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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Domestic Violence Resources

As I have noted several times, my first professional interest was in domestic violence. Domestic violence during pregnancy is unfortunately very common (though often overlooked during screenings) and, indeed, often the first incidence of intimate partner violence in a relationship occurs during the woman's pregnancy. In 2003, I wrote a short book about talking to battered women (nothing specifically about pregnancy) and it is available as a free e-book version here.

I think all birthworkers have a professional responsibility to be informed about intimate partner violence and its incidence during pregnancy. (I've also previously written about violence and birth, as it is sanctioned by the American medical care system.) Several helpful free DV resources for professionals came to my attention recently and I decided it was time for another post on the subject!

From an email list, I received this announcement:

Power and Control: Domestic Violence in America is a comprehensive and timely exploration of the shocking persistence of domestic violence in our society. The complex issues around domestic abuse are refracted through the story of Kim, a mother of three in Duluth, MN. Kim's journey takes her from a domestic violence shelter, to a promising fresh start, and then through a disturbing final twist.

The film also tells the story of the leaders who created the hugely influential "Duluth Model," the set of domestic violence policies that have been widely adopted around the world. Today the Duluth approach faces a challenge from increasingly vocal outside critics. At the same time the leaders of the battered women's movement are struggling to maintain the spirit of sisterhood that has
propelled the movement for 30 years.

For more about the film, including 40 interview excerpts with survivors, advocates, police, health care providers, batterers and founders of the battered women's movement, visit: http://www.powerandcontrolfilm.com/

For your free screening (good for 2 days for each user), visit: http://bit.ly/PowerAndControl

Additionally, the Family Violence Prevention Fund has a serious of free webinars about domestic violence available here.

--
Molly
CfM Blogger

Medical Control as Acceptable

Still going through my saved-things-to-blog-about and want to share these thoughts from the book Brought to Bed: Childbearing in America 1750-1950 in the epilogue:

Many of birthing women's successes in increasing their powers over childbirth procedures have depended upon women reeducating themselves about childbirth. The enormous proliferation in recent decades of popular literature about giving birth, much of which advocates decreasing routine medical interventions, is evidence of women's attempts to reclaim knowledge previously more commonly held within women's world. When birth moved to the hospital and became dominated by technical interventions, women lost their understanding and familiarity with the processes of labor and delivery. Many women, realizing that their lack of knowledge distances them from their own bodies, are trying tor recover some of that lost knowledge through self-education in normal functions...

In addition to the women who completely challenge medical authority and those who want to find ways to work in cooperation with it, there is a third group of American women today who find medical control of childbirth as practiced in most hospitals perfectly acceptable. They find the prospect of delivering babies frightening or uninteresting, and they wish to experience as little of it as possible. They want to be assured of a healthy outcome, but they do not feel the need to participate actively in bringing it about. They, like many women of the 1920's and 1930's, eagerly turn over their decision-making power to their doctors, who, in turn, readily accept it. The women hope that medicine can provide a streamlined and easy experience and that they will not have to suffer too much either in the process of labor and delivery or in its aftermath. Many women enter the hospital and emerge from it with their babies without having given the experience itself very much thought. (emphasis mine)

This third group (as discussed in the second paragraph) is a conundrum to me and I think it is the main reason why the birth culture in the U.S. ISN'T changing rapidly in response to evidence-based information, great books, informative publications and websites, helpful doulas, awesome childbirth classes, etc. How do you reach women who just don't care? And, why as advocates, do we care if they don't? :( And, is it any of our business if a large subset of the population finds medical control of birth perfectly acceptable and even desirable?

I'd like to explore why I think it is our business in a later post, but first I have to clarify why exactly that is...

--
Molly
CfM Blogger

Grassroots Network: Survey for Patients/Consumers on Overtreatment

Survey for Patients/Consumers on Overtreatment

Dear Friends,

Hope you all are enjoying the start of summer!

First of all, we at CfM apologize that our Grassroots News Messages have been so sparse lately. Much has been going on in all of our lives, and unfortunately our news messages have taken a back seat. In the coming months, we promise to refocus our energy and use this network to spread the news about maternity care. If you have anything that you are interested in sharing, we encourage you to contact us at info@cfmidwifery.org. Additionally, if you would be interested in helping regularly with the Grassroots Network messages, we’d love to hear from you.

