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.

April is Cesarean Awareness Month

For those of you who do not know, April is Cesarean Awareness Month. Did you know that our national cesarean rate continues to increase every year? Over 31% of births take place surgically via cesarean section. Consumer Reports has named cesarean surgery one of the top overused procedures in the United States. Even though the US tends to deal with pregnancy and childbirth from a medical perspective, our country’s maternal/fetal outcomes are among the WORST in the industrialized world. I hope you will take some time this month to learn about cesarean surgery, why women in your communities may not consider cesarean-born babies to have been birthed, why women are having more trouble post-cesarean with becoming or staying pregnant, why women may have less access to birthing options following a cesarean, and why women should be searching for less medically-interventive options for pregnancy and childbirth. Talk to people in your community about preventing unnecessary cesareans (keeping in mind that cesareans are appropriate for some emergent situations and in case of emergency), midwifery care (nurse-midwifery and professional midwifery), birth venue choices, and how to help someone recover from a cesarean. For more information on Cesarean Awareness Month, visit http://www.ican-online.org and also search for a local chapter. Together we can make a difference, one birth at a time.

Natural Breech Birth Deserves Our Support!

A friend posted a link to the Coalition for Breech Birth on her gmail status. I’m so thankful to know about this resource now.  The following quote applies to all low-risk mothers (regardless of fetal presentation or previous cesarean):

“However, caesarean surgery, while it presents many advantages for the surgeon, has lifelong ramifications for the birthing woman and her family, including issues with subsequent pregnancies, secondary infertility, vbac availability, and depression, not to mention a risk of death in childbirth increased threefold over vaginal birth. Women should not be obliged to accept these serious risks as ‘standard of care’. . .”

Please have a look at this site which provides links to the original report that caused breech birth to fall off the natural birth map and the subsequent research that DISPROVED the report authored in 2000 that continues to govern obstetrics & midwifery access and practice to this day.

What drew me to childbirth advocacy

I received an excellent question from a Facebook friend the other day.  And even though my response is brief, I suppose this might be a question that a lot of folks have for people like me!

“So I’m curious… What led you to become involved with ICAN? Personal experience or passionate commitment to natural childbirth? Or both?”   “I am always interested in how people come to be involved in this kind of advocacy.”

My brief response:

I had a cesarean in 2004 and didn’t fully understand the impact of it until much later. I joined ICAN when it was time to try for another baby and have been involved ever since. So, now it’s personal experience as well as passionate commitment to evidence-based practices in obstetrics as well as spreading the word about the benefits of natural childbirth, VBAC, homebirth, birth plans, doulas, midwives, whatever! Also, I’m very concerned about the national cesarean rate and our local rate in Missoula. That’s it in a nutshell!!

And of course I suggested that she have a look at my blog!

It was a big day

Phew, 7pm and I’m exhausted.  Here’s a summary of my activities today:

The twins – yes, I said twins, look good.  I’m not quite as far along (only by a couple of days) as I would have thought, and this is an agonizing alteration to my pregnancy “schedule.”  What I mean is that as a loss momma, that last thing I want to be doing is backing up in time… adding MORE time into the 1st trimester.

Both babies are measuring about the same size.  Both babies’ heartbeats were easily detected and measured right around 130 which is good for 6 weeks 4 days or so.  We were so thankful to see those sweet flickers again.

My husband and I found out definitively about the twins about a week ago.  A nurse at the RE’s office recommended a scan because my HCG numbers doubled too quickly.  At about 5-1/2 or 6 weeks we were able to see two sacs and even visualize the heartbeats for both babies.  I call them my little flickers.

Health Reform:  I was thrilled to have been invited to attend a local health reform meeting to represent consumer concerns.  I introduced myself as an University professor and a professional opera singer which of course got a couple of laughs.  Then, I continued by saying that I’m a consumer advocate and come to this gathering as a woman with a scarred uterus.  The main concerns I articulated as a cesarean mom were:

  1. A high local cesarean rate (around 31%); a low VBAC rate (about 1%) at the hospital
  2. A lack of support for the local birth center
  3. Decrease in numbers of CNMs locally
  4. Insurance and health care costs
  5. Insurance company driven health “care”

Additionally, it alarms me that even with my supposed “good” health coverage, I am struggling to pay last year’s medical bills.  The bills are overwhelming, so they pile up, and my credit score is suffering as well.

Arts Advocacy:  I am one of the educations outreach directors for a new opera company.  We had a meeting today to help prepare for the next board meeting and our upcoming educational outreach program.

I even managed to mop the floors.  I’d say it was a pretty darned productive day.

Legislative Alert: American Association of Birth Centers Announcement

I am just a messenger.  This is extremely important and requires quick action.  I know it’s a crazy busy time of year, but please do take a moment to make these calls.  Midwifery is good for women and babies!  Support a woman’s access to ethical and mother/baby-friendly care.

American Association of Birth Centers
Legislative Alert

URGENT – Make Calls before December 22nd!

We are making progress with education of the House and Senate about the need to add the birth center facility to Medicaid covered services! But, many Representatives and Senators have not yet had a call from you or your clients. We must have sponsors from both parties! We are also targeting key people who will vote YES or NO whether our bill will get out of committee and to the floor — once we have introduced the bill.

For background information click here.

Please make calls to congressional health staffers this week before the holiday recess!

1. Click here to get the names and phone numbers of the Washington D.C. offices of your two Senators and your Representative.

2. Ask the name of the healthcare staffer and ask to speak to them.
3. Write down their name and phone number.

4. Tell them you own/direct/work at/are a consumer of/care about the services of a birth center.

5. Tell them that a bill will be introduced soon to add birth centers to Medicaid. [NOTE: the bill does not yet have a bill number.]

6. Ask for their support and sponsorship of our bill to add birth centers to Medicaid. That’s all you need to say–we’ll do the rest.

7. Then call or email AABC’s lobbyist Karen Fennell (301-830-3910, karenfennell50 @ yahoo.com or me (423-253-4455, jkalliman @ yahoo.com to tell us what they said. We will follow up.

NOTE: We do not have a bill number because it is not yet introduced, but we want to introduce the bill in January and need sponsors now. We can send them the draft bill language if they are interested in sponsoring the bill.

justinandelise (flickr)

image attribution: justinandelise (flickr)

This is urgent if we want to sustain birth centers in the United States. Please call today.

Please pass this on to your Friends of the Birth Center groups and ask them to call too.

Sincerely,

Jill Alliman, CNM, MSN
Legislative Chair
American Association of Birth Centers