Mother's Choice

A tale of two births

2010-04-13T00:01:00.006-06:00

I had one of those moments today where I wondered about the way that my beautiful daughter may have been affected by her birth.

She got injured at school, nothing too major, but for sure a painful bonk on the head from a baseball bat. The teacher told me she was very brave and didn't cry at all, but by the time we got home it had caught up to her and the tears started to flow. I pulled her onto my lap in a comfy chair and tried to cuddle her, but as she sat their stiffly I realized she didn't want to be held and cuddled. I asked her if she wanted to be alone and she went off to lay on her bed. I thought of her in that little plastic box that they put the babies in at the hospital and wondered.

Now, I certainly realize that all people are different and some are more touchy-feely than others. I don't know if that's just the way she is (and it is certainly a fine way to be, I don't mean to disparage), but the part of me that is obsessed and possessed with birth can't help but see the difference between her and her brother without wondering how her less than touchy-feely beginnings contribute to that aspect of her personality.

Even if there really were no long-term effects from her birth, I still mourn for the beginning she did have. She was yanked into the world (by the feet according to the operative report) and taken to a hard table surrounded by strangers and bright lights. There were no familiar voices talking to her, only strangers, and strange sounds, doing strange things to her fragile little self. When she finally did get to see her Daddy and finally hear a familiar voice it was through the plastic of an oxygen hood. He was scared to touch her and no one told him it was okay to do so. She was wrapped in rough towels and had a rough bath. She cried through the whole thing until her whole body was red with the effort and no one stopped to comfort her or cuddle her even still. Finally dried and wrapped up like a present she was rolled in her plastic box to meet her drugged out, zonked out mother. I'm not really sure how I greeted her, I don't remember much of it. At least she was surrounded by family and people who loved her when I was too sleepy and out of it were able to hold her and greet her properly.

Meeting Roxy, hours after her birth

Obviously she is a sweet and adorable, kind and dear little person so we know that our birth is definitely not the predetermining factor on our personalities. But it's still not what I wanted for my baby and I put a lot of effort into making sure my next baby got a better welcome. I couldn't control everything about it but I wanted to do everything I could to make sure it was a more gentle beginning. He was eased into the world, as gently as possible. The midwife helped receive him, but he went immediately into my hands. He didn't leave them for hours afterwards and even then only to the end of the bed for a quick newborn exam. A midwife gently checked him over, always touching and soothing him, so that he never cried. He was immediately cuddled again by a loving relative and anytime I wasn't the one holding him someone else who loved him was. Again, I don't know if it is directly caused by their births, but he feels much different about wanting to cuddle with his mom and he always has, and either way I wish that Roxy had gotten the same warm, gentle welcome.

Meeting Erik, instantly

I'm grateful for my cesarean with Roxy, things had gone rotten and she needed to be helped out by doctors and I'm very thankful for their skill, but I still mourn for what we missed out on. I can't help but wonder if I had been up walking around instead of lying in a bed on a monitor if her little head would have fallen into the pelvis where it belonged. If her head had engaged then she might not have been able to do a somersault and the cord might not have prolapsed. Or maybe if I hadn't been bent over a table for 10 minutes while an epidural was being placed, what effect did that have on her position? Obviously crazy stuff happens and I could have done lots of things differently and she may have still have done that same somersault, but I can't help wonder how even those small interventions may have taken her birth off course.

Nothing can be done differently for my daughter's birth, it is in the past now, but what about the babies that are yet to come? I really hope that we can think more about the ways we disturb birth and whether it is worth the ramifications for our babies. The U.S. cesarean rate is abysmal which means that 1/3 of all babies get a beginning almost as crappy (or crappier) as my daughter got. That sucks America, it really does.

Now for the caveats...yes, I know that many cesarean babies get a more gentle beginning than mine did. Most of the time the baby's dad is in the room and the mother is awake and able to greet her baby, but it is never ideal. I'm grateful for the care providers who do work hard to make things gentle, and hope that more providers learn from them.

Cesarean moms, this post is in NO WAY intending to make you feel guilty about having an abdominal birth. We all did the very best thing we could for our babies in that moment in time. We all did the noble thing and laid on that table to be cut from hip to hip so that our babies could be safe. Unfortunately we know that with a 33% cesarean rate, not all those operations were necessary and that is the part that I want to change. I truly honor the women who sacrifice their own bodies to get their babies here safely.

My experiences giving birth

2009-11-12T09:25:00.004-07:00

I wrote up Erik's birth story for a natural child birth blog if anyone is interested they can check it out there...

http://naturalchildbirthstories.com/eriks-birth/

It's a nice blog, check out their photo gallery, such lovely photos:

http://naturalchildbirthstories.com/gallery/

Your right to bodily integrity? Not at this hospital!

2009-10-02T08:18:00.003-06:00

A recent newspaper article from the Lake Powell Chronicle reports about a hospital in Page, Arizona has told a local woman that they will not allow her to give birth vaginally in their hospital. The hospital has a policy against vaginal births after caesarean sections (VBACs), and have said that they will get a court order requiring the woman to have surgery if she won't consent to it.

This situation is outrageous, but unfortunately it happens every day in America. Most women just don't get as vocal about it as this woman has.

There are thousands of hospitals in the US that have policies against allowing VBACs. Many are rural hospitals like this one where the woman's only other option is to travel hundreds of miles to give birth. This isn't about safety really, it is about liability and the risk that the hospital will be sued. This mother is no more likely to need emergency services than any other woman giving birth, the medical community is just terrified of VBAC and would rather do a c-section. They don't care that the medical risks to the mother are higher with major surgery, they only care that their risk of being sued is lower. It is another case of money being more important than patient health or autonomy.

Canadian Study

2009-09-09T16:24:00.003-06:00

A new Canadian study isn't as large as the study just released from the Netherlands, but it backs up the point that home birth is a very safe choice.