Below is information regarding a survey from TreatmentTrap.org and Consumer Union's Safe Patient Project dealing with overtreatment. While the site doesn't specifically mention childbirth, overtreatment, unnecessary treatment and other errors are frequent in maternal health care in the U.S. We encourage you to share your experiences with these incidents, especially as they relate to childbirth. The survey reflects the beginning of attention to overtreatment in general, and an awareness of related issues such as a lack of informed consent and being given misleading medical information. This is a chance for all of us to draw the attention of the sponsoring organizations to the severe and costly problem of unnecessary and overtreatment in maternity care in particular. Through raising these issues, we can actively support a woman's right to the childbirth she sees fit, and her right to be treated honestly and respectfully by her care providers, both of which are essential for improving the state of maternal health care in the US.

Please read the information below and participate in the Survey!

Sincerely,
Stephanie Hucker and Susan Hodges of Citizens for Midwifery

New Survey Launched to Query Patients/Consumers on Overtreatment

A new survey is being launched to enable patients to share their experience of overtreatment, an emerging quality and patient safety issue in health care today.

The survey is a partnership between TreatmentTrap.

org and Consumer Union's Safe Patient Project. While not a scientific survey, it aims to elicit patient experiences of overtreatment to raise public awareness. Patient experiences of overtreatment can be useful to health care leaders and policy makers as they establish priorities to reduce overuse.

The survey can be found by going to: www.treatmenttrap.org. Click on "Share Your Story" and you will be directed to the CU Safe Patient Project survey.

The "Share Your Story" survey asks two questions: "Have you had medical care you thought was unnecessary?" and "Have you declined medical care you thought was unnecessary and obtained a medically appropriate alternative?"

The survey prompts respondents to share experiences of overuse including those identified as overused by the National Quality Forum's National Priorities Partnership. These procedures include: spine surgery, heart bypass surgery, hysterectomy and prostatectomy.

For further information, contact Rosemary Gibson at rosemarygibson100@gmail.com

Grassroots Network: Opportunity for VBAC Feedback at Upcoming NIH Conference

Dear Friends,

I am the new president of Citizens for Midwifery, and I will be attending the Vaginal Birth After Cesarean (VBAC) Consensus Development conference sponsored by the National Institute of Health (NIH) in Washington DC on March 8-10, 2010. This conference will examine the research around VBAC and may impact birth, especially VBAC, for the next decade.

We know from our experience with the NIH's so-called patient choice cesarean conference that our presence, pressure and input can make a difference. On the issue of VBAC, we want to make it clear that hospital bans on VBAC violate our right to informed consent/informed refusal. Curiously, there is no speaker specifically addressing this Patients Rights point. We need to hammer it home at every opportunity...with evidence of the overuse of C/S in the first place...with evidence of the safety of VBAC and the risks associated with repeat C/S...and armed with our Constitutional right to bodily integrity: with or without evidence.

Even if you can't get to DC, you can watch the conference and participate online. You can also sign up to receive the resulting statement and watch the video archive afterward. Indeed, I'm asking everyone to sign up to receive the statement that will be the result of this conference: go here and find the Pre-order Statement button at the top of the page. Signing up to receive the statement - all by itself - communicates to the NIH that there is tremendous interest and public involvement on this issue.

At the same website, you will see an outline of the speakers list and agenda and sign up for the live webcast or there are several ways in, via calendar, for example: here or here. If you are at all able to view all or part of the live webcast I urge you to do so.

There is generally an opportunity for the audience to ask questions or redirect attention after each presentation. If you can watch, and want to ask a question, email me at willa@cfmidwifery.org, post on the wall of our Facebook Fan page, or text me at 585.729.5161, and I'll do my best to make your points live and in person. If I can't, there is an opportunity to submit written feedback on-site. It may also be possible for webcast viewers to leave feedback in real time, and you can post comments on the draft document on Wednesday morning.

Please plan to watch and weigh in.

