send it to info@cfmidwifery. org... with "For the grassroots network" in the subject line. We will definitely consider using them! LEARN ABOUT CfM! Check out our website Check out our blog Like us on Facebook GET INVOLVED! Are you interested in volunteering with some dynamic women in a supportive environment? Help CfM promote the Midwives Model of Care! We have many ways to get more involved. Get in touch with us! DONATE! CfM couldn't do it without your support. Make your contribution here!

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.

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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.

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Molly
CfM Blogger

Response to Boston Radio Program About CPMs

To hear a recent discussion on legislature to create a registry for CMs and CPMs in Massachusetts and read the posted comments, click on this link. Dr Eugene DeClerq did a great job during the interview and our own Susan Hodges posted the following informative comment:

Midwives and midwifery clients and advocates have been working for many years to achieve meaningful regulation for midwives in Massachusetts. The current bill this radio show refers to would create a Board of Registration of Midwifery, which will license and regulate the practice of Certified Nurse Midwives (CNMs), Certified Midwives (CMs), and Certified Professional Midwives (CPMs). The point of having such legislation is both to create a reasonable system of accountability AND to increase access to midwives in all settings.

There is no one type of provider or one birth setting that is best for all pregnant women, because we are all unique individuals. There are always some risks in childbirth, no matter where or with whom you give birth. For most women, pregnancy is a normal process that proceeds on its own unless interfered with, but this process can also be affected by the mother’s beliefs and feelings, and by how she is treated by the people who are with her and their beliefs about birth. Furthermore, a great deal of standard hospital and obstetric practices and interventions applied to women in labor are not based on any evidence at all. Therefore, it is only reasonable that women should have a range of proven options available to them. Passing legislation that enables credentialed midwives to practice legally and with accountability makes sense. No one is going to force any woman to have a home birth, or to have a midwife, but for those of us who would prefer to be attended by a midwife in hospital, birth center or home, such legislation would certainly increase our options.

ACOG is a professional organization accountable only to its members. It does not have evidence to support its anti-home birth stance, it is based purely on belief! See their statement at http://www.acog.org/from_home/publications/press_releases/nr02-06-08-2.cfm . It states: “ACOG believes that the safest setting for labor, delivery, and the immediate postpartum period is in the hospital, or a birthing center …” without citing a single reference to support this “belief”. So much for scientific medicine. In fact, a large collection of studies over many years and in a number of countries has consistently shown that for a woman having a normal pregnancy a planned homebirth with a trained midwife is as safe as the hospital, with far fewer interventions and less morbidity for mothers and babies. (for just one example, see http://www.cfmidwifery.org/pdf/CPM2000.pdf and see more fact sheets and resources on the CfM website).

Obstetricians and hospitals are not accountable for their outcomes. For example, while the cesarean rates have been increasing every year (now over 30%!!) in the absence of any medical justification for such high rates, no one in state or federal government offices has even been asking: Are we having better outcomes for mothers and babies with these rates of cesarean sections? In fact, research has shown that when cesarean rates rise above 10 to 15%, more babies and mothers die than are saved by the surgery. Similarly, no one has been asking about outcomes related to the huge increases in induction, use of drugs to intensify labor, and use of epidurals. In contrast, even the relatively rare instances of a midwife transferring a laboring woman to a hospital for medical care usually are scrutinized critically.

Informed consent in hospital-based maternity care in general is a joke – women are not adequately informed about the pros and cons (including the % risk) for specific interventions and for NOT doing the intervention. Hospitals and obstetricians rarely if ever inform women that there are economic incentives behind each and every “suggested” practice and intervention, ie, conflicts of interest. In contrast, most states that regulate out-of-hospital midwives require extensive disclosure documents that the client must read and sign.

A woman can find out far more information about a used car than she can find out about her obstetrician. In most states, she may be able with some difficulty to find out rates for some interventions (cesarean section, induction) and outcomes (perinatal death, maternal death) for a local hospital, but not for individual obstetricians. For rates of episiotomies and cesarean sections, research has shown enormous variation among individual providers, even within the same hospital, demonstrating the lack of evidence for the high rates of these practices. A midwife is trained to observe and monitor, but not to intervene unless there is clear justification, because her focus is on supporting the normal birth, not getting in the way. For most women choosing a midwife, especially outside the hospital, she can be pretty sure she will not be subjected to any unnecessary interventions.