The studied matched three populations; two giving birth under the care of midwives at home, one group birthing in the hospital with the same midwives providing the care and the third group being cared for by physicians in the hospital. I thought it was interesting that even though the women were cared for by the same midwives the infant mortality rates and outcomes were improved for the women giving birth at home. I think this is explained by the psychological benefits that come from laboring in our own safe, comfortable and familiar home environments. Psychological well-being during labor = a safer, smoother labor. It could also be that with the technology of the hospital in close proximity the midwives were choosing to use medical interventions more often than they did at home, and that affected the outcomes negatively.

Either way the outcomes for moms and babies at home were excellent, less hemorrhaging and tearing for moms, less trauma and need for rescucitation for babies (compared to their hospital counterparts.)

It is also interesting to note that both groups cared for by the midwives, whether at home or in the hospital, did better than the group of women cared for by physicians. The physician/hospital group had a higher mortality rate, higher risk of needing rescuscitation or oxygen therapy, and higher risk of trauma and meconium aspiration.

Here is a link to an article about the study.

PDF with the details of the study can be found here.

Public perception of home birth

2009-09-09T15:51:00.001-06:00

I thought this story from Ohio was a good reminder of why midwifery and home birth advocates need to speak out about their birth choices and educate the public about the safety of out-of-hospital births. This situation would never have happened in a country like the Netherlands where birthing at home is considered a normal way to give birth and police officers would never think that the couple was endangering their child by making that choice.

A family in the Dayton area is entangled in a criminal prosecution as a result of their homebirth. Nine weeks ago, the Levier family welcomed the second child to the world at home with the assistance of a midwife. He was born safe and sound. A few hours later, they were a bit concerned about mom so they made the decision to call 911 just to be safe.
In Montgomery County, whenever 911 is called and a child is involved, the police show up as well. The EMTs insisted that the newborn baby needed immediate medical attention (despite being perfectly happy and healthy) so mom and baby transported in the ambulance and baby was monitored for a while to confirm his good health. Meanwhile the police further investigated, taking statements from Dad and the midwife, who identified herself as a doula.
Six weeks later, the Levier family was given asummons to appear in court regarding charges of child endangerment. Both parents have been charged and arraigned. The next legal step is in late September. Their attorney hopes to have the charges dismissed, but in the meantime, they are facing the expenses of attorney’s fees for representing BOTH of them while dad’s work schedule has been drastically reduced for September.
...Read the rest of the blog entry from the Ohio Familes for Safe Birth at their blog. This family needs help with their legal expenses...

Tribute from a midwife

2009-08-26T14:25:00.004-06:00

My dear friend and mentor Jules Johnstun created this video montage in celebration of the women she has served as a midwife.

Isn't that just so lovely! I had the honor of being present at some of these births. These women are amazing, strong and beautiful. I'm grateful that they are willing to share their pictures and their birthing experiences with me. I'm also grateful for midwives like Jules that give so much of themselves to the women they serve!

Largest study to date on home birth

2009-04-22T16:01:00.005-06:00

A very exciting new study was released last week in the Netherlands proving once again that 'planning a home birth does not increase the risks of perinatal mortality and severe perinatal morbidity among low-risk women...'. Because the study included over 500,000 women, the findings will satisfy the argument that home birth safety can't be proven because the prior studies have all been too small. The entire study can be found at the following link:

http://www.cfpc.ca/local/user/files/{F249B8FE-6B6A-4426-BF21-57FA51A28796}/Home%20Birth%20Netherlands.pdf

There is a lot to be learned from the Dutch maternity system and the American system would likely have to be tweaked to accomodate the difference in American geography and culture. The Dutch maternity system is completely integrated with the midwives providing primary care and seamlessly working with doctors who provide the secondary care for higher risk situations. In America, the home birth care providers are still very much separated from the hospital providers and because of our private/'for profit' medical system the two are direct competitors instead of allied partners. The UK is already looking at this study as more motivation to continue the NHS' move to offering more home births, let's hope America someday follows suit.

Pondering Fear

2009-02-26T17:23:00.005-07:00

I've had a number of conversations both online and in real life recently about why women and our society in general is so afraid of birth, and so convinced that it a horrific and painful experience that requires medication every single time. (and I'm not trying to say that women should NEVER use medications, they are a fabulous tool in some situations, but they also have risks and repercussions that seem to be largely ignored).

I have been thinking that far too often it feels like by the time women are actually having babies their fears of giving birth are already so entrenched that it is difficult to undo. As I talked about this to a friend lately I started thinking about a video I had seen recently, it was supposed to be funny, it was just a group of teenagers all facing a screen, the narrator tells us that they are in health class watching a birth video. The girls are all screaming and covering their eyes, horrified at what they are watching. I thought it was so sad. I wondered what kind of video it was and how it portrayed birth and thought about what we watched in our health class. I realized that often times birth is presented to teenagers as a deterrent to having sex (or at least to encourage them to use birth control) and is made out to be a painful, miserable experience. I guess the hope is to motivate these girls to avoid pregnancy and the subsequent 'horrors' that come with childbirth. I think these messages create fears that stick and then when women are ready to become mothers they go to great lengths to try and dissociate themselves from the horrors they expect with giving birth. Usually just by having an epidural as soon as possible, but sometimes by insisting on a c-section or even avoiding having children altogether.

I know I felt this way before I had my first baby. A man I worked with suggested that a home birth was a wonderful way to go and I told him that "I wasn't crazy, I was having an epidural"! When I got the hospital and suffered through contractions lying on my back with no support and no clue how to help myself, my belief that birth is intolerably painful was confirmed. Of course nobody suggested that I walk around, stand up, have a hot pack, any of the things that might have really helped, and I certainly didn't know how much my fear and tension was making it worse. It took a lot of reading, several years, witnessing some births first hand, and finally the desperation to have a VBAC (and the conviction that I needed to be at home for it to happen) to really get me to accept birthing unmedicated. Obviously when it turned out to be a completely comfortable experience (thanks self-hypnosis!) I was definitely convinced that birth is totally do-able, but it would have been tough to convince me of that 8 years ago.