Willa Powell, President

Citizens for Midwifery

willa@cfmidwifery.org

Note from Molly: I'm not sure if all the links are working correctly--the calendar link doesn't work for me, but I think maybe I am missing something.

Grassroots Network: MAMA Campaign Update

Dear Friends,

Just in case some of you haven’t signed up with the MAMA Campaign, below is the latest e-mail update. Regardless of your opinions about the existing Health Care (Insurance) Reform bills, they include some things that are good for mothers and midwives. What Congress will do with health care reform is still up in the air, but we can all communicate to our Congress people that maternity care is still an urgent issue that should not be ignored in the midst of the political hoopla. We still need real care, access to midwives, and birth practices that are based on evidence, not legal fears or economics.

Sincerely,
Susan Hodges, “gatekeeper”

-----------------------------

A Call to Arms for Women and Families!

Now is the time to call and write to your legislators for women and families!

The political landscape of health care reform changed dramatically last week with the election of Scott Brown to fill Ted Kennedy’s seat in the Senate, but women’s needs for maternity care reform did not!

• Women in the many counties across the nation with no maternity care provider at all need access to care for their births
• Women whose previous cesarean section is deemed a pre-existing condition by insurance companies need access to reimbursement for their birth
• Women being pressured to have an induction at 40 weeks or to undergo other unnecessary interventions need access to evidence-based care
• Women who are part of the 32% cesarean section rate in the US need access to VBAC
• Women need access to normal birth options, increasingly rare in the US
• Women insured by Medicaid need access to birth centers
• And women need access to the care of CPMs if maternity care is to be reformed in the US!

With health care reform in jeopardy, the hard-won provisions that benefit childbearing women in the bills are in jeopardy, including:

• Senator Cantwell’s provision that would effectively require the payment of the provider fee for CPM births in birth centers
• The mandate for Medicaid to reimburse the facility fee for birth centers
• Childbirth Connection’s provision requiring the implementation of maternity care performance measures – a crucial step towards evidence-based maternity care
• Equitable reimbursement for Certified Nurse Midwives

Whatever your politics, please call your House Members and Senators today! If you are in favor of health care reform, let your legislators know today! Even if you are not in favor of the health care bill, tell your legislators to provide for the needs of childbearing women by preserving the above provisions in legislation!

Where is MAMA now?
MAMA is determined to look for every opportunity to see that the needs of childbearing women for improved quality and access to care are addressed by Congress. MAMA representatives were on the Hill to the last possible moment advocating for CPMs in the current health care reform legislation. As our lobbyist, Billy Wynne, told us, CPMs made more progress on the Hill in these last eight months than most provider groups new to the Hill make in 3-4 years! MAMA is extremely pleased with the extraordinary support gained from key Congressional leaders – thanks to all of your calls and letters to your legislators! And MAMA is especially grateful to Senator Cantwell for her determination to find a way to “get the ball rolling” for CPMs and for her provision in the Senate bill that would have the effect of requiring reimbursement of the provider fee for CPM births in birth centers. MAMA is grateful for these accomplishments and is determined and well-positioned for the next steps as we move forward into 2010.

Now is the time to regroup, evaluate and plan for success in 2010 for Federal recognition for CPMs. And MAMA is doing just that. The Campaign Steering Committee will soon:

• Meet in Washington, D.C. to capture all that we have learned so far and to solidify a strategy for 2010
• Hold a webinar for supporters about the progress of the campaign to date and to engage you in next steps for CPMs and mothers

Your Dollars for MAMA Make a Difference!
We are so close to our fundraising goal to finish out this phase of the campaign for Federal recognition for CPMs. We are so grateful for your support! Midwives and mothers, parents and grandparents, state midwifery associations and state consumer advocacy groups, have made possible this historic fundraising success! We need to raise just a few thousand dollars to reach our goal. Can you help? Any amount will make a difference. Please donate today. Thank you!

How to be Social With MAMA
In order to tell more people about our efforts, MAMA has been exploring the world of social networking! We not only have an active MAMA Campaign Group on Facebook, but we also have a MAMA Campaign Cause (sponsored by our non-profit fiscal agent, Foundation for the Advancement of Midwifery.) We want all of you to join the Facebook MAMA Campaign Cause and then let your friends know about it as well! It will only take a few minutes and we promise it will only hurt a little.

