Bad news for homebirth in Utah

From an article in the Salt Lake Tribune:

    The bill would put new limits on direct-entry midwives, who are licensed and attend home births. By defining a “normal” birth, it bans them from administering to women with a host of medical conditions, from diabetes to hypertension.
    They also would be stopped from assisting women whose babies are breech or who want a vaginal birth after a previous cesarean section (VBAC).

How is it that people who never see “normal” birth (a term that is easily usurped and unfortunately true of augmented birth in this day and age) are able to determine normalcy.  If they can determine “normal”, then perhaps they should start overtly forcing more women into induction, augmentation, and other interventions.  Medically-managed labor & delivery is certainly most common in a hospital setting.  In fact, why don’t we just get rid of the mother’s (and other vested persons’) desires altogether?  Many – if not most – OBs are contemptuous towards mothers with birth plans anyway.

I can tell you that “normal” should equate to “natural”, but it doesn’t any more.  And really the only venue for assuring natural birth is home.  Sure “natural” might not happen for everyone.  I’m not even trying to suggest that all women should give birth at home.  But these restrictions . . . why not ensure that direct-entry midwives are well-trained for breech, twin, and VBAC scenarios.  How do you ensure this?  By keeping it legal and supporting midwives who feel confident in their skill level with breech, twin, and VBAC labor.  Just as an OB should know if s/he is the appropriate person to deliver a breech baby or perform an amniocentesis (and lemme tell you, some simply are NOT), so should a CNM or direct-entry midwife.

I’ve written about “normal” and “natural” before – click here to read!

Trust Birth or Don’t?

I can’t resist.  You would think that since I am new to homebirth and haven’t had a VBAC yet that I wouldn’t bother myself with polemics regarding homebirth.  I’m obviously not that bright.  My homebirth google alert today included a post about the power of positive thinking and the homebirth movement.  I had to check it out. 

I won’t link to this weblog out of principle, but if you search for the quote using your favorite search engine, you’ll find it easily enough . . .

“. . . if you ‘trust’ birth, and refuse to accept the fact that birth is inherently dangerous, you will be rewarded with the birth experience that you desire.”

I’d like to play with the words a bit:

“If you refuse to trust birth and insist that birth is inherently dangerous, you will be rewarded with the birth experience that you desire.”

Some people, practitioners and women, simply refuse to trust birth.  Some will insist that birth is inherently dangerous.  They will likely achieve the birth experience that they desire, and it will likely be overly-managed, overly-medicated, potentially surgical, and definitely exorbitantly expensive.

“If you don’t trust birth and accept the fact that birth is inherently dangerous, you will be rewarded with the birth experience that you desire.”

And somewhat similarly:

“If you don’t trust birth even though you don’t believe that birth is inherently dangerous, you will likely have trouble achieving the birth experience that you desire.”

Some people don’t trust birth and have accepted the “fact” that birth is inherently dangerous.  They will likely create that reality in their birth experiences.  If women engage practitioners with this guiding philosophy, they will likely lose faith in the natural processes of life and end up dissatisfied with their birth experience even if the outcome is positive.

Some women know that birth isn’t dangerous most of the time but lack the trust needed to achieve particular outcomes.  Perhaps this was me once upon a time.  I never really considered that birth might be dangerous.  Why would I be created for a particular skill if it were inherently dangerous to me or my offspring?  However, I’m not sure that I trusted myself enough last time.  I didn’t trust my body.  I didn’t trust my instincts.  That’s probably the worst part of it . . . I didn’t listen to my inner voice.

“If you trust birth and acknowledge that birth is inherently natural to our species, you will likely achieve the birth experience that you desire.”

If you trust birth you are fortunate enough to understand that certain life events are natural and far less risky than some of the every day activities in which we engage.  Things like riding in cars.  That single activity is far more risky (statistically speaking) than giving birth.  If you trust birth you may not be “rewarded” with a particular birth outcome but understand that complications and poor outcomes are possible.  Trusting birth is not about sticking your head in the sand.  It’s about understanding that most of the time women can achieve normal birth when given appropriate support, time, and space.

Going back to the original quote:
“. . . if you ‘trust’ birth, and refuse to accept the fact that birth is inherently dangerous, you will be rewarded with the birth experience that you desire.”