Nearly 25 years ago, when intervention rates were far lower than today, I was pregnant with my first baby. My husband (a scientist, and from a medical family) and I did extensive research regarding our options and birth practices. Even then, there was plenty of evidence that unless you had a real medical reason to be in a hospital to give birth, you would be better off at home with a midwife. As a result, at 7 ½ months we switched to a home birth midwife (who happened to be one of very few CNMs with a home birth practice at that time). It was one of the best decisions I’ve ever made. Not only did I get outstanding care and support, but my midwife competently, safely and non-intrusively addressed a minor “variation on normal”; had I been in the hospital, standard practice would almost certainly have caused a life-threatening hemorrhage. Glad I was at home with a midwife!

Susan Hodges

Disclosure: I am a founding member of and current president of Citizens for Midwifery, a national non-profit organization providing information about midwives and the Midwives Model of Care.

Grassroots Network: TODAY show in bed with ACOG

Dear Friends,

Friday morning’s TODAY show included a segment about the “perils of home birth.” The show included a sad home birth (with a nurse-midwife) where the baby died of a cord accident, without mentioning that such deaths can happen in the hospital also, or addressing the US’s high perinatal mortality rate. Representatives of ACOG described home birth as “the equivalent of a spa treatment”! Definitely not even-handed reporting, but looks like ACOG is out to get media for their biased beliefs.

You can watch the segment at http://today.msnbc.msn.com/id/26184891/vp/32795933#32795933

You can read comments about the show (and add your own) at: http://www.newsvine.com/_question/2009/09/11/3252633-is-choosing-a-home-birth-with-a-midwife-worth-the-potential-risk. Almost all of the comments are pro-midwife.

And if you want to e-mail the Today show and let them know the real reasons more women are choosing home birth, or that you’d like to see an HONEST segment on home birth, you can write to them at Today@NBCUNI.com.

Finally, true to form, the Big Push has fired off an eloquent Push Alert (see previous post).

As the saying goes, any attention is good attention, or at least a great opportunity for getting more and better attention!

Thank you to the several individuals who brought this to my attention, including the links.

Sincerely,

Susan Hodges, “gatekeeper”

The Big Push Press Release: Physicians Take Anti-Midwife Smear Campaign to the Airwaves

I was getting ready to write about this myself--thinking of calling it, "ACOG Makes a New Friend"--but the indomitable Big Push Campaign beat me to it and their release is so pointed that I have nothing more to add!

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If you have difficulty viewing this message, please visit the PushNewsroom.

Home Birth Mothers, Celebrities, Insulted on National TV FOR IMMEDIATE RELEASE WASHINGTON, D.C. (September 11, 2009) – Referring to women who choose to give birth in out-of-hospital settings as "hedonistic" and likening childbirth to a "spa treatment," members of the American College of Obstetricians and Gynecologists, a trade group representing the professional and financial interests of OB/GYNs, took their anti-midwife campaign to the airwaves in a Today Show segment rife with insults, stereotypes, and misinformation, using one family's tragedy as a platform for the organization's well-funded assault against choices in childbirth. "About the only thing ACOG has right is that women are choosing out-of-hospital deliveries in record numbers," said Steff Hedenkamp of The Big Push for Midwives Campaign. "What Erin Tracy and other apologists for the group's anti-midwife position fail to see is that one of the forces driving women to seek out-of-hospital care is the paternalistic, profit-driven model of maternity care that far too many of its own members provide." During the segment ACOG reiterated its claim, which has been thoroughly debunked by a large and growing body of medical literature, that out-of-hospital delivery is unsafe. Describing women who choose to give birth in private homes and freestanding birth centers as "hedonistic" mothers who knowingly put the lives of their babies at risk for the sake of an "experience" they believe will be like a "spa treatment," members of the group echoed last year's position statement claiming that women who choose out-of-hospital deliveries base their decisions on what's "fashionable" or "trendy." "ACOG clings to this ridiculous fantasy that women choose to deliver their babies outside of the hospital because they want to be like Ricki Lake, Demi Moore or Meryl Streep and that if women would only watch enough fear-mongering stories on morning television they'll be brainwashed back into hospitals," said Katherine Prown, Campaign Manager of The Big Push for Midwives. "Insulting our intelligence and promoting policies that deny us choices in maternity care are not exactly winning strategies for stemming the tide of women seeking alternatives to standard OB care." Earlier this year, a New York City couple lost their baby during a planned home birth under the care of a Certified Nurse-Midwife. Licensed and regulated in all 50 states, Certified Nurse-Midwives are trained to provide hospital-based maternity care. By contrast, Certified Professional Midwives, who undergo specialized clinical training in out-of-hospital birth, are legally authorized to provide care in 26 states, although outdated regulations effectively prevent them qualifying for licensure in the state of New York. Legislation to license and regulate Certified Professional Midwives is currently pending in an additional 18 states, despite staunch opposition from the American Medical Association, which has joined with ACOG in adopting position statements that would deny families who choose out-of-hospital maternity care legal access to nationally credentialed midwives with specialized training to provide it. The Big Push for Midwives Campaign represents thousands of grassroots advocates in the United States who support expanding access to Certified Professional Midwives and out-of-hospital maternity care. The mission of The Big Push includes educating national policymakers about the reduced costs and improved outcomes associated with out-of-hospital birth and advocating for including the services of Certified Professional Midwives in health care reform. Media inquiries: Katherine Prown (414) 550-8025, katie@thebigpushformidwives.org ### The Big Push for Midwives Campaign | 2300 M Street, N.W., Suite 800 Washington, D.C. 20037-1434 | TheBigPushforMidwives.org