Easy Step-by-Step Instructions for joining Facebook and the MAMA Campaign Cause:

1. Get a cup of tea, a piece of chocolate...whatever relaxes you.
2. Turn on your computer...which is already on if you are reading this so go back to step one and then skip to step 3.
3. Go to your Internet search engine and type in "facebook"... if you are already a member of facebook then skip to step 6.
4. Join facebook by filling out the form clicking the button that says "sign up"
5. Get distracted for a little while trying to set up your profile (this is the painful part).
6. Type in www.causes.com/mamacampaign and hit enter.
7. "Bookmark" this cause so that you can find it again
8. Click the button to “Join the Cause.”

Congratulations! Now, invite your Facebook Friends to the Cause:

1. Now that you are a member of one of the most elite causes on the Internet (just kidding), you can invite a select group of your friends to join as well (actually, invite all of them).
2. When you first sign up, Facebook will prompt you to invite your friends; or as a member of this cause you can scroll down on the home page and see two incredibly important green buttons. One says "donate" (self-explanatory) the other says "Tell Friends"
3. Click on "Tell Friends" and you get an opportunity to post to your profile.
4. You can select up to 60 of your friends (popular people will have to do this over again for a few days) and then send them a message asking them to join the cause. Here is a sample message that you can use: “The Midwives and Mothers in Action (MAMA) Campaign now has a Cause page (sponsored by the Foundation for the Advancement of Midwifery) at www.causes.com/mamacampaign. I’ve joined the Cause because… (insert your own personal reason). So please spread the word and tell your friends. Help support federal recognition of Certified Professional Midwives.”
5. Now don’t forget to click on the “Donate” button on the Cause. The MAMA Campaign is within a few thousand dollars of our campaign fundraising goal. Here is your opportunity to help MAMA over the top! Any amount, $10, $20, $50 will make a big difference to the Campaign. Go ahead and give a little…
6. You're done. Now get off the computer and do something in the real world for awhile. Thanks for your time and attention.

MAMA Is Blogging Health Care Reform, visit our blog the Grapevine.

If you have any questions, concerns or comments please contact the campaign at info@mamacampaign.org.

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

News from the MAMA Campaign: THE TIME IS NOW

"THE TIME IS NOW"

With those words on Wednesday night, President Obama urged Congress and all of us to work together to reform the U.S. health care system. And as the President noted, committees of Congress are already hard at work writing health care reform bills. _This means that now is also the time to stand up for Certified Professional Midwives (CPMs) as part of health care reform._

In his speech to the Joint Session of Congress, President Obama restated the basic components of his plan for health care reform, and addressed some of the controversies and misinformation that have been in the headlines. View the speech at http://www.npr.org/templates/story/story.php?storyId=112695048

Based on the responses of Representatives and Senators from both sides of the aisle, there was strong agreement that the health care system has major problems and needs to be fixed, and that health insurance needs reform. While not everyone agrees on the best way to accomplish these goals, adding CPMs to the list of Medicaid providers is a no-brainer -- it would add a high quality, low cost choice for maternity care for women on Medicaid, and eventually for women on most insurance plans.

While details of reform are still being worked out, President Obama
mentioned that there is already agreement on about 80% of what is in the various draft bills. While the "public option" remains a contentious topic, it is only one possible part of the package. The MAMA Campaign goal to have Certified Professional Midwives added to the list of Medicaid providers does NOT depend on a public option being part of the health care reform plan.