“Trust” – in the original text, the blogger puts the word “trust” in quotes; this diminishes the validity of “trust” in relation to childbirth
“Refuse to accept” – ultimatum . . . polemic
“Inherently dangerous” – emotional scare tactic
“Reward” – as if there’s a prize involved???
“Desire” – as if all that matters for homebirthers is what the woman desires

Do you see yourself anywhere in my “play on words” section?  Where do you want to be?  Do you want to be afraid to be pregnant?  Do you really want to go into labor and delivery afraid?  Do you really want to go into labor and delivery lacking trust?  What is positive and proactive about being fearful and lacking trust?  What do you as a pregnant and/or laboring woman gain from that perspective?  I would say nothing.  You have lost your power and are no longer an active participant in your care when you are afraid and can’t trust.  Perhaps you (and your birth experience) are more manageable that way.  How do you feel about that?  Do you want to be managed?

I can’t really define homebirth for you.  Everyone comes to homebirth from different paths.  Some women always know that they’ll have their babies at home.  Some women are involved in social structures that are more inclined to promote homebirth, homeschool, extended breastfeeding, attachment parenting, and the like.  Some women are disgruntled consumers.  Some women aren’t given the choice to have a vaginal hospital birth and turn to homebirth as their only choice.  Some women who give birth at home don’t fall into any of these generalized categories.

For me homebirth is about safety, sanctity, Faith, Trust, natural life processes, achieving physiologic birth, what’s best for me and baby, avoiding an unnecessary cut, vaginal birth after cesarean, comfort, family, community, and a whole host of other things that I haven’t even discovered yet!

Homebirth in South Dakota

South Dakota isn’t particularly close to me here in Western MT.  However, SD is a neighboring state, and I have relatives who live in that state, so birth news from SD is important to me!

SD is working on legislation that will allow women to birth at home with assistance of certified nurse midwives (CNM). 

Current laws require South Dakota’s Certified Nurse Midwives to have a signed collaborative agreement with a physician as a pre-requisite to practice.  However, South Dakota’s physicians have failed to cooperate with any Certified Nurse Midwife for homebirth.
 
The South Dakota Chapter of the American College of Nurse Midwives supports the measure and provided testimony on Wednesday citing the safety of low risk mothers who have planned home births with Certified Nurse Midwives.

I don’t believe that Montana allows CNMs to attend homebirths.  I do know that doctors who used to provide back-up support for direct entry midwives (different certification and oversight than CNMs) in my community no longer do.  I like the language in the article – “. . . physicians have failed to cooperate . . .” – indeed!

Jeanne Prentice is a CNM from South Dakota that currently attends homebirths in Wyoming. 

Prentice is alarmed at the growing number of mothers who are choosing to deliver without any help at home because they fear what may be forced on them in the hospital delivery setting.

Indeed, many of us know well enough that hospital delivery can be interventive.  Women are not in a position of power with regard to their bodies, their babies, and their birth plans.  I am not talking about balking at medically-necessary intervention.  However, very little of what goes on in labor and deliver is NECESSARY.  Women are subject to a number of routine procedures and protocols upon entrance to to the hospital.  Women are resisting, and I believe this has caused 2 things:

  1. Care providers, especially medical providers, insurance companies, and other medical institutions are becoming more restrictive, more interventive, and less woman-centered.  This is evidenced by declining maternal-infant outcomes, increased cesarean deliveries, increased PTSD & PPD, and declining VBAC rates.
  2. Out-of-hospital birth is on the rise.  Women and finally starting to realize (I know I am) that their chances of having a good and safe childbirth experience are declining in hospitals.  Women are learning and owning the benefits of natural physiologic childbirth, when possible, and insisting on finding care providers who will enable that.

Musings on Birth Safety

Which is it – childbirth is safe, normal, natural or dangerous, wild, and unpredictable?  Do we really need to draw a line in the sand like that?  Isn’t childbirth all of that – normal, natural, wild, unpredictable, sometimes just fine, sometimes not?

No, childbirth is not always safe.  I work with a gal who has nearly died in childbirth several times.  She lost one child along the way.  She birthed at hospitals under the care of a high-risk obstetrician, and that was a necessary reality for her.  A friend of mine recently birthed a baby still.  They don’t know why the baby died during birth.  Another friend of mine suffered an uterine rupture.  Her smart baby was blocking the artery that was compromised, and that is why she is still alive today.