Grassroots Network: Big Push exposes ACOG’s bogus research

Dear Friends,

The Big Push let folks know about ACOG’s attempt to collect anecdotal information about poor home birth outcomes; so many people posted good home birth outcomes, that ACOG quickly made the page password protected. The survey was poorly constructed with no way to verify any reports or avoid duplication, a good example of what ACOG considers “research”! Read the Big Push news release below, which includes a link to a copy of the survey page as it originally appeared.

Sincerely,
Susan Hodges, “gatekeeper”

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Trouble viewing this PushNews Release? Please visit the PushNewsroom here.

PushNews from The Big Push for Midwives Campaign

CONTACT: Katherine Prown, (414) 550-8025, katie@thebigpushformidwives.org
FOR IMMEDIATE RELEASE: Monday, August 31, 2009

Viral Internet Campaign Exposes Bogus Research on the “Problem” of Increased Demand for Midwife Care
Thousands of Activists Nationwide Force Physician Group to Scrub Its Website

WASHINGTON, D.C. (August 31, 2009)­In under 18 hours, a viral internet campaign targeted at the American College of Obstetricians and Gynecologists forced the group to take down a public plea asking its members to submit anecdotal, anonymous data about patients who planned out-of-hospital deliveries. According to the request, which was originally linked from ACOG's home page, the professional trade association for OB/GYNs is "concerned" about the "problem" of growing numbers of women seeking out-of-hospital maternity care.

"Just follow the money," said Steff Hedenkamp of The Big Push for Midwives Campaign. "ACOG does not want to continue losing patients to Certified Professional Midwives and out-of-hospital birth, so they’re telling members to send in more of the same old tall tales that far too many OBs love to scare women with. Well, we have news for ACOG­it's not working."
The campaign to expose the physician group's plans began on Facebook and Twitter and rapidly drew thousands of women to ACOG's website, where they submitted their own data about their healthy deliveries in private homes and in freestanding birth centers throughout the country. In response, ACOG moved quickly to scrub its website and placed its request for unsourced data from members behind a password-protected firewall.

"This was almost as fun as last year's campaign pressuring the American Medical Association to back off from its ridiculous claim that Ricki Lake is responsible for the increase in out-of-hospital deliveries," said Sabrina McIntyre, mother of two. "The AMA and ACOG seem to forget that women are capable of making rational, informed decisions about our maternity care providers and birth settings. We don't appreciate fear-mongering tactics meant to try and scare us away from using safe and cost-effective, community-based alternatives to our current maternity care system."

"Analysts familiar with ACOG expect the group to use the anecdotal data collected from members to support its ongoing state and federal lobbying campaigns aimed at denying women access to out-of-hospital maternity care and Certified Professional Midwives, who are specially trained to provide it. "ACOG admits in its own documents that they've been forced to use 'hardball tactics' against women who are advocating for choices in maternity care," said Hedenkamp. "Frankly, this latest stunt of theirs to troll for 'fresh' folklore reeks of desperation.

"The Big Push for Midwives Campaign represents thousands of grassroots advocates in the United States who support expanding access to Certified Professional Midwives and out-of-hospital maternity care. The mission of The Big Push includes educating national policymakers about the reduced costs and improved outcomes associated with out-of-hospital birth and advocating for including the services of Certified Professional Midwives in health care reform. Media inquiries: Katherine Prown (414) 550-8025, katie@thebigpushformidwives.org

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The Big Push for Midwives Campaign | 2300 M Street, N.W., Suite 800 | Washington, D.C. 20037-1434 | TheBigPushforMidwives.org

