Undue Burden and Access to Evidence-Based Maternity Care

I’ve been reading Jennifer Block’s Pushed and really enjoying what a journalist can bring to childbirth advocacy.  I’ve learned many new things – what a nice surprise.  It’s not that I’ve learned everything there is to know about childbirth, but I think I got “stuck” in reading books that basically said the same thing but in different ways.

A new term for me is “undue burden.”  Wikipedia’s definition falls short, in my opinion, but between Block’s discussion of it and other internet sources, I’ve come to understand it better (at least from a layperson’s perspective) and how it might apply to a LOT of women in the childbearing years.

I’ve learned that undue burden has been applied to reproductive rights issues, specifically abortion.  However, I don’t think we advocates have worked this “angle” enough in terms of childbirth choices.  Abortion rights activists have advocated for “morally agnostic undue burden standard[s]” [1]  Likewise, I would call for an “agnostic” undue burden standard applied to childbirth.

The undue burden standard is utilized in American constitutional law and historically has been applied in such areas as abortion rights, affirmative action, tax laws, and more.  The Supreme Court applied this concept to abortion, ruling that a state can’t put up so many obstacles to abortion procedures that a woman’s individual rights are violated.  [2] An undue burden is created when obstacles are severe and/or not justified.

Do you see where I’m going with this?  I feel like I am a victim of undue burden.  I have no reason to believe that I can’t successfully birth my twins naturally.  But the state has deemed that my preference of birth venue is not valid – women with breech babies or multiples are not allowed to birth at home with a licensed midwife.  My choices are to (1) birth unassisted at home, (2) go to the hospital against my will, or (3) enlist the services of an illegal midwife.  Additionally, the only services that would be covered by my insurance are hospital services.

In most states women with breech babies have no choice but to go to the hospital for a cesarean section even though breech presentation has traditionally been referred to as a version of normal.  We’ve lost access to vaginal breech birth.

In most locations women with multiples are pressured to succumb to cesarean surgery.  A number of folks have voiced their concern for my choice to birth these babies vaginally.  They simply don’t know any better.  Luckily I have found an obstetrician who is not afraid of normal birth.  However, I realize now that he may not be there for me when it comes time to go to the hospital.  He takes a week of vacation each month of the summer and is out of town twice next month, my birth month.  I found this out accidentally from his reception staff.

It is possible that I will show up at the hospital and some OB whom I’ve never met will show up and start pressuring me into surgery or ignore (or at least be unaware) of my birth preferences.  So because the state has deemed that twins should not be birthed at home, and because my insurance company won’t cover home birth anyway, I can either “choose” to go to a hospital that doesn’t practice evidence-based obstetrics or go eff myself, I guess.

Isn’t this an example of undue burden?  Lack of access to the care of my choice?  Paying for health care that doesn’t support evidence-based maternity care and forces me to go to a specific hospital in my town with a high cesarean rate and low VBAC rate?  Unjustifiably restricting scope of practice for midwives?  Not offering alternatives/access to the type of care I require?

I don’t want to be a patient.  I don’t see any need to expose myself or my newborns to the hospital environment.  Even my 4 year old doesn’t understand why I would go to the hospital to have babies.  “Mommy, are you sick?”

Don’t get me wrong, if I or the twins needed emergency medical services, you bet we’d go to the hospital.  I’m thankful to have access to obstetrics when necessary, but I resent being forced to utilize services that go against common sense, research, and are expensive and wasteful as applied to the great majority of laboring women.

I hope natural birth advocates, women’s studies researchers and writers, and lawyers will work together to expand application of the undue burden standard to the women who don’t have access to ethical, evidence-based care in childbirth, and are forced instead to incur great expenses to access the care they desire, to hire “illegal” or “under the radar” practitioners, to utilize unwanted services and support the over-payment of those services, or to go at it alone.

Please, give me back my right to birth.  Give me back my body.

1 – “Destacking the cards…,” Gender & Sexuality Law Blog, accessed 7/18/09.
2 – Jennifer Block.  Pushed. p.262.

5 responses to “Undue Burden and Access to Evidence-Based Maternity Care

  1. What an incredible post, Kimberly. One of those posts that snaps you out of yourself for a minute. I *know* all of this, but to have it put so simply and so personally, is a reminder of how far we really have to go.

    It really is as simple as giving us our right to birth, giving us our bodies. If I can help you at all on your journey, please do not hesitate to ask.

    Christie

  2. Well put. It is a shame that women are “forced” into situations like yours. Not having true options for birthing locations. It is wrong. I hope that your OB is in town when your babies are born.

  3. AMEN! My mom is disgusted that your doctor is not willing to be there for you and your girls. He should consider it an honor and privileged to be part of the whole experience!
    I ran my first half marathon for me, my next one is for you and your advocacy!
    You are in my thoughts and prayers!

  4. There is a possibility that you may be able to legally utilize a Written Advance Directive to protect and retain your birth choices. This is like a birth plan, but signed by witnesses in preparation for attempts to undermine your autonomy. It might also be a good idea to see what kind of twin research trials are running in your area in order to avoid becoming another number.

    Your doctor may also take it for granted that he may have to cut his vacation short and travel back for your birth. Talk to him and ask him about his plans for this summer and the what-ifs. The reception staff may have it wrong. Even if they are correct, you may gestate longer than you anticipate. I made it 39 weeks (and would have gone longer without the induction or dead babies song and dance) and another lady I know went 42+3 with her VBAC twins. She had a beautiful vag. birth in hospital.

    Having to fight for best-practice maternity care IS an undue burden in itself, and even the low-risk women have to jump through hoops to avoid social interventions. This is a civil rights issue, hands down, but there’s got to be a case in front of the Supreme Court which establishes precedent before we’ll see a system wide change.

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