But often pregnancy and childbirth is normal and uneventful.  (Well, it’s always a big life event, but it’s not nearly as dramatic as Baby Story would have you believe.)  It seems like it is more fun for people – some natural birthers and some who want all of the technological bells and whistles – to hype up childbirth.  “Ugh, it was SO PAINFUL I just HAD to have my epidural.”  “No one is going to take away my VBAC.”  “Oh my gosh if I hadn’t had that c-section, I’d have died in childbirth.”  “I’ll have to be dying before I let anyone take me to the hospital again.”  (For what it’s worth, I said that last statement following my October miscarriage.)  Drama drama drama.  Me me me.  I want I want I want.  I’m being a bit extreme here, but I read so much selfishness and self-indulgence and self-glorification on both sides of the proverbial childbirth fence.  Does this help women?  Does this empower women to make informed choices that “make” childbirth safe?

Let’s come back to that term “safe” as it applies to childbirth venue.  If you don’t believe homebirth is a safe choice, then it’s not . . . for you.  If you don’t believe that you can have a natural non-interventive birth in the hospital, and that’s important to you, then you probably won’t have a good experience in the hospital.  If you don’t trust anyone but your self and perhaps your partner in childbirth, you will probably prefer unassisted childbirth.  We’re only “safe” when we believe we’re safe.  I honestly don’t believe that MOST women are safer in the hospital or safer at home or safer at a birth center.  They perceive a level of safety and psychologically, and even physiologically, respond to that way of thinking.  Certainly there are plenty of “yeah, but” scenarios out there, but I very clearly wrote “MOST women” above.

Be afraid to birth at home.  That’s fine.  But don’t call a woman crazy for choosing to feel safe at home, especially if she is surrounded by well-trained and caring support.  You can be afraid even when someone else isn’t.  Be afraid to birth at the hospital.  That’s fine.  But don’t criticize the woman who chooses to deliver at a hospital, especially if she is surrounded by well-trained and caring support.

It is an unfortunate reality that babies die in childbirth . . . that women die in childbirth.  I think doctors, midwives, and other childbirth support providers are all interested in reducing negative outcomes in childbirth.  I just wish, hope, and pray for the day when these parties can meet and work from a point of mutual respect.  That’s when we’ll have a maternal-child healthcare system that is woman-baby centered and certainly safer for all involved.

We can’t make changes if we don’t talk.  Debate is not talk.  People who debate don’t listen.  I think people who get caught up in debating issues without stopping to listen and learn are afraid.  They are frightened sad unhappy people.  I have my own set of fears just like anyone else, but I strive to run my life from a place of power and trust.  I don’t want to pass fear along to my children.  I don’t want to be remembered that way.  I don’t want to approach God that way.

May you find power, faith, and love, now and forever.

Gloria Lemay Responds to ABC Segment on Unassisted Birth

“The baby could be born in a breach [sic] position, or with the umbilical cord
wrapped around its neck. The mother could suffer from significant tearing or
from a maternal hemorrhage and bleed to death in as little as five
minutes.”

Dear Women,

The above quote is by a physician who was interviewed by Good Morning America for a program about Unassisted Birth on Jan 8, 2008.

I think it’s very important to address the statement that a woman can hemorrhage and bleed to death in as little as five minutes. This is a very horrifying comment for a doctor to make and, for anyone who doesn’t really know birth, it could be enough to send them running for the hospital.

First of all, yes, it’s possible to hemorrhage and bleed to death quickly in birth IF YOU HAVE A SURGICAL WOUNDING.  Women die from bleeding in cesareans and with episiotomies. The closest to death that I have ever seen a woman in childbirth was in a hospital birth where the ob/gyn cut an episiotomy, pulled the baby out quickly with forceps and then left the family doctor to repair the poor woman. We were skating in the blood on the floor and desperately trying to get enough I.V. fluids into her to save her life while the family doctor tried to suture the episiotomy wound as fast as he could.  I have never seen anything like that in a home birth setting or a hospital birth that didn’t involve cutting.