So why was I so afraid and why are most of the women I know so afraid? How is the information being presented in health class to high school kids and how can we convince educators to give kids a more balanced view? (ironically, my own father was a health teacher for years, so I will be having this conversation with him for sure) How we do we counteract all those crazy dramatic births that they show on TV and in the movies? How can we 'infiltrate' the colleges and present the idea of birth being normal?

How can we get them to see this video:

http://www.themidwife.net/index_files/Page340.htm

instead of The Baby Story?

I wish I had the answers, sometimes it feels like it an impossible task to make birth a more 'treasured' experience in this country. I feel like people put so much effort, time, though and preparation into their weddings, but do none of the above for the births. How can people spend thousands for their weddings, but get bent out of shape at the idea that they might have to pay to give birth to their children? They want and expect insurance to pay for all of it and are happy to let their insurance companies dictate which hospital they can go to and which provider they can see? Would women accept the same situations at their weddings "sorry honey, but I'm paying for this wedding and this where your getting married and this is the person who is doing it". I can't see a lot of brides being very happy about that situations why are prospective mothers okay with taking whatever is given to them for their births?

(okay now I realize this analogy is kind of bad because some people don't have fancy weddings and don't spend much money on that either - I am one of those people - but I'm speaking in generalizations here and on average Americans spend $20000 on their weddings. Shocking to me, I got married in Las Vegas at $50 chapel, but even people who don't spend anywhere near this much still spend easily a couple of grand out of pocket, but most people FREAK OUT at the idea of spending $2000 out of pocket for their births. (oh and i'm talking Utah dollars here, double that if you live back East))

I would just really like to see women feeling as empowered about giving birth as they do about planning their weddings. Brides do tons of research, they pay for a wedding planner to be their expert guides, read all the reviews, visit all the receptions centers, they OWN that wedding. I want women to OWN their births too. I want them to know all their options and be as excited about the idea that it is going to be a beautiful and positive day in their life, not just a day that they have to get through.

Apologies for this being a rambling post without much purpose, I'm digging through all these thoughts in my head and spewing them out into this blog hoping that somehow I'll be inspired about where to find answers.

Time reports on VBAC

2009-02-19T18:02:00.003-07:00

I have been letting this poor blog get ignored these days as I focus on other things. Stuff that might have gone up here before is now going up on the Utah Friends of Midwives blog

This article needs to be splashed around the web as much as possible. Not enough people are aware of the problems facing women wanting a VBAC.

http://www.time.com/time/magazine/article/0,9171,1880665-2,00.html

In my experience the comment in the article about the doctors leading towards women towards the c-section is true. When the doctor has so much to gain by doing the surgery - he gets paid more, spends only an hour of his precious time, has less liability - then he isn't in a position to give the women the risks and benefits without being biased. Not to mention the subtle cues that they give women about their babies seeming big, their pelvises being small or just asking each week if they are ready to schedule yet (when women are big and tired of being pregnant that's a big temptation!). They have sway and most of them are surgeons first, of course that is going to be their preferred method.

All the more reason for every woman to have a midwife as the primary care provider. She can keep things normal, screen for the abnormal and collaborate when the expertise of a surgeon is truly necessary.

December Midwifery Rules Committee Meeting

2008-12-05T09:56:00.006-07:00

It has been a while since I blogged about the legal issues relating to midwifery in Utah, but it is time for an update.

As you may recall the Utah Medical Association launched another bill last year attempting to restrict the births that Licensed Direct-Entry Midwives could attend. They claimed that the midwives had asked to do only low-risk births at home, but they were attending births that the doctors considered too high risk to be done at home. (Don't worry your pretty little head about what the mother considers high risk.)

The bill was incredibly restrictive in its original inception and would have eliminated nearly all home births, but we fought back. Compromises were struck and most of the restrictions were removed, but the real sticking issues were breech births, twin births and VBACs. All three are considered 'high risk' by the medical community, breech births are basically an automatic c-section and twins are most of the time too. VBACs happen in some hospitals where they have the resources to care what they considered a high risk birth. VBACs are generally not available in hopsitals outside of the Salt Lake valley, those women will have to have a repeat cesarean or travel to Salt Lake.

The midwives conceeded twins and breech, they are fairly rare anyway and unlicensed midwives will still be able to attend them if the women really are intent on a home birth.

VBAC though just has to stay. The difficulties that women run into getting a VBAC birth at the hospital, especially a natural, intervention-free birth, are just so great - they need home birth. I did, for lots of reasons, but a big one was the requirement that women be monitored constantly while they labor. Depending on the provider you might run into a whole lot more requirements, it isn't uncommon to hear that to doctor requires the woman have an epidural. Or other times they get to 36 weeks and the doctor tells them that if they'll go ahead and schedule the c-section for their due date because if they haven't gone into labor by then the'll need to have the "elective" repeat cesarean (ERCS). If a woman truly wants to avoid having another cesarean and wants to improve her chances by staying unmedicated, off the pitocin and upright, she may have no alternative besides home birth.

Fortunately midwives were able to keep the wording in the bill that allows VBA2C, but another consequence was that the Rules for the Licensed Direct-Entry Midwives must be rewritten, this time allowing the UMA to select the doctors who sat on the board (I'm not sure why there aren't any midwives on the Medical Board). The bill dictates the basic guidelines but the fine details of the rules that midwives must follow in their practice are to be hashed out by the Rules Committee. The bill does have language give the Rules Committee license to further restrict the VBAC births that LDEM requires but it does not mandate exactly which births.

So far there have not been any real surprises about the changes made to the existing rules. They were required to change the things necessary to match the new bill and that has been done for a number of issues. There has been much discussion about everything but nothing terribly offensive or restrictive has made it into the new rules. On the agenda at yesteday's meeting was the discussion of the VBAC portion of the rules. The requirements written into the law state the midwives can do vaginal births after 2 sections, but the woman cannot have had a classical, J or T type of incision. (Basically those are variations to the way that the obstetrician actually cut into the uterus during the caesarean surgery. Most women get what's called a low transvere incision, which everyone agrees is the most safe type to have had when attempting VBAC.) The women are also required to get an ultrasound to verify that their placentas are implanted away from the scar.

