Wednesday, February 13, 2008

Earthy Birthy Mama Says a Mouthful

As you may know I am a doula. I have been attending births on and off since 1999. I have also taught some childbirth education classes. I still do not consider myself an expert on childbirth, but I have been around the block a bit. I am not anti-OB and not anti-medicine, but I am also not 100% supportive of the model of maternity care the US has been locked into for the past several decades.

I am very supportive of women educating themselves about the birth process and finding a care provider who supports them and their wishes for their birth, someone they can trust to inform, guide and give quality care, and not dictate every step of the process. The care provider could be an OB at a hospital or a midwife at home. I am very supportive of midwifery model of care. I have delivered both of my babies with Certified Nurse Midwives. One at the hospital and one at home. Both were wonderful births. Here in Illinois a Midwife can not practice legally unless she also has a nursing degree. Using a Certified Professional Midwives or Direct Entry Midwife is not really option unless you want to go under the radar and hire someone who probably lives in Indiana.

Some of you may have been hearing the buzz about ACOG's statement on home birth.

ACOG has basically come out saying they can not support home birth as a safe practice, period. The statement suggests that women choose home birth either out of ignorance or to conform to the latest trends. Not only that they imply (more then imply!) that the high cesarean rate in America is the fault of us women for either choosing it, or being too fat and old and unhealthy to deliver vaginally. At least that sure is how it reads!

Now, I am not surprised that ACOG has finally formalized their stance against home birth in the form of an official statement. Nor have I ever expected ACOG to down in strong support of home birth or of midwives, especially those who do not have a nursing degree...they are after all in a different camp. However, the language in the statement is harsh and accusatory toward the women that they are meant to be caring for and also unsupported by statistics. However, I am guessing that the issue is not really that home birth is never safe because many studies have shown it is safe, especially for low risk women, including those conducted by World Health Organization and The British Journal of Medicine, but that OB/Gyn's and ACOG can not support home birth and will not attend home birth because of liability issues. Medical Liability costs in this country are soaring and it is affecting the way OB/Gyn's practice. ACOG released a study in 2006 showing that the way Obstectrics are practiced has been negatively affected of late by physicians fears of being sued. Here are a few of the many statistics they released:

"Changes made by ACOG Fellows because of the risk of liability claims or fear of being sued:
  • Decreased the number of high-risk obstetric patients-33%
  • Stopped offering/performing VBACs—33%
  • Increased the number of cesarean deliveries—37%"

So it is not surprising that ACOG will not support home birth. Nor is it surprising that you can hardly find practitioners to perform home births anymore since it seems they are all afraid of law suits and also can not even afford their own liability insurance. I like the way ICAN phrased the problem with what is happening, "Women and children should not bear the brunt of malpractice risks being conveyed into physical, mental, emotional and spiritual health risks in order to protect their physicians."

As for the accusations that women are choosing home birth to be trendy, popular with a clique of girlfriends or simply out of ignorance I strongly disagree. I think that women are becoming more aware and more informed about birth and they want more choices and a different quality of care then hospital births are able to provide. I believe women are doing more research and are very strongly considering the outcomes for their baby and themselves when they choose home birth. To state that women who choose home birth are putting the birth process over the safety of their babies is condescending, patronizing and overly moralizes the issue. I know for myself that if at any point I thought I was putting my baby at risk I would have changed plans. My midwife also would have changed plans as her primary concern was also the safety of my baby and myself.

Home birth is not for everyone. Some people really need hospitals and interventions to save their lives and the lives of their babies. Thank God we have modern medicine for those circumstances. However, it shouldn't be any trade union or liability insurance costs that decides how and where women have babies. It should be each woman deciding with her family having the guidance (and certainly not guilt tripping) of a trusted care provider what is best for her and her baby.

I think instead of pointing fingers we need to find a way to provide more safe options for women including more free standing birth centers and more home birth practitioners from both the OB camp and the midwifery camp. Wouldn't it be great if OBs, CNMs and CPMs could all actually work together in a supportive fashion to give the best maternity care to women in this country?

Well, now that my brain hurts I may have to actually stop there. I think I have more to say, but I will probably just begin to ramble. Check out some of the links below. If you have written about this issue post your link in the comments so I can check it out. Thanks for listening and happy birthing in whatever manner you choose! Perhaps I'll tell you my birth stories someday soon.

Oh, to my knowledge ACOG has not done their own study on home birth.

More Fun Related Reading:

ICAN's full response to the ACOG statement on home birth: ICAN Responds
Check out Crunchy Domestic Goddess' post at Blogher

Interesting article from Boston Magazine about women in Boston questioning their maternity care.


TwoSquareMeals said...

I definitely agree with you on this one. I hope my last comment didn't make you think otherwise. I am all for midwife assisted births at birthing centers or at home. I am definitely for women being more informed and involved in the birthing process not matter where it happens or who helps out with it.

I think you hit the nail on the head. This comes down to a malpractice issue. I can say from my own experience with my father that doctors live every day in fear of malpractice suits. One good thing is that the cost of malpractice insurance has lessened the number of doctors who go into the profession to make money. They don't make good money anymore, at least not comparatively. Most doctors really want to help folks. If they wanted to make money, they would become malpractice lawyers.

I do think the ACOG statements was condescending and overreactionary. I think the solution, besides promoting discussion between midwives and OB's, is reforming our malpractice system. The doctors are certainly not to blame for this one. It is a much bigger issue having to do with our culture of entitlement and our expectation that we should always be safe. Oh, yeah, and the sort of lawyers who are looking to pad their own pockets while wrecking our medical system. But that's for another post...

Anyway, thanks for bringing this ACOG statement to light. I wish my dad were still around so I could talk to him about it. He never was a big fan of ACOG because of his strong pro-life stance, and I wonder what he would have thought of this.

Crunchy Domestic Goddess said...

Thank you for your comment on my blogher post and for writing about your thoughts here. I think the more people that write about this and get the word out, the better.

The condescension in the ACOG statement really bothered me. I think (and hope) most women are smart enough to see through it.

"Wouldn't it be great if OBs, CNMs and CPMs could all actually work together in a supportive fashion to give the best maternity care to women in this country?"

YES! It can happen in other countries, maybe someday it will happen here too. We can hope.

I think there needs to be a HUGE shift in the current birthing practices in this country. The Big Push for Midwives is making some headway. Let's hope we can keep the momentum going.

painted maypole said...

Babies have been born in homes for decades. Centuries. Millenia. They'be been being born in hospitals for how long?

bubandpie said...

This is such a great deconstruction of the condescending rhetoric of the ACOG report. Thanks also for the link to the BlogHer article - I was particularly amazed by the ACOG's claim that studies supporting the safety of home birth were not scientifically rigorous, so it's good to see confirmation that home birth can be and often is a safe choice.

(This, by the way, is coming from someone who was quite happy with her care from obstetricians with both births, who has never used a midwife and would never consider a home birth!)

Karen said...

re: Bub and Pie - exactly!! there is no reason why women cannot make their own choice free of external constraints! Polarizing and moralizing the issue is another version of mommy wars actually being somewhat made up by people who are not actually mommying. Why do we have to had homebirth v. hospital birth when we could have homebirth and/or hospital birth.

Lisa b said...

I think my experiences are unusual but the doctors who were present at my first daughter's birth mentioned a recent study that indicated homebirths tended to be as safe as hospital births.

I wanted a homebirth with my second child but a complicated pregnancy had my midwife suggesting a hospital birth. Even though I was under the care of the high risk pregnancy group she caught the baby. A rare example of how well the system can work together.

My daughter spent three months in the NICU and most kids were preemies but some were meconium babies from homebirths. I asked a nurse if the baby would have been ok if born in the hospital and she said she just didn't want to think about it.

I think there are no clear answers here. If you choose to deliver a baby at home and something goes wrong would you not then feel you hadn't been informed of all the risks?

Heather said...

Great comments everyone...

2 square meals, I took no offense to your last comment and even if you did disagree with me that would be okay.;-) Your insight is valuable as you have seen an OB practicing and trying to do his best by his patients. I wish I could hear from individual OBs about their thoughts on the ACOG statement. I'm sure there are vastly differing opinions.

Heather said...

Crunchy DG--

Thanks for stopping by to read the post!You're right the more we keep the discussion going the better.

K, B&P and Maypole---preachin' to the choir here obviously. ;-) Thanks for your comments!


Thanks for coming by too! Sounds like you had really great care providers. That's what we want for everyone! It's very common that midwives who do homebirths will not continue to work with you if you are high risk. They recognize there is a place for hospital birth and for working with OBs. The kind of attitudes and collarborations you experienced is what I would hope for all women from their care providers.

As someone who has given birth in a hospital and at home I think personally I was aware of the risks in both situations. I feel like I went in with my eyes open. Also, I knew that I could not control everything. I think if something had gone wrong at either birth I would have just done whatever was necessary in the moment. Ofcourse later I would have questioned things in either case...that's human nature...that's being a mother.

I think the question about regrets can be asked about hospital births too. For example here's a scenario I've seen many times: a woman who is told she needs an early induction for a baby that is "too big" based on an ultrasound.The induction spirals into more unplanned interventions and even a cesarean because the monitor showed the baby in distress after long hours of pushing.Then the baby is born and she is two pounds less then predicted. Now she has a baby born early who had a little trouble starting breathing and had to go to the NICU, but seems pretty healthy, but the woman has also had major surgery. Would she question her choices? Maybe, or maybe not. That's why each woman & family needs to decide what she/they are comfortable with.

We need to educate ourselves and eachother about the realities, risks, benefits of each choice and still have the right to choose it. If ACOG was backing their statement up with good data and saying that women need to be better informed when making that choice that's one thing. However they seem to be playing the guilt card on women and also trying to strip us (and perhaps even some OB's who would like to practice homebirth) of a otherwise valid option for healthcare.

Ooo...that was a much longer response then I intended. Anyway, truly thank you for your comment! Let's keep asking all these questions.

Lisa b said...

Hey Heather
I totally agree the risks to the mom for a hospital birth are far greater and contribute to worse outcomes for infants. I also agree that the ACOG should have decent data and not assume women are uninformed. My experience just gave me a slight glimpse into why doctors might oppose home births. As you say it is human nature to look back with regrets so I can see how they are frightened of lawsuits.
I suppose it is difficult to quantify how many unnecessary csections are done vs how many tragedies like the meconium baby I mentioned occur. Is there an acceptable ratio? Is there real data or are we comparing apples to oranges as midwives tend to deal with low risk births?

Carrien said...

I continue to be shocked and aghast at the US obstetrical model.

MY first two children were born in Canada, in a province that supports midwife care and home births are part of the provincial health care system, and covered. Midwives have hospital privileges and patients can choose home birth or hospital birth with a midwife attending, unless she is high risk, The midwives won't attend a high risk home birth but they will go to the hospital for one and arrange a consult team with an OB.

FOr my 3rd child I lived in CA and hired a midwife to attend my home birth. Since I had the insurance to cover it I also booked time with an OB so that there would be continuity of care should I need a hospital transfer. I was upfront and honest about my plans to home birth and my desire to have this as a back up in case it was needed. The staff in the office were very supportive but once my chart passed the desk of the administrator the OB had to refuse me care because they didn't want to be held liable for anything that may have happened before a hospital transfer.

I'd never heard anything so ridiculous, but then, I'd been giving birth in Canada. I sent a little letter informing them that some people might consider them responsible for anything that does go wrong if they canceled care without giving me my antibody screen, etc. since I was in the 29 week and I wanted insurance to pay for the blood work. SO as a medical courtesy they continued care for another few weeks but they would not be responsible for or attend my labor.

Anyway, that illustrates your point about litigation quite well. And it does work in other countries where the medical establishment is more open to other methods.

Heather said...


Sorry I did not respond earlier. I've been away from the computer for a while.

I think you raise good questions. The best I can do is refer to you World Health Organization which views the highest acceptable cesarean rate to be around 15%. The US is up to around 30% for cesarean deliveries.

I think comparing home birth and hospital birth can be comparing apples and oranges if you are looking at a high risk hospital birth vs. a low risk home birth. Comparing low risk to low risk (regardless of setting) should give a pretty fair analysis.

I also encourage you to check out the ICAN website if you have time. They have some great resources there.

Carrien...thank you for sharing your thoughts and your story.