President Obama stated: "_One of the unique and wonderful things about America has always been our self-reliance, our rugged individualism, our fierce defense of freedom and our healthy skepticism of government. And figuring out the appropriate size and role of government has always been a source of rigorous and sometimes angry debate_." The work of Certified Professional Midwives exemplifies these valuable characteristics, but making it possible for all women to have access to the choice of midwifery care in out-of-hospital settings is one appropriate place for federal government to play a role- just as it has successfully done in states across the country. _Adding Certified Professional Midwives to the federal list of Medicaid providers is a simple step to make this possible, and is why it should be part of any health care bill that comes out of Congress!_

Let's make sure CPM recognition is part of any health care bill that comes
out of Congress! Support MAMA today, donate at http://www.nacpmcommunity.org/content.aspx?page_id=301&club_id=962241

To read more about President Obama’s speech, visit
1. http://www.nationaljournal.com/congressdaily/hca_20090910_4249.php
2. http://www.kaiserhealthnews.org/Stories/2009/September/10/obama-speech-expert-panel.aspx

-RECESS IS OVER...TIME TO GET TO WORK
All summer long, and especially during the August recess, members of
Congress have been busy responding to questions about health care from their constituents. At town hall meetings across the country, people have been asking their legislators about pre-existing conditions, insurance costs, and the public option.

_But did you know that Americans nationwide were also asking about midwives?_

We do. We’ve seen the results of it. _Thanks to your letters and emails
and our weekly visits to Washington DC, legislators’ support is growing to
extend Medicaid coverage to include CPMs._ They are now considering our provision. With your help we can get them to include CPMs as a priority and put our amendment into the bills.

USE YOUR VOICE!
Congress is likely to act on health care reform this month. The more
legislators learn about Certified Professional Midwives, the more support
they show for an amendment that would reimburse CPM’s services through Medicaid. But legislators are cautious. They will not distinguish our amendment from the many proposed amendments unless they know that there is something special about it. They need to hear that their constituents want to be able to choose CPMs for their maternity care providers. There are still opportunities to insert our amendment into the House and Senate health care bills.

SO PLEASE CONTACT YOUR LEGISLATORS TODAY!
Ask them to support federal recognition for Certified Professional Midwives as Medicaid providers.

If you signed up to help at www.mamacampaign.org and you live in a key
state [ http://finance.senate.gov/sitepages/committee.htm] or district [http://energycommerce.house.gov], chances are that you have already heard directly from us over the last month asking you to call or write your Senator[http://www.senate.gov] or
Representative [http://www.house.gov] at their local or district offices. Thank you to all of you who have contacted your legislators in these key states and districts.

As the president puts pressure on congress to make reform happen, we need more letters from supporters across the country. Please write a letter to your own Congress members! Go to [http://mamacampaign.squarespace.com/contact-your-legislator] for instructions on writing and sending your legislators a letter. THANK YOU to all of you who have already written.

MAMA IS BLOGGING HEALTH CARE REFORM
You can follow the health care reform debate with MAMA! Read the latest post on our blog, The Grapevine at http://www.mamacampaign.org/grapevine

DONATE YOUR RESOURCES!
Your donations keep this campaign going. And we thank you for your
support. If you haven’t donated yet, please donate today! Your gift of $25, $50, or even $100 will ensure that legislators continue to hear about the importance of federal recognition for Certified Professional Midwives.Visit http://www.nacpmcommunity.org/content.aspx?page_id=301&club_id=962241 to make a donation today. MAMA is working for you!

Please help your MAMA!

Grassroots Network: Big Push Health Care Strategy

Dear friends,

Below is a press release from The Big Push campaign. This strategy--of asking politicians to think about "beginning of life" issues as they think about "end of life" issues in terms of health care reform--may work well when you go to talk to your local legislators or Town Hall meeting about maternity care!

Sincerely,
Arielle Bywater, "sidekick"

Advocates Spotlight Absence of "Beginning-of-Life" Provisions in House Bill
Maternity Care Crisis Ignored as Controversy about End-of-Life Issues Continues

Washington, DC (August 17, 2009)­As the controversy over the inclusion of end-of-life provisions in the House health care reform bill continues, questions emerged about the lack of "beginning-of-

life" provisions in the bill that would expand access to maternity care providers and settings and ensure that patients receive adequate care across their life span.

"The U.S. has one of the worst infant and maternal mortality rates in the developed world," said Elizabeth Allemann, MD. "The cesarean section rate has skyrocketed to more than a third of all births in the country, and with nearly half of all births being paid for by Medicaid, taxpayers are getting hit hard. We have a crisis on our hands and we need to start paying as much attention to beginning-of-life issues as we do to end-of life-issues."