Dr. Lamb, one of the doctors on the committee, came prepared with a number of proposed changes to the rules. His first proposal was to require that the midwife must verify the incision type and if she can't, then the woman must be transferred, no exceptions. There was much debate to this idea because it can sometimes be difficult to get those records and if a woman transfers into midwifery care late in pregnancy they may not show up until after the baby is born. Even if the woman is sure her surgery was low-transverse, and her external scar is low and there isn't any reason to believe otherwise, she still couldn't have her VBAC at home if she couldn't produce that piece of paper.

Considering that the hospital is the entity that needs to give you that piece of paper, but they are also going to lose your business if they give it to you. You think that they aren't going to stall or accidentally lose something? Sorry, maybe I'm cynical but it is oftentimes quite difficult to get medical records and it doesn't help when they really aren't motivated to want to give them to you!

The midwives refused to add this requirement to the rules, they were willing to require that they try to get the operative report, and have the woman sign another informed consent document that she understood the risk of not knowing what type of scar she had, but they weren't willing to make it a requirement! The doctor basically said that he wouldn't vote to approve it the way it was. The other doctor didn't say, but likely she won't vote to approve the rules either, which is fine unless the nurse-midwife won't vote for them either. She either approves or the vote is tied.

The discussion moved onto whether the rules should allow the midwives to attend women who are having a vaginal birth after having two prior caesareans. The docs adamantly oppose this, and the only doctor who came as a member of the public, a retired doctor, that has come to watch the last couple of meetings had plenty of commentary. He told us how it is their job to protect the 1-5% of babies that are going to be harmed when there is a bad outcome (hello, what study did that number come from?).

This is where my blood pressure was really starting to rise. His implications were very upsetting and his opinions were outdated and completely opposed to everything we believe. It is offensive to be told that your not qualified to decide where or how to give birth, that only the doctors should make that call. He also said we should be required to have an IV, that there must be a blood supply on hand, and that after every VBAC that it should be required for the midwife or doctor to reach up inside the woman and verify if the scar is intact. That is an invasive and barbaric procedure, and there is absolutely no evidence that it is either safe or beneficial.

Later when he got the chance to speak for a few more minutes he shared more of his opinions. He felt that the rules should dictate who should be allowed to attempt VBAC based on his criteria for who is a good candidate. He said that women who had prior c-sections for a large baby shouldn't be allowed to try if their second baby is large too (well how exactly do we know that until the baby is born?). If I understood correctly he was okay with women having a VBAC at home if they had a proven pelvis, in other words if they had given birth before. That would eliminate the VBAC option for so many women, especially if they had a c-section for their first birth, then the only place available to do the first VBAC is the hospital and we've already talked about how restrictive that can be.

When time ran out it was a stalemate and I guess that is fine. No votes to allow any rule changes were made, so nothing really changed. It may draw out the process, but so far no change is a good thing.

It is frustrating to have a system that gives the medical community such an elevated status in society that they are allowed to dictate how everyone else should manage their medical care (or lack thereof). I'm a fierce libertarian, so I know that my beliefs are pretty radical and I think that a woman wants to give birth in the woods attended by only a shaman then that is her call, just like a person with cancer can choose whether they will have every surgery and drug known to man or no drugs and no treatment at all. We allow Christian Scientists to do have autonomy over their medical decisions, even when know that it is a high risk thing to do, I'm really not clear on why anybody else shouldn't have the same right.

I know the answer my critics will give, because of the baby. They feel entitled to intervene because they need to protect the baby from what they believe is a bad choice their mother might make. Who are they to decide which choice is right or wrong? How can we ever really know beforehand what will be the best course of action.... Have an ERCS and give birth to a baby with breathing problems who later develops asthma and suffers from severe, even life-threatening allergies or have an ERCS and zero problems, there isn't really any way to know for sure which it will be. Even for the mighty Obstetrician, he just can't know, so why isn't it my call to decide how I will handle my birth. As Michelle says, "My Body, My Baby"

Birth Choices: Panel Discussion at The Leonardo

2008-09-26T08:33:00.010-06:00

Last night I attended a discussion at The Leonardo, a museum in Salt Lake City. This event was part of a series The Leonardo is doing about "Choices". The museum is currently hosting the Body Worlds exhibit and has chosen body related subjects for the discussion series in conjunction. Last night the subject was choices and birth, here is the museum's flyer:

http://www.utahsciencecenter.org/documents/Birth.pdf

Joe Andrade PhD, a history professor, was supposed to talk about the history of birth (or something?), but he wandered off subject quite a bit. He did mention that Brigham Young had sent women to medical school in Philadelphia so that they could care for the health of the pioneer mothers, and I had never heard about that before.

Richard M Hebertson is a retired Ob/Gyn, a former head of Obstetrics at LDS hospital. He talked about the birth of his first child and how he was isolated in the waiting room and not given any information. His wife had pushed for four hours to give birth to that first child, but she didn't remember the birth because she had been given nitrous oxide gas. He went on to talk about how he had practiced during a glorious age of obstetrics *cough* when they had learned so many things. He was particularly impressed with regional anesthesia, which he saw as a big advancement over the 'twilight sleep' drugs used when he began his practice. Dr. Hebertson talked about letting the fathers back into the room for birth and how he had trained in natural childbirth, which I took to be some training with the Bradley Method. He was also impressed with the introduction of electronic fetal monitoring, which made the ladies I was sitting with roll their eyes back into their heads!

The next panelist was a currently practicing Perinatologist at the University of Utah, Kirtly Parker Jones, MD. She really impressed us when she first began to talk about choices, because she seemed to be embracing home birth and really supporting women's options. We got less impressed as the discussion progressed.