PushNews: Physician Group Pulls the Plug on Women’s Autonomy

Issues Policy Statement About What Women in Labor Will Be "Allowed" to Eat and Drink FOR IMMEDIATE RELEASE WASHINGTON, D.C. (August 25, 2009) – Displaying a stunning lack of regard for patient autonomy, the American College of Obstetricians and Gynecologists (ACOG) issued a statement this week declaring that the group will "allow" laboring women to drink "modest amounts" of clear fluids during labor while continuing to prohibit access to solid food. "Once again ACOG has issued a position statement with little regard for the evidence or for the ability of women to make decisions for themselves," said Susan Jenkins, Legal Counsel for The Big Push for Midwives Campaign. "It's insulting that ACOG actually believes that laboring women should be grateful that they will now be 'allowed' to have more than just ice chips, when we have long known how vital nutritional sustenance is to mothers and babies not only during pregnancy, but during labor as well." Hospitals routinely adopt ACOG position statements as standard policy governing the treatment of pregnant and laboring women, despite the fact that a number of the organization's position statements do not acknowledge all of the risks and benefits associated with common procedures. "ACOG is asking laboring women to do the physical equivalent of a marathon on the power of a 'modest' amount of clear liquid," said Sabrina McIntyre, mother of two. "Thanks but no thanks. I'll stick with my midwife and her wisdom of keeping up my physical stamina for such a monumental event." Policies restricting food and liquid intake date from an era when laboring women were routinely given general anesthesia and risked aspirating food into the lungs. Modern anesthetic techniques have virtually eliminated this risk, which is further reduced by the fact that only a tiny minority of laboring women, even among those who deliver via cesarean section, actually receive general anesthesia. "The women I care for eat when they are hungry and drink when they are thirsty, all without asking for ACOG's permission first," said Elizabeth Allemann, MD. "Women deserve to be fully informed about what the evidence actually shows, and it's time that the medical profession abandoned policies based on the outdated and paternalistic idea that patients should play no role whatsoever in the decision-making process." The Big Push for Midwives Campaign represents thousands of grassroots advocates in the United States who support expanding access to Certified Professional Midwives and out-of-hospital maternity care. The mission of The Big Push includes educating national policymakers about the reduced costs and improved outcomes associated with out-of-hospital birth and advocating for including the services of Certified Professional Midwives in health care reform. Media inquiries: Katherine Prown (414) 550-8025, katie@thebigpushformidwives.org ### The Big Push for Midwives Campaign | 2300 M Street, N.W., Suite 800 Washington, D.C. 20037-1434 | TheBigPushforMidwives.org

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The Unnecesarean also picked up this press release and shared some additional thoughts as well as a very amusing graphic--check it out!

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Molly
CfM Blogger

Items of Interest

On the Mindful Mama website this past week I was interested to read an article called Five Things Every Woman Should Know Before Giving Birth.

Written by the author of a fairly new book titled Homebirth in the Hospital, she suggests 6 "C's" for having a "homebirth in the hospital":

• First, take responsibility for your choices.
  

• Expect communication to be open and flowing both ways

• Pay attention to continuity of care

• The confidence you have in your provider and in your birth team is essential.
  

• In any hospital, there must be control of protocols...I can not stress this point strongly enough: Protocols are the most disempowering aspect of modern maternity care, giving the message that our bodies don’t really know how to have babies without someone else managing the process for us.

• Finally, the sixth C to consider, the one that should never be allowed into a birth: conflict. Conflict releases stress hormones that work against the powerful hormones that facilitate birth. Humans are mammals, and no mammal gives birth easily when fearful or in an unsafe situation. If you resolve most issues long before your first contraction, you shouldn’t have to fight for your choices while you are in labor.

The author is also interviewed in a video clip on the site about Finding Your Power in Birth:



Also from Mindful Mama is another short Penny Simkin video called Alternative Ways to Relieve Labor Pain (she teaches a hand massage technique):



Finally, I'm a little behind in mentioning this, but a Letter to the Editor from OBOS director Judy Norsigian regarding Evidence-Based Labor and Delivery Management was published in the American Journal of Obstetrics and Gynecology in May. The conclusion of the letter was: "In the absence of adequate evidence, we believe that the American College of Obstetricians and Gynecologists should retract its strong opposition to home births."

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Molly
CfM Blogger

Fetal Monitoring

I started to write about this in my previous post and then realized it actually belonged in its own post!

The author of Bearing Meaning spends an entire chapter analyzing Williams Obstetrics and the language of birth contained therein. In Williams fetal monitoring is referred to as an "elegant means" of "demonstrating the effect of the forces of labor and delivery on the baby's heart rate." However, as the author of Bearing Meaning (Robbie Kahn) notes, "The tracings don't record labor in a generic sense. They record it under specific conditions--the hospital...Thus, monitor tracings hardly are elegant, if elegant means imparting information at high levels of sophistication. Indeed, the monitor may be simply recording responses characteristic of a woman laboring under the conditions imposed in the hospital rather than imparting sophisticated information about childbirth in general." (emphasis mine).

This observation reminded me of Henci Goer's recent post on the Science and Sensibility blog: The Labor Environment: “Many things that count cannot be counted." In this post, she looks at a recent study published in the June issue of Birth, "gauging the effects of modifying the labor room to encourage mobility, reduce stress and anxiety, and discourage routine medical intervention." The labor environment impacts women's birth experiences in a number of ways (some that cannot be quantified for research studies) and my observation is that fetal monitoring is one of the most significant elements of the labor environment. It creates conditions for laboring women that then alters their normal, physiological, spontaneous responses to labor and thus cannot be seen as accurately reflecting the influence of labor on the baby.

Speaking of fetal monitoring, ACOG just issued new guidelines refining the fetal heart rate monitoring guidelines. The guidelines briefly refer to manual auscultation. Quoted in the release is the following comment: "'Since 1980, the use of EFM has grown dramatically, from being used on 45% of pregnant women in labor to 85% in 2002,' says George A. Macones, MD, who headed the development of the ACOG document. 'Although EFM is the most common obstetric procedure today, unfortunately it hasn't reduced perinatal mortality or the risk of cerebral palsy. In fact, the rate of cerebral palsy has essentially remained the same since World War II despite fetal monitoring and all of our advancements in treatments and interventions.'"

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Molly
CfM Blogger

Grassroots Network: More organizations support out-of-hospital birth!

Note from Molly: The links to the midwifery editorial referenced below are kind of touch and go. If you have trouble accessing it, go here and then do a search for the editorial title (The 'Authorities' Resolve Against Home Birth) or for the author's name (Nancy Lowe), and you'll be able to read it that way!

Dear Friends,

The Big Push has issued a news release highlighting the fact that organizations including nurses and perinatal specialists have recently made statements supporting the use of midwives and the choice of out-of-hospital birth. In particular, the editorial by Nancy Lowe, editor of the Journal of Obstetric, Gynecologic, & Neonatal Nursing, the official journal of the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) here is an especially good statement.

Read the release below, forward it, and follow the links below to read the various statements!

Sincerely,
Susan Hodges, "gatekeeper"


PushNews from The Big Push for Midwives Campaign
CONTACT: Steff Hedenkamp, (816) 506-4630, steff@thebigpushformidwives.org
FOR IMMEDIATE RELEASE: Tuesday, February 17, 2009


Physician Groups Out-of-Step as the Number of Health Care Organizations In Support of Certified Professional Midwives (CPMs) and Out-of-Hospital Birth Rapidly Increases

Nurses, Perinatal Health Care Specialists Echo Consumer Reports Magazine in Calling for Integrating Midwives into U.S. Maternity-Care System


WASHINGTON, D.C. (February 17, 2009)Two major health care organizations have joined the growing number of groups calling on policy makers to increase access to Certified Professional Midwives (CPMs) and out-of-hospital maternity care. Acknowledging the large body of evidence supporting the safety of home delivery with CPMs, who are specifically trained to care for mothers and babies in out-of-hospital settings, nursing and perinatal health care organizations criticized the American Medical Association (AMA) and the American College of Obstetricians and Gynecologists (ACOG) resolutions calling for bans on CPMs and home birth. The groups also joined Consumer Reports magazine in highlighting the need for a major overhaul of the U.S. maternity care system.
"I am very proud to be an American, but I am embarrassed that our country, founded on the ideals of individual liberty and freedom, can also support 'authoritative' initiatives such as these by the ACOG and AMA, initiatives that are founded on neither science nor an understanding of the physiologic and psychosocial needs of mothers and babies," said Nancy K. Lowe in an editorial published in the Journal of Obstetric, Gynecologic, & Neonatal Nursing, the official journal of the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN). "What is most risky about home birth in the United States is that for most women who desire it there is a scarcity of qualified providers of home birth services." [Read the complete editorial here.

Consumer Reports magazine cited the desire for economic gain as one of the driving forces limiting access to CPMs and Certified Nurse-Midwives (CNMs), who are licensed in all 50 states and practice primarily in hospital settings, but who remain subject to anti-competitive regulations promoted by the AMA and ACOG. CPMs are legally authorized to provide out-of-hospital care in just half the states, while advocates working to reform the law in the remaining states face stiff resistance from physician groups seeking to establish a monopoly on the maternity care market in the U.S.

"Midwives provide a safe and cost-effective alternative to the current model, where the market is dominated by high-cost, high-tech specialists producing less-than-optimal outcomes," said Katie Prown of The Big Push for Midwives Campaign. "Babies delivered by midwives are far less likely to be pre-term or low birth-weight, which are two of the leading causes of neonatal mortality and of the enormous costs associated with long-term care. Midwives and out-of-hospital birth are an integral component of responsible health care reform, and the AMA and ACOG know this. That’s why they’re fighting so desperately to protect their turf, even if it means denying women maternity-care options in the process."

The National Perinatal Association (NPA) added to the growing list of organizations calling on the AMA and ACOG to end their vendetta against midwives and home birth and instead follow the World Health Organization’s (WHO) call to "'work in a spirit of recognition and respect for each other’s authority, responsibility, ability and unique contribution.'" [See their statements on place of birth and on midwifery here.

The Big Push for Midwives is a nationally coordinated campaign to advocate for regulation and licensure of Certified Professional Midwives (CPMs) in all 50 states, the District of Columbia and Puerto Rico, and to push back against the attempts of the American Medical Association Scope of Practice Partnership to deny American families access to legal midwifery care. Through its work with state-level advocates, the Big Push is helping to build a new model of U.S. maternity care built on expanding access to out-of-hospital maternity care and CPMs, who provide affordable, quality, community-based care that is proven to reduce costly and preventable interventions as well as the rate of low birth-weight and premature births.

Media inquiries: Steff Hedenkamp (816) 506-4630, steff@thebigpushformidwives.org.

Birth Video Contest, Breastfeeding Posters, & Midwifery Editorial

You may have already heard that Birth Matters Virginia is having a birth video contest (you do not have to live in VA to participate). I'm sure it will be exciting to see the results!

I recently came across some very nice free educational posters and other breastfeeding resource materials from the British Columbia Baby Friendly Network (I originally found the link on the Passion for Birth blog)

Finally, I wanted to mention an editorial in the Journal of Obstetric, Gynecological, and Neonatal Nursing called The Authorities "Resolve" Against Homebirth. Written by a CNM it is a look at the AMA and ACOG's position against homebirth. I learned about this editorial from the Woman to Woman blog, which includes several good quotes from the editorial.

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Molly Remer
CfM Blogger

Grassroots Network: NEW! CfM Tool Kit: Stand Up for Home Birth

Dear Friends,

Citizens for Midwifery officially announces a new addition to our website, our Advocacy Tool Kit: Stand Up for Home Birth!

Take a look here. You will find a comprehensive collection of information, facts, links, how-to’s, talking points for any occasion, and other useful advocacy tools, organized in sections. We would recommend you start with the Introduction section, but also read the new articles in the Important Information section: About AMA & ACOG, Safety, and Rights. Also take a look at the Resources section within the Tool Kit.

CfM developed this Tool Kit in response to the American Medical Association’s anti-home birth “Resolution 205” (adopted last spring): “… 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 ….” as well as the American College of Obstetricians’ continued opposition against access to home births and the midwives that attend them. Neither organization has any reputable evidence to support these positions.

Our purpose was to provide information and tools for everyone to use to undermine the “authority” of the AMA and ACOG and make the case for access to home birth and home birth midwives. Some of the material is oriented for use with legislators, specifically to help them learn and understand more about the nature of ACOG and the AMA and why their motives and opinions should not be trusted, in addition to understanding the evidence and “bigger picture” regarding routine maternity care and midwife-attended home birth. However, virtually all of the material is useful for many situations and circumstances.

Please make use of the information, fact sheets, and links!

Sincerely,

Susan Hodges, “gatekeeper”

GRN: Big Push for Midwives News: ACOG ups effort to eliminate home birth midwives

Dear Friends,

The Big Push for Midwives Campaign continues to put out PushNews and PushAlerts. (If you haven’t heard of the Big Push for Midwives Campaign, look up Grassroots Network Messages from earlier this year, or read more at the website).

Today’s PushNews notes that the American College of Obstetricians and Gynecologists (ACOG) has moved gettting rid of home birth midwives up to the #2 spot on their list of State Legislative Issues for 2008! You can see the whole list here.

I have copied the PushNews (which includes some great quotes) below. It is not yet posted on the Big Push website. If you are interested in receiving PushNews and Push Alerts, contact Steff Hedenkamp.

Citizens for Midwifery supports the work of the Big Push for Midwives Campaign!

Sincerely,
Susan Hodges “gate keeper”


PushNews from The Big Push for Midwives Campaign
CONTACT: Steff Hedenkamp, (816) 506-4630, steff@thebigpushformidwives.org
FOR IMMEDIATE RELEASE: Monday, September 1, 2008

Number Two With a Bullet

Critical Women’s Health Issues Neglected as Physician Group Yet Again Sets its Sites on Midwives

WASHINGTON, D.C. (September 1, 2008)In the newest phase of its ongoing effort to deny women the right to choose their maternity care providers and birth settings, the American College of Obstetricians and Gynecologists (ACOG) has announced that eliminating access to midwives who specialize in out-of-hospital birth is now the second most important issue on its state legislative agenda. This move puts restricting access to trained midwives ahead of such critical issues as contraceptive equity, ensuring access to emergency contraception, and the prevention and treatment of perinatal HIV/AIDS.

“ACOG claims to be an advocate of women’s health and choice, but when it comes to the right to choose to deliver your baby in the privacy of your own home with a Certified Professional Midwife (CPM) who is specifically trained to provide the safest care possible, ACOG’s paternalistic colors bleed through,” said Susan M. Jenkins, Legal Counsel for the Big Push for Midwives Campaign. “It is astonishing that an organization that purports to be a champion of women’s healthcare would put a petty turf battle that affects less than one percent of the nation’s childbearing women ahead of pressing issues that have an impact on nearly every woman in this country. If this is not dereliction of duty, I can’t imagine what is.”

In recent years, ACOG has led a well-financed campaign to fight legislative reforms that would license and regulate CPMs and has now teamed up with the American Medical Association (AMA) to promote legislation that would prevent families from choosing to give birth at home. Despite these joint efforts, the groups have not been successful in defeating the groundswell of grassroots activism in support of full access to a comprehensive range of maternity care options that meet the needs of all families.

“Wisconsin is a good example of what ACOG and the AMA are up against,” said Jane Crawford Peterson, CPM, Advocacy Trainer for The Big Push. “Our bipartisan grassroots coalition of everyday people from across the state managed to defeat the most powerful and well-financed special interest groups in Wisconsin, all on an expenses-only budget of $3000 during a legislative session in which $47 million was spent on lobbying. When you try to deny women the fundamental and very personal right to choose where and how to give birth, they will get organized and they will let their elected officials know that restrictions on those rights cannot stand.”

Noting these successes, ACOG has recently launched its own grassroots organizing effort, calling on member physicians to recruit their patients to participate in its “Who Will Deliver My Baby?” medical liability reform campaign.

“ACOG itself admits that we’re facing a critical shortage of maternity care providers,” said Steff Hedenkamp, Communications Coordinator for the Big Push. “They certainly realize that medical liability reform is nothing more than a band aid and that increasing access to midwives and birth settings is critical to fixing our maternity care system and ensuring that rural, low-income and uninsured women don’t fall through the cracks. Midwives represent an essential growth segment of the U.S. pool of maternity care providers, but instead of putting the healthcare needs of women first, ACOG would rather devote its considerable lobbying budget to a last-ditch attempt to protect its own bottom line. This is not a happy Labor Day for our nation’s mothers and babies.”

The Big Push for Midwives (http://www.TheBigPushforMidwives.org) is a nationally coordinated campaign organized to advocate for regulation and licensure of Certified Professional Midwives (CPMs) in all 50 states, the District of Columbia and Puerto Rico, and to push back against the attempts of the American Medical Association and the American College of Obstetricians and Gynecologists to deny American families access to safe and legal midwifery care. The campaign plays a critical role in building a new model of U.S. maternity care delivery at the local and regional levels, at the heart of which is the Midwives Model of Care, based on the fact that pregnancy and birth are normal life processes. Media inquiries: Steff Hedenkamp (816) 506-4630, steff@thebigpushformidwives.org.

A Response to the AMA Resolution

Submitted by Jeanne Batacan as an example of an "Opinion" page contribution for local papers in response to the AMA's Resolution against homebirth.

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The American College of Obstetricians and Gynecologists (ACOG) is now pushing for the American Medical Association (AMA) to lobby Congress for a law banning out of hospital birth.

Despite a statement by ACOG, regarding a patient's right to informed consent and informed refusal, it seems that more and more decisions and "recommendations" made by ACOG, are moving further away from that basic tenet. This is resulting in thousands of women being stripped of their basic right to choose safe maternity care based on balanced informed consent or informed refusal.

Not all ACOG members are happy with the current situation. Dr. Fischbein, a California physician stated, "ACOG's little 'guideline' paper on vaginal birth after Cesarean (VBAC) in 2004 where the word readily was changed to immediately has had the chilling effect of doing away with VBAC options at hundreds if not more hospitals. Not due to patient safety, or the ideal of giving true informed consent but really, let's be honest, to fear of litigation. I have seen how patients have become counseled by obstetricians at facilities where VBAC has been banned. They are clearly given a skewed view of the risks of VBAC but rarely told of the risks of multiple surgeries. If a hospital cannot handle an emergency c/section for VBACs - and most emergencies are for fetal bradycardia, hemorrhage (i.e. abruption) or shoulder dystocia, not for ruptured uteri - then how can they do obstetrics at all?" Indeed.

ACOG needs to defend their position in encouraging the AMA to lobby Congress for yet another
restriction on the freedom of choice that belongs to all women and their families. Those choices include midwifery care and the right to give birth wherever best fits their needs and desires.

Today's Midwives are well trained professionals and are required to have obstetrical backup. Interestingly, in the countries that have the lowest maternal and infant mortality rates the vast majority of pregnancies and births are managed by midwives.

The U.S. spends more money on maternity care than any other country in the world. Yet, we rank somewhere below 32nd (NOT 1st) in maternal and infant safety. Our maternal mortality rate is on the rise, as well a premature birth, epidemic rates of labor induction and Cesarean Section. Knowing this, ACOG needs to turn it's attention on reversing this alarming and shameful trend by welcoming the superb care that midwives provide and then, taking a long hard look at -- what is it, that Singapore, Sweden, Japan, Hong Kong, Iceland, France, Finland, Norway, The Czech Republic, Germany, Switzerland, Spain, Israel and TWENTY-NINE other countries are doing so much better than us?

What Would an Evidence Based Statement from ACOG Say?

I just got the summer issue of Midwifery Today. In it was an article by Judy Slome Cohain in response to the ACOG homebirth statement issued in February. Given all of the recent uproar over the AMA's resolution, I thought her piece was very timely. It is called "What Would an Evidence-based Statement on Homebirth from ACOG Say?" and it opens like this:

"This is the statement ACOG would file if facts interested them: We at ACOG recognize that, according to our most recent poll, none of our members have homebirth practices and, therefore, making a homebirth statement is unnecessary since this subject is outside the expertise of ACOG members. For the purpose of making an informed choice, consumers should not look to ACOG for a statement on this subject."

:-D

Homebirth Petition

From MCFI e-news

"Resolutions were recently introduced by the AMA to support ACOG's position against home birth and to '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.'" "Please help send a message to the AMA and ACOG, and to our state and federal legislators, to tell them that we object to these resolutions and we view legislation that would restrict a woman's right to choose a home birth as a being contrary to scientific evidence and a violation of women's basic human rights." Petition

AOL News on the AMA Resolution

Ricki Lake was interviewed by AOL News regarding the comments made by the AMA singling her out for her promotion of homebirth. There have been TONS of comments on the article already, so if you check it out, be warned that you may be in for some long (and sometimes frustrating) reading.

Grassroots Network: Comments re AMA on Huffington Post Blog

The AMA is getting the heat regarding their Resolution on Homebirth (see previous post). You can contribute to the conversation! Ricki Lake, Abby Epstein and Jennifer Block wrote on the Huffington Post blog, and the comments are pouring in, some negative, some positive.

You can read the blog and comments so far here.

You do have to sign up/log in before you can post comments. However, after you have read some of the more ignorant/hostile posts, you may feel moved to sign up! This is a place where you can speak up for facts that support midwife-attended home birth, and point out that the issue is not making “all” women have natural childbirth at home, but that the AMA does not have any business dictating that “all” women give birth in hospitals (or specifically accredited birth centers which are few and far between).

There probably are other blogs where this discussion is going on, but this is the first one pointed out to me.

Some thoughts to consider:

The AMA and ACOG are the health care professionals who have brought us the highest cesarean section and induction rates ever in the US, along with the worst standing yet for perinatal mortality and worsening rates for maternal mortality. Furthermore, rates for premature birth have been increasing, and recent studies have connected this increase with the increase in cesarean sections (for example, see here). The same professionals who have brought us these sad outcomes are claiming their way is best???

Many complications in labor and delivery actually are caused by medical practices and interventions, and are not common problems of pregnancy, labor or vaginal birth. Denying food and drink during labor, preventing or discouraging mothers from walking and other physical activity during labor, using drugs to "start labor” (ie, induction) or hasten labor (augmentation), not “allowing” mothers to be in a vertical position to push the baby out, using directed breath-holding pushing, are all examples of routine hospital/obstetric practices (most not even considered to be interventions) that have been shown to interfere with the normal process of labor and cause complications, causing harm and not benefits to mother or baby. These practices are rarely if ever used by midwives in the home setting, who have very low rates of cesarean section (ie, low rates of transfer to the hospital for cesarean section) and very low rates of other interventions (see http://www.cfmidwifery.org/pdf/CPM2000.pdf and http://www.cfmidwifery.org/pdf/cesarean2x.pdf ).

One has to ask if modern obstetricians are even competent to attend normal birth, as they seem unable to resist meddling with the process and causing problems in so many ways. There is no question that sometimes interventions, even cesarean sections, are needed and can be life saving. However, it is likely that many fewer mothers would have complications if typical routine obstetrical practices did not interfere with the normal process so much.

If there is going to be legislation, maybe it should require obstetrician wanna-be’s to complete midwifery training before their OB specialty training. In my personal opinion, ACOG and the AMA have no business trying to restrict women’s choices when it comes to birth.

Sincerely,
Susan Hodges “gatekeeper”