Among the measures being promoted by advocates seeking to reform the maternity care system is the addition of a provision to the House bill that would provide access to out-of-hospital birth and the services of Certified Professional Midwives, who are specially trained to provide it, for women receiving Medicaid.

"We know that women cared for by Certified Professional Midwives experience significantly reduced rates of low birth weight and preterm births, two of the leading causes of cost increases and growing racial and ethnic disparities in birth outcomes," said Jane Peterson, LM, CPM. "Moreover, Certified Professional Midwives are able to produce these outcomes at a fraction of the cost of traditional maternity care. The House bill represents a golden opportunity for us to embrace maternity care reforms that truly can make a positive impact on our health care system and on the lives of mothers and babies."

David A. Anderson, Professor of Economics at Centre College, calculates that if the rate of births that take place in private homes and in freestanding birth centers increased by less than ten percent, we would realize an annual savings of more than $9 billion. A 2008 study commissioned by the state of Washington found that its licensed midwife program generates a savings of more than $3 million to private and public insurers each biennium.

"With all of the talk about the importance of end-of-life issues," said Dr. Allemann, "It's time for us to also recognize that giving everyone a good start at the beginning of life has far-reaching implications for our health care system. Including out-of-hospital maternity care and Certified Professional Midwives in health care reform is a small but very important first step."

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 the public and policymakers about the reduced costs and improved outcomes associated with out-of-hospital birth and Certified Professional Midwives, the maternity care providers trained to provide that service. 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

Book Review: Homebirth in the Hospital

Homebirth in the Hospital
by Stacey Marie Kerr, MD
Sentient Publications, 2008
Softcover, 212 pages
ISBN: 978-1-59181-077-3
www.homebirthinthehospital.com

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

I would venture to say that most midwifery activists and birth professionals have said at some point, “what she wants is a homebirth in the hospital…” This comment is accompanied with a knowing look, a bit of head shaking, and an unspoken continuation of the thought, “…and we all know that’s not going to happen.”

Well, what if it is possible? A new book by Dr. Stacey Kerr, Homebirth in the Hospital, asserts that it is. She was originally trained at The Farm in TN (home of legendary midwife Ina May Gaskin) and after going to medical school realized that she, “…needed to balance my new knowledge with my old priorities. I missed the feeling of normal birth, the trust that the birthing process would occur without technology, and the time-tested techniques that help women birth naturally. And so it was that I went back to midwives to find the balance.”

If you are a dedicated homebirth advocate, I recommend reading Homebirth in the Hospital with an open mind—clear out any cobwebs and assumptions about doctors, hospitals, and birth and read the book for what it is: an attempt to create a new model of hospital birth. What Dr. Kerr proposes in her book is a model of “integrative childbirth”—the emotional care and support of home, while nestled into the technology of a hospital.

The opening chapter explores the concept of integrative childbirth and “the 5 C’s” of a successful integrative birth: choices, communication, continuity of care, confidence, and control of protocols (“protocols are the most disempowering aspect of modern maternity care…”).

This section is followed by fifteen different birth stories, beginning with the author’s own (at a Missouri birthing center—my own first baby was born in a birth center in Missouri, so I felt a kinship there).

The births are not all happy and “perfect,” not all intervention-free, and most are quite a bit more “managed” and interfered with than a lot of homebirthers prefer (one is a cesarean, several involve epidurals or medications). I, personally, would never freely choose a “homebirth in a hospital” (I also confess to retaining a deep-seated opinion that this phrase is an oxymoron!). However, that is not the point. Over 90% of women do give birth in a hospital attended by a physician and I appreciate the exploration of a new model within the constraints and philosophy of the hospital.

The book closes with a chapter called “how to be an integrative childbirth provider.” The book has no resources section and no index.

I certainly hope that doctors read this book. I am also glad it is available for women who feel like homebirth is not an option or not available and would like to explore an integrative approach. Even though my opinion is that none of the births are really “homebirths in the hospital” as most bear little resemblance to the homebirths I know and love, unlike the content of the standard hospital birth story, they are deeply respectful births in the hospital and that’s the issue truly at the heart of this book.

Jennifer Block Articles

I've been out of town for a while, so I'm a little behind in mentioning some new articles by Jennifer Block that were published recently.

On RealityCheck she wrote about birth and medical care reform: Where's the Birth Plan? In the article, she points out: "A new economic analysis forecasts savings of $9.1 billion per year if 10 percent of women planned to deliver out of hospital with midwives. (Right now, just one percent do). If America is serious about reform, midwifery advocates are saying, 'Hey, how about us?'"

And on Babble, Block wrote a thought-provoking article called Birth Wars: Who's really winning the homebirth debate. There is a sort of "companion" article on the same site, Pushing Back, that takes a critical look at whether the natural childbirth movement has "gone too far."

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Molly
CfM Blogger

Birthing Bodies as Machines

From the book In Labor: Women & Power in the Birthplace:

Under the title Normal Delivery, an obstetrical teaching film purports to show the 'use of various drugs and procedures used to facilitate a normal delivery.' another 'normal delivery' film is a 'demonstration of a normal spontaneous deliery, including a paracervical block, episiotomy.'

These are the normal, noninterventionist techniques, the physician just helping things along. The analogy that comes to mind is of the person with a new color television, endlessly fiddling with the fine tuning, occasionally giving a whack on the side for good measure. The person's not really doing anything to the TV--not taking off the back panel or rewiring. Once the body is conceptualized as a machine, then it is going to be treated in much the same way as any other machine in our society--pushed to be more efficient, more economical, faster, neater, quieter. An infinite number of procedures and interventions are so readily normalized because that fits in with our view of the world: one is compelled to take action in order to get results. In medicine, as in much elese in technological society, even action with very little chance of success is preferable to no action at all, on the spurious assumption that doing something is better than doing nothing.

I really like the analogy of tinkering with the television.

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Molly
CfM Blogger

Homebirth in the Hospital

I recently finished reading a new book called Homebirth in the Hospital (watch for my full review in the fall issue of CfM News). The book proposes an "integrative" model of childbirth--integrating natural childbirth with modern medicine. Interestingly, immediately after finishing the book I happened to come across the website of an OB practice in New York City called Village Obstetrics. With the tagline "minimally invasive obstetrics," this practice seems to be exactly the sort of integrative practice proposed by Stacey Marie Kerr in her book. I thought it was a neat coincidence. I was especially interested in the practice statistics on the Village OB site--they are excellent! (And it goes to show that when providers are proud of their stats, they have no trouble sharing them. It is a red flag if you ask a practitioner about their stats and they "aren't sure" or an unwilling to reveal them to you.) Without including scheduled cesareans (which appeared to be for legitimate reasons), they have a 6% cesarean rate (+ an additional 15% for various reasons)!

The Homebirth in the Hospital book doesn't address statistics specifically, but I assume physicians following that model would have similar, lower rates of interventions. (Do note that there are other things on the Village OB site, such as encouragement of continuous monitoring, that do not seem consistent with an integrative model.)

I finished the book (and the OB practice's site) feeling like a "homebirth" in a hospital is most definitely not for me (not really enough like homebirth at all!), but also feeling glad and optimistic that there are medical care providers out there who are seeking to practice in integrative ways that respect birth and women. I also am fully aware that the vast majority of American women give birth in hospitals and I think we desperately need other hospital-based healthy birth options to meet those women's needs!

I was also reminded of a section in the book Birthwork that addresses complementary care:

Parents who have quite comfortably given birth naturally and taken responsibility for their health are often perplexed by the zeal with which the medical model is upheld and promoted...Conversely, ardent natural birth activists can similarly perplex and infuriate those who have been grateful for necessary medical help their received when they gave birth in a hospital.

Like all great systems of belief, the revelations and tools of borth modern medical birth and natural birth are there to be embraced by those who choose to embrace them, and to be kindly offered to those who may benefit from them. We need to begin by negotiating the confusion that exists around the availability and right to medical help for a planned natural birth, and the availability and right to birth naturally within a medical setting. Rather than insisting on one right away, we need to appreciate that different systems of care can be complementary and helpful to one another. They can work together.

This section also reminded me of the recent study from the Netherlands about the safety of homebirth and how their maternity care system is is much more cooperative than we see here as it promotes access to midwifery as well as a good transportation and referral system (which necessitates working, egalitarian relationships between care providers).

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Molly
CfM Blogger

Physicians & Birth

A few weeks ago, I read an older book titled Woman-Centered Pregnancy and Birth. I marked the following quote to share because I thought it succinctly summed up one of the primary issues in maternity care:

"The major problem which arose almost as soon as physicians started attending women in birth is the same problem which exists today in obstetrics: physicians use their medical techniques when they are not really necessary and their technology and practices often create more problems than they solve. It is possible to appropriately apply this criticism to nearly every form of technology which has been used by physicians on women in birth from the 1500's to the present."

I also noted an observation from the book Birth Tides: Turning Towards Homebirth: "To these people, it seems as thought the medical system has been reduced to a form of social control. [Another woman] makes the point, however, that controlling women has always been an intrinsic part of antenatal care."

I think the recent AMA resolutions I've posted about and the situation with private midwifery in Australia lend credence to the idea that the medical system is a form of social control!

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Molly
CfM Blogger

Another Interesting Attempt by the AMA

I already posted about the AMA's outrageous move regarding "ungrateful patients" (luckily, the resolution did NOT pass!). Though it isn't directly related to midwifery, I cannot help but post about the other quite arrogant maneuver also suggested recently:

AMERICAN MEDICAL ASSOCIATION HOUSE OF DELEGATES
Resolution: 605 (A-09)

Introduced by: Illinois Delegation

Subject: Removing the Word "Provider" in Reference to Physicians
Referred to: Reference Committee F (David C. Fleeger, MD, Chair)

Whereas, Physician status becomes eroded when addressed by the word "provider"; and

Whereas, The word "provider" conveys subservience, lack of independence, lack of authority, lack of decision making, lack of specialized knowledge, lack of separation from other ancillary personnel, lack of respect for the MD degree, servant status; therefore be it

RESOLVED, That our American Medical Association consider the generic terms "health care providers" or "providers" as inadequate to describe the extensive education and qualifications of physicians licensed to practice medicine in all its branches (New HOD Policy); and be it further

RESOLVED, That our AMA institute an editorial policy prohibiting the use of the term "provider" in lieu of "physician" or other health professionals for all AMA journals and publications. (New HOD Policy)

Fiscal Note: Staff cost estimated at less than $500 to implement.

Received: 05/05/09

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The most significant phrase is this, "The word 'provider' conveys subservience, lack of independence, lack of authority, lack of decision making, lack of specialized knowledge, lack of separation from other ancillary personnel, lack of respect for the MD degree, servant status..."

So, they would prefer a word that conveys "being the boss"? I think this resolution is further indication of a desired erosion of personal rights with regard to medical and health care decision making. Not only should women not be allowed to choose midwifery care or homebirth (according to the AMA), but they may also not view physicians as there to "serve" them, but instead as an ultimate authority and ruler supreme?! Hmm. As someone else on a discussion group noted, "I'm beginning to think that the ordinary citizen needs to rise up and [have a resolution] not to be called 'patients' because that implies a lack of independence, subservience, lack of authority about their own bodies, lack of decision making, lack or respect, servant status..." No kidding!

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Molly
CfM Blogger

More about "Medical Care"

Interestingly, shortly after I posted "Health Care or Medical Care?" the very same topic came up in the book I am currently reading.

I have been using the terms health and medical as though they are interchangeable, but they are not, and I should not. Health care emphasizes primary prevention and covers a wide range of life activities, many of which have little to do with doctors and hospitals. Medical care is what the current health care system provides--secondary and tertiary care that employs technology for screening, allopathic medicines, and surgery. It would take a lot more than reimbursement plans granting universal access to care for us to have a national health care system. At best, at the present moment the United States might develop a national medical care system.

This is actually from the 1995 book, Bearing Meaning: The Language of Birth, which I previously mentioned wanting to read. Thanks to my sister-in-law, I am currently reading it! (birthday present).

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Molly
CfM Blogger