Mary Rizzuto was the next panelist to speak and her angle was that by receiving both a heart transplant and a kidney transplant that she had been reborn. Nobody was quite seeing how organ donation really fit into the choices facing women giving birth, but her story was interesting nonetheless. She knew her part of the panel was a little disjointed and kept her comments brief.

The final panelist was a woman named Linze Floyd who had given birth this spring at home. She talked about how she had researched her birthing options and come to the conclusion that a home birth was the best option for her. They showed a slideshow from her birth while she talked, with some really beautiful pictures. The second picture showed her in a birth pool, and I thought I know who her midwife is, I've seen that tub before!

The moderator of the discussion showed a graphic map of the world that reflected the birth rates around the world, and a second map that showed how the world's maternal deaths are largely taking place in Asia and Africa. There was a good question about how US maternal death rates compared to Europe and Dr. Jones felt that was because America had what she called "3rd World Counties" where poverty and lack of access to care raised the maternal death rate. This is true, but she wasn't going to accept that our over-use of technology was any part of that.

One of the doulas I was with, Michelle made some good points about how the medical community sometimes acts as though you have plenty of choices, but when the choice you make isn't what they had in mind, you are attacked. She made sure to mention the American Medical Association's plans to outlaw homebirth.

The discussion turned to risk and Dr. Jones tried to make a point about the choice women usually make when their pregnant, and that is to take all the risks on themselves in order to protect their babies. I started to take issue with some of the things she was saying, because the implication is that women who want to have vaginal births are being selfish somehow by not submitting to surgery. The doctor is right that women pretty much will do everything in their power to give the best to their babies, and for some of us that means going to great lengths to AVOID surgery, because we know that a surgical birth carries risks for baby too.

Linze made some good points talking about the restrictions she'd encountered when she investigated a hospital birth, and how she was required to have a heplock in place and would have to submit to electronic fetal monitoring. Dr. Hebertson seemed to fall back on the old excuse that it is really difficult to get changes made and how hard he had to work to get the Certified Nurse Midwives permission to practice at LDS Hospital. I think it's admirable that he worked for that choice to be created for women, but it doesn't really explain why it should be so hard give women the autonomy to give birth as they really desired without hospital politics getting in the way.

There was a lot of information that got fired around the room, and in the end I'm not sure if any progress was made on any fronts. The doulas I was with all left still feeling frustrated. We can talk all day about how many wonderful choices women have, but we know full well that a woman who wants to have a vaginal birth after a cesarean is going to find out that her choices are actually very limited indeed. And we know that when we go into the hospital the women will hear "well we need you to do X because it is hospital policy" and "you can't do Y because the hospital doesn't allow it" and that when it comes right down to it women don't have much choice at all about some of the things that will happen to them.

This just keeps coming up.

2008-08-28T15:32:00.005-06:00

I know I harp on this all the time, but I came across another article about hospital-acquired infections... I think this is one of the best arguments for home birth for normal, healthy women (especially if they don't like hospitals)

http://www.msnbc.msn.com/id/9818616/

In case you didn't catch this information from the sidebar...

— Infections contracted in hospitals are the fourth largest killer in the United States, causing as many deaths as AIDS, breast cancer and auto accidents combined.
— One out of every 20 hospital patients gets an infection. That's 2 million Americans a year, and an estimated 103,000 of them die.
— The single most important way to reduce hospital infection, according to the federal Centers for Disease Control and Prevention, is for doctors and other health care workers to clean their

hands in between treating patients.

1 out of 20 patients! Holy moly!

At The Farm, a commune in Tennessee and home of modern midwifery pioneer Ina May Gaskin, they have tracked their statistics for births managed by their midwifery service for more than 30 years. For the low-risk women that they cared for from 1970-2000 95% completed their births at home (or someone else's home) and only 1.3% were transported in an emergency situation (that doesn't mean that they weren't fine in the end, but that something did go wrong that they required hospital care quickly). That is 1 in 100 women, roughly, who had an problem that the midwives couldn't handle and was potentially life threatening. 1 in 20 vs 1 in 100 -which risk do you prefer? Women should be entitled to make that choice based on their own instincts and situations, there isn't a really obvious right answer.

The AMA disagrees with me, they think that they are entitled to make the choice for you by outlawing home birth.

Broken down system

2008-08-18T11:01:00.005-06:00

This information came across my radar today...

Medical expenditures associated with an uncomplicated pregnancy and hospital birth averaged about $7,600 in 2004, according to a new report released by HHS‘ Agency for Healthcare Research and Quality, CQ HealthBeat reports (CQ HealthBeat,10/19). For the report, the agency gathered data from 2001 to 2004 from three panels of the Household Component of the Medical ExpendituresSurvey. [...]
http://www.all-healthtalk.com/average-medical-costs-for-prenatal-care-childbirth-in-us-about-7600.html

I am amazed. $7600 for an uncomplicated birth, imagine a complicated one! It just boggles my mind that it can cost that much and yet the women in the hospital are still hooked to a machine and left alone for most of their stay. You'd think that with that kind of financial outlay that the hospital could afford to at least get enough nurses on staff to have only 1-2 patients per nurse.

Of course that isn't where the money goes... Big chunk to malpractice insurance, big chunk to bureaucracy, and then of course you have to pay the CEOs of the HMOs and insurance companies. How expensive is that? Take a look:

Here is a list I recently obtained of insurance executives salaries:
1. Oxford Health Plans, Norman C. Payson, former chairman and CEO, $76million.
2. WellPoint, Leonard D. Schaeffer, chairman and CEO, $21.8 million.
3. Coventry, Allen F. Wise, president and CEO, $21.7 million.
4. UnitedHealth, R. Channing Wheeler, CEO, Uniprise, $9.6 million.
5. Aetna, John W. Rowe, MD, chairman and CEO, $8.9 million

And unexercised stock options:
1. UnitedHealth, William W. McGuire, MD, chairman and CEO, $530 million
2. WellPoint, Leonard D. Schaeffer, chairman and CEO, $93.1 million
3. Oxford Health Plans, Norman C. Payson, former chairman and CEO, $25.6million
4. Aetna, John W. Rowe, MD, chairman and CEO, $24.1 million
5. Health Net, Jay M. Gellert, president and CEO, $23.5 million.

The nurses make a living wage, but certainly aren't getting wealthy. The doctors constantly battle to keep their heads above water with their outrageous malpractice costs and having to stand on their heads for every dollar from the insurance companies. The government is not setting a good example either, they reimburse doctors a pitiful $500 for a Medicaid delivery. No wonder it is so difficult for poor people to get care when no doctor can afford to attend them and stay in business.

Our health care dollars are so poorly managed, not nearly enough of it pays for actual medical care! The anarchist in me says it is time to destroy the system and start from scratch. I just hope congress and the next administration can find a way to work for the needs of the people instead of the needs of their campaign donors.

Another case...

2008-07-17T08:07:00.002-06:00

This time in the UK...

http://www.harrowtimes.co.uk/news/localnews/display.var.2399633.0.hospital_has_made_a_lot_of_mistakes.php

'Hospital has made a lot of mistakes'
By Jack Royston
Comment Read Comments (2)
Nasim Ghaznavi attacked the hospital for their treatment of his wife
A GRIEVING husband says hospital staff were responsible for the death of his wife, who gave birth on its maternity ward.
Zahra Ghaznavi, 28, of Central Road, Wembley, was the third woman to die at Northwick Park Hospital in just ten months, causing the trust which runs it to launch an internal review into maternity care.
Her husband, Nasim, told the Harrow Times he found it too painful to talk about the woman he lost in March, but he described the events he believes led to her death.
What should have been one of the happiest periods of his life turned into a tragedy when Zahra fell into a coma less than a week after giving birth to their daughter Sahar.
Nasim, who runs a tailoring business, said on March 20, the day she died, a doctor at Northwick Park Hospital told him staff on the maternity ward were responsible for her death, which was caused by a bacterial infection.
After the delivery, he says, she suffered from internal bleeding and doctors plugged her birth canal with tissue.
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But he claims they did not change it or take it out for two days and he believes it may have been responsible for the infection.
He said: "I felt very bad. At first we were happy because the baby came but then she had to go to the operation room because there were problems."
He said the coma hit when the bacteria spread up to her chest and eventually to her brain, despite surgeons taking out a section of tissue from her body in an attempt to remove it.
After an agonising wait, a doctor sat Nasim down to tell him the news that would change the course of his life.
He said Nasim and Zahra had become like a son and daughter to him, but he had to tell Nasim his wife had a one per cent chance of survival. He said they would only be able to wait a day before turning off her life support.
Nasim says he noticed a lot that disturbed him throughout the time he spent on the ward, leading up to the birth and during the time she was unwell.
He said the nurse who was helping Zahra asked for support from her colleagues but was refused it, and so had to take on the job by herself.
He said: "This hospital has made a lot of mistakes.
"For 11 days I was there looking after my wife and the same doctor who was helping us with the operation was serving us food, so what do you think is going to happen?
"At the same time a doctor is a nurse and then becomes a caterer as well. I will not go back there, I hate this hospital."
I met Nasim in his two bedroom flat in Wembley, where he sat smoking while a television, nestled beside a stereo, played persian pop songs.
We were waiting for his cousin to arrive and translate some of the more complicated aspects of what happened, but his new home tells the story just as well.
The flat is far too small for the family he should be supporting, and he shares it with a friend instead of the woman he might have spent the rest of his life with.
His baby daughter stays with another cousin in Reading, where Nasim spends every other evening.
But he suffers from headaches, which his GP can neither explain nor treat, and he thinks he may be suffering from depression.
Nasim's life was torn apart and now he can only wait to get an official account of what went wrong.
If the result says the hospital is to blame he plans to take legal action.
An inquest into Zahra's death is expected to take place on September 24, but Nasim has been promised a private meeting with staff, and a draft result of an internal investigation launched following her death was sent to the Healthcare Commission, a government watchdog on Friday.
The report will also look into two other deaths on the ward, which both took place last year.
A post mortem said Zahra's death was caused by E Coli and Septicemia.
Sarah McKellar, a spokesman for North West London Hospitals NHS Trust, which runs Northwick Park, said the it is taking Nasim's concerns seriously but will not be able to publish the outcome of the investigation until staff have spoken to him first.
She said: "We would like to re-iterate our deepest condolences to Mr Ghaznavi and his family at what must be a very difficult and upsetting time for them."
7:07am today

This took place in the UK rather than America, but to me it is certainly a great argument against the assembly line care given in many hospitals.

It could also be an argument against a national health care system, but I think it is just a warning to build a betters system than the UK has done. When (I hope!) we build public health care in this country I think we need to do very careful due diligence to model our system on the best parts of the successfuly countries like France, the Netherlands and Finland, working hard to predict and avoid the pitfalls that we hear so much about.

No guarantees

2008-07-12T18:46:00.003-06:00

It isn't fair to pick anecdotes out of the news and say see this is why I'm right and your wrong. Anecdotes are not science and don't prove anything, but they can be very persuasive and they are a favorite tool of the medical community. I've seen it used time and again by doctors and others to show why women shouldn't give birth outside hospitals. So I'm going to be childish and turn the table for a moment to share this frightening little news article...

Teen mother still in hospital four months after giving birth
Fri, 2008-07-11 23:16.
Catherine Sherriffs
It's been four months since a 16-year-old girl was admitted to the Maisonneuve-Rosemont hospital to give birth, and it will another several weeks before she's released.
Melissa Belanger has had a portion of her legs amputated after she contracted a bacterial infection while giving birth to her son on March 15th.
The bacteria rapidly attacked the girl's body, forcing doctors to amputate 10 centimeters of her legs.
Belanger's uterus and ovaries have also been removed.
Doctors at the Maisonneuve-Rosemont hospital say they've never seen such a severe case before.
http://www.cjad.com/news/565/753319

While these extreme complications are certainly rare, and if we are rational we shouldn't fear them because statistically they are not likely to happen to us, but they doesn't mean we shouldn't be aware that the risk does indeed exist. Obviously most don't lead to such horror, but hospital acquired infections are quite common. The CDC estimates the incidence to be more than 2 million cases per year and hospital acquired infections may lead to as many as 70,000 deaths each year.1 The woman in the article didn't die so she isn't included in that number, and my quick web research didn't yield statistics on how many people are left disabled by infections.

Aggressive and antibiotic resistant strains of bacteria generally don't exist outside of the hospital environment. Women who give birth at home encounter mostly familiar germs that her body already has resistance to and are unlikely to make her ill. Her care is given by only a midwife or two and she won't have to worry about what germs the team of hospital workers that she will encounter are bringing into her room. (or what was left behind by the last customers) During a hospital stay a woman may deal with 5 or 6 different nurses, a lab tech, a doctor, anesthesiologist, and depending on the hospital a whole squadron of interns and residents. If the baby goes to the nursery then the baby will potentially have contact with even more people. That is an awful lot of germ traffic!

The AMA wants to eliminate the choice to give birth at home, but they cannot guarantee our safety in their hospitals (of course they can't, there ARE NO GUARANTEES IN THIS LIFE!). Women need to understand what the statistics say and that most likely she will be fine no matter what she chooses, but she should have the information. She should have a choice about how she wants to handle her birth and which risks she chooses to accept for herself and her baby.

1. Wenzel R, Edmond MD. The impact of Hospital Acquired Blood Stream Infections. Emerg Inf Dis. Mar-Apr 2001;7(174).

And the debate marches on...

2008-07-09T08:12:00.002-06:00

If you are like me and read birth blogs and hear most of the birth related news then you didn't miss the recent American Medical Association statement that they were going to "develop model legislation in support of the concept that the safest setting for labor, delivery, and the immediate postpartum period is in the hospital, or a birthing center within a hospital complex, that meets standards jointly outlined by the AAP and ACOG, or in a freestanding birthing center that meets the standards of the Accreditation Association for Ambulatory Health Care, The Joint Commission, or the American Association of Birth Centers."

The news release was like pouring gasoline over the slowly burning, but never extinguished, coals of the home birth debate. A flurry of blog posts by birth advocates, midwives, and mothers choosing home birth went up on the web. News sources and community websites posted articles and stories, many including polls and comments sections where the people of the internet can share their opinions. There was a similar burst of activity when Ricki Lake released "The Business of Being Born" in January, and now that the AMA is publicly responding to the movie it all flares up again.

I have google alerts (google it if you don't know about them, it is really cool) that email me all the new web content relating to birth, and home birth specifically. The google alerts make it possible to get a sense of what happens each day on the web, it is fascinating to watch the debates unfold.

It plays out nearly the same every time...

An article is posted
The comments began to come in, the first usually from home-birth proponents correcting any errors in the article and speaking on behalf of birth at home.
A slurry of women with the "I would have died at home" birth stories post how crazy it is to birth at home.
The same anti-home birth vigilante pipes in to give the same exact (TIRED!) argument that she gives every time.
The proponents fire back, try to educate and debunk the same tired argument.

Most of the time, I don't get involved with the debates. There isn't much point in repeating the same things over and over (even I am not that big of a glutton for punishment). There are also many smart women that are already posting and need no help from me.

I didn't really see the AMA's statement as blog-worthy. It isn't news to me at all; it is the same agenda as always. The statement is a publicity effort with the hopes of counteracting whatever effect “The Business of Being Born” had on the women of the US. I highly doubt that the movie caused a sudden surge in the home birth rates, but apparently the AMA felt threatened.

The thing that I still can’t figure out is why they go on the offensive and try to eliminate home birth, instead of just hearing what caused Ricki and the other women of the movie to leave the hospital in the first place. If your concern is really about the safety of the babies then doesn’t it make more sense to try to figure out what you can do differently to bring these people back to your facility instead of trying to push them all underground again? Perhaps the obstetric community could even recognize that the statistics show that midwives have better outcomes, i.e. lower cesarean rates, less preterm birth, fewer traumas to mothers – and maybe, just maybe, there is something to be learned from the way midwives do things.

Of course the whole thing is a moot point because when it comes right down to it the malpractice insurance companies and HMOs are in charge. And heaven knows the only thing that matters to them is the almighty dollar.

Asking questions about where to give birth

2008-04-20T08:09:00.005-06:00

This is a paper that I wrote for an assignment my mentor midwife gave to me. The assignment was to create a referenced handout that will give famlies informed consent about the risks and benefits of home birth. I did not think that families could have clarity without a comparison to hospital birth so that was the angle I chose. Sorry it is so long:

Home vs. Hospital: Choosing your child’s birth place

Choosing a birthplace requires critical thinking. Most people will offer the simple argument that ‘well obviously the hospital is safer because of the possible need for emergency services’ but the choice is actually not so clear-cut. Birth in the hospital comes with risks that you do not encounter at home, and many people are not aware of some of the benefits that come with giving birth at home. Ultimately birth in both locations is quite safe, especially with qualified care providers. Parents must look at the risks and benefits on both sides of the equation and decide what is best for them.

So let us look at some of benefits and risks that we accept when we choose our place of birth. And let us ask ourselves some thought-provoking questions as we do so. There is data available on some of these questions, use the Internet and books like Henci Goer’s Obstetric Myths Vs Research Realities, to find out what the most recent studies have shown. Some of these questions will depend on the situation and can’t be answered on a broad level, only on a case-by-case basis. You may have opinions and preferences but often you can’t know for sure what will be best until the decisions present themselves. Maybe the questions will only tell you that you need to do more research before you can form your opinions.

Benefits to hospital birth:

· No responsibility for supplies or cleaning of the birthplace.

Giving birth in your own home does require a certain amount of preparation and supplies. The issue will be handled differently depending on your midwife, some will provide the supplies and some will provide a list of necessary supplies and guidance on protecting your mattress, carpets, etc. Most midwives do clean up after the birth. Some provide towel service and take care of all the laundry. Midwives will expect a certain level of cleanliness and order in your home prior to the birth. This often works out fine for nesting moms who are cleaning everything in sight at the end of the pregnancy anyway! Hospitals take care of all of this for us, but of course we do pay for it!

How clean is the hospital?
How clean is my home?
What services does my midwife provide?
What supplies does my midwife provide?

· Medical equipment is available.

Certainly there are times when an electronic fetal monitor or forceps can be of tremendous benefit to a mother or baby. But how often are they dangerous? (This will be addressed more later on)

What risks are there to using the various pieces of equipment and what are the benefits?
What equipment does your midwife carry?
How often does she use it?
If a midwife feels a piece of equipment is necessary can she transfer the mother to the hospital in order make it available?
What will she try before she makes the decision to transfer?
What factors will go into the hospital care providers’ decision to use a piece of equipment?
How often do they use the equipment?

· Medications are available.

Similar to equipment, medications at times can be a real benefit, but of course they also have risks, sometimes very serious ones. This is of course going to depend on the drug being used and of course there are times when the benefits certainly outweigh the risks. Some midwives carry only herbal preparations and some carry drugs, and that may be a factor in which midwife is right for you or whether homebirth is a good option for you. In general pain medications are not available at home, but many midwives do carry drugs to treat excessive postpartum bleeding.

What medications does your midwife carry?
How often does she use them?
What medications are used at the hospital?
How often?
What are the risks and benefits of each medication?

· Emergency services

In most people’s minds this is the big one of course, everyone imagines that worst-case scenario where the mother or baby is “crashing” and an immediate cesarean or other life-saving procedure is required. Certainly an emergency cesarean has saved babies or mothers, but how often? Are emergencies over-diagnosed in hospitals? Are services always available any faster when you are actually IN the hospital? In regards to cesarean sections the American College of Obstetricians and Gynecologists has recommended that hospitals have a 30-minute ‘decision to incision’ time[i]. In other words even in the hospital it may take 30 minutes for the physicians and nurses required to arrive, and the preparations to be made for a cesarean to be done. Sometimes it is done faster; it would depend on the circumstances. But the reality is that it does take some time and most homes are near enough to a hospital that when a midwife recognizes a complication, she can call the hospital and by the time the operating room is prepared and the physician readied the laboring mother has arrived for a very timely cesarean. The distance from your own home to a hospital is another factor in your decision as to whether home birth is a good choice for you.

What is your own personal risk level?
Do you have any pre-existing conditions?
Has your pregnancy been normal and healthy?
Would your doctor be present the whole time you are in the hospital?

Risks of hospital birth:

· Serious infections, often antibiotic-resistant are common in hospitals.

The Centers for Disease Control and Prevention estimates that 90,000 people die annually from infections they contract in U.S. hospitals.[ii] This problem is unique to hospitals and does not exist in homes. You have already had exposure to the germs in your own home and have good resistance to them.

Can I prevent infections in the hospital?
Can I prevent infections at home?

· Medical mistakes are incredibly common and major cause of death in the United States.

There are approximately 110,000 deaths per year from medical mistakes.[iii] This is a serious problem that speaks for itself.

What can be done to prevent errors?
Are errors made at home?

In 1976 Lewis Mehl and his associates did a study that compared two equivalent groups of 1146 patients, one group giving birth at home and one group giving birth in the hospital. In both groups there were very few, and essentially the same number, of infant deaths and no maternal deaths. The hospital group had more complications, including the following:

· More cases of maternal high blood pressure
· More infants in distress during labor
· More cases of birth injuries to the infants (there were no infants injured at home)
· More babies that needed resuscitation
· More cases of postpartum hemorrhage

The following interventions are not required in a hospital birth, but aren’t available at home, thus there is no pressure to use them (or more accurately MISUSE them). They are all used very commonly in hospital births[iv]. They may still be needed for some attempted homebirths, but midwives feel they are necessary far less often.[v]

· Electronic fetal monitoring (EFM)

Electronic monitoring introduces risks to the baby and mother without any statistical improvement in outcomes. Risks include: increased number of operative deliveries for fetal distress, infection (with internal monitoring), and a difficult to quantify risk of how the labor progress and pain relief is affected by the mother’s restricted movement. [vi]

· Cesarean section

The attitudes about cesarean section have contributed to the belief that it is just as safe as a vaginal delivery, but this is absolutely not true. Cesarean sections are major surgery and carry the same serious risks including infections, blood clots, and complications from anesthesia. A mother’s risk of postpartum death is increased three-fold with a cesarean.[vii]

· Forceps

Clearly when forceps are truly needed they can be very helpful, but the large differences in their rates of use by midwives and doctors leads one to believe that they are over-used by some providers. Forceps can cause damage to both baby and mother.[viii]

· Pitocin and other medications to induce or augment labor.

Risks of uterine stimulants include, uterine rupture, fetal distress, increased pain for the mother, and increased rates of neonatal jaundice.[ix]

· Pain medications

More use of medications increases the likelihood of a bad reaction or dosage error. There are 7000 deaths per year from medication errors[x] and non-fatal errors occur in about 1 of every 5 doses administered in hospitals.[xi] Epidurals carry a myriad of their own risks including potentially serious complications from the anesthesia and increased rates of instrumental, drug, and surgical interventions.[xii]

· Episiotomy

Experts agree that episiotomies rarely have any benefit and carry many risks, but they are still performed in as many as a quarter of all births in the U.S.[xiii]

Benefits to home birth:

· One-on-one care from a midwife

In the European countries that have with the best infant mortality rates midwives provide the majority of the care for pregnancy and birth. America spends billions of dollars on health care for pregnant women, but approximately 39 other countries had better infant mortality rates according to 2005 data.[xiv]

What kind of care will you receive in the hospital?
How often will you see your doctor?
How many patients is your doctor or nurse caring for?
What is prenatal care like with a doctor?
What is prenatal care like with