Think about it - would any midwife ever go to a homebirth if it was possible for the mother to die from bleeding in five minutes?  I know I wouldn’t go if that could happen. We had a visit here in Vancouver BC from an ob/gyn from Holland back in the 1980′s. Dr. Kloosterman was the head of Dutch maternity services for many years and he was a real friend to homebirth and midwifery. He told us that you have AN HOUR after a natural birth before the woman will be in trouble from bleeding. Does this mean that you wait for an hour to take action with a bleeding woman? No, of course not. If there’s more blood than is normal, you need to call 911 and transport to the hospital within the hour, but you’re not going to have a maternal death before an hour is up. I have had 10 transports for hemorrhage in the many homebirths that I have attended (over 1000). Two women have required transfusions. The other 8 recovered with I. V. fluids, rest and iron supplements. Of course, no one wants to see blood transfusions in this day and age. We also don’t like to see a woman anemic after having a baby because it makes the postpartum time very difficult. The most important action after having a baby is to keep the mother and baby skin to skin continuously for at least the first 4 hours.

What doctors won’t tell you is that the most severe cases of postpartum anemia are in women who have had cesareans. Major abdominal surgery results in anemia. I have a friend who is a pharmacist in a hospital. He spends most of his days trying to figure out individual plans to help cesarean moms get their hemoglobin counts up. He finds these cases of severe anemia in post operative mothers very distressing.

I hope this information is helpful to you.

As far as the other nonsense this person is trying to frighten you with:

1. Significant tearing—if you look with a mirror at your vulva after birth and there seems to be skin that “flaps” away from the rest of the vulva structures, you can always go into the emergency ward and have someone suture the wound. Tears do not bleed like cuts do. This should not dissuade anyone from staying away from the place where the scalpels reside.

2. Breech position—you’ll know if your baby is breech. When the membranes release, you will see black meconium coming out the consistency of toothpaste. With a head first baby, the meconium colours the water green or brown but with a breech, the meconium is being squeezed directly out without mixing with water. The other way that you should suspect a breech presentation is if you have a feeling from about 34 weeks of pregnancy on that you have “a hard ball stuck in your ribs”. Breech presentations are about 3 percent of births.

3. Cord wrapped around the neck—the smart babies put their cords around their necks to keep them out of trouble. If you have a baby with the cord around the neck, it can be unwrapped very easily either during or right after the birth. The most important thing is to keep the cord intact.

Gloria Lemay, Vancouver BC Canada
Advisory Board Member, ICAN
Contributing Ed. Midwifery Today Magazine
Teaching midwifery on the internet at www.consciouswoman.org
Speaking at the Trust Birth Conference, Redondo Beach, CA in March 2008
www.trustbirthconference.com

I have to give a shout out to Bellies and Babies for her most recent post, some of which is excerpted below.  I encourage you to go read the entire post.  My commentary continues below the excerpt. 

16 Recommendations from the World Health Organization

These 16 recommendations are based on the principle that each woman has a fundamental right to receive proper prenatal care: that the woman has a central role in all aspects of this care, including participation in the planning, carrying out and evaluation of the care: and that social, emotional and psychological factors are decisive [emphasis mine] in the understanding and implementation of proper prenatal care.

1. The whole community should be informed about the various procedures in birth care, to enable each woman to choose the type of birth care she prefers.

2. The training of professional midwives or birth attendants should be promoted. Care during normal pregnancy and birth and following birth should be the duty of this profession.

15. Obstetric care services that have critical attitudes towards technology and that have adopted an attitude of respect for the emotional, psychological and social aspects of birth should be identified. Such services should be encouraged and the processes that have led them to their position must be studied so that they can be used as models to foster similar attitudes in other centers and to influence obstetrical views nationwide.

The WHO report, Care in Normal Birth, she draws from is dated 1997.  However, this does not negate the principles outlined in the post.  Perhaps the normal birth advocacy groups should appeal to the WHO to update this report, since some people might be inclined to discredit the information due to the time stamp.  Again, I stand by the information in the report that I have read thus far and that has been collated by Bellies and Babies.  Kudos to you, my friend!

I would like to draw special attention to point 15 regarding critical attitudes within the maternal care system.  I agree that it is imperative to identify care providers in our local communities who are critical of the over-use of technology, medication, and other interventions in normal (natural) birth.  Birth advocates must join with these individuals and work together to decrease the unnecessary complication of normal (natural) birth.  

There is a time to “fight” the system, but there is also a time to “join together”.  It doesn’t matter that I desire to have a homebirth in the future if 9 other women I know still prefer to go to the hospital.  It doesn’t matter that my neighbor might have a baby at the birth center even though I have been “risked” out of that possibility.  We need to work for mutual understanding and respect for all birth options and guide women and their careproviders to make evidence-based, ethical, and empowering decisions.

Where to birth

I found this rather simple yet possibly effective intro mainstream news article about birthing “venues” on Cape Atlantic ICAN’s blog.  Check out this site, because Tiffany is posting really great stuff there.  Kudos to Montrose, CO and the care providers there who are doing their part to improve birthing outcomes in their community.  I’d like to discuss a few points made in the article:

*~*~*~

“I think our society, we control so much — we control (birth) too.”

LAY MIDWIFE

“The worst machine in the hospital is the clock,” [Bill] Dwelley [midwife] said, adding that he allows the natural process to continue for as long as needed if everything is moving along healthy.

He said 90 percent of children are born without complications. Of that 10 percent that do have complications, an experienced midwife or doctor can handle 7 percent; 3 percent require surgical care.

But because of increased inductions, which increases the risk of c-sections, surgical intervention is rising. MMH has a 17-percent c-section rate.

“It’s about keeping the right to choose,” Dwelley said. “We are doing it in the spirit of the woman gaining power.”

These are powerful and perceptive statements.  Indeed, a woman who labors in the hospital is put on a clock.  Labor that does not happen according to established norms will be “helped”.  A 17% cesarean rate is really not that bad – perhaps that is a reflection of a fairly healthy birth culture?  It is important to remember that only a small percentage of babies are born with complications, most of which can be resolved with time, confidence, and supportive care.  When these complications cannot be resolved, transfer to a hospital is prudent.

NURSE MIDWIFE

“I love that this is available to us,” Baskfield said. She added that she feels she can choose to have her baby naturally and that she is comforted with the idea that she can take as long as she needs “without feeling like it’s wrong.”

As far as inductions and c-sections, CNM DeEdda McLean said they don’t offer the option unless there is a medical reason.

The nurse-midwife experience is about encouraging empowerment and supporting the road the mother wants to take.

Consider that these births are taking place in the hospital and therefore more succeptible to the medical model of birth.  Keep in mind that CNMs are generally overseen by obstetricians.  This nursing group is managing more than a third of the hospital births in this area, and it is likely that their cesarean rates are lower than that of the obstetricians.  In my case (I must admit my bias), the CNM began suggesting intervention as soon as she arrived at the hospital.  I believed, as did Baskerfield (quoted above), that a CNM would not take me down the road of intervention, and in the heat of the moment we both caved.  In retrospect I am diappointed that her care in labor & delivery didn’t match the excellent care given prenatally.

HOSPITAL

In a larger hospital, there may be a nurse taking care of the mother before, another during and even more attending to the baby. In Montrose, she said, it’s usually one nurse and so a bond can be formed with the family.

But she said patients do choose a hospital and the hospital has rules. This means an IV tube must be set up for emergencies and intervention is possible.

“When they are coming here we have to be ready for a disaster. If they choose a hospital, they choose to have interventions available,” she said.

In a small town, mothers may receive more consistent care.  It is important to find out about the nurses’ schedules and how many would be attending you in labor and recovery.  I had excellent care from my nurses.  I also recommend knowing the hospital protocol ahead of time.  You can refuse things such as automatic IV, heplock, or continuous fetal monitoring.  Yes, you can refuse it.  Those are interventions that are unnecessary if you are a low-risk patient.  “If they choose a hospital, they choose to have interventions available.”  Keep that in mind – if the interventions are available to you they are also available to your staff.

Physician Jacqueline Garrard said the birthing world is “pretty liberal,” allowing mothers to choose when and how they want to deliver.

Liberal is not how I describe the birthing world.  Childbirth is still largely governed by men who treat the female body like personal property.  Besides, not all mothers are “allowed” to choose how they deliver.  Ask any number of women who are denied VBACs in this country every year.  We have a long way to go before someone like me will call the birthing world “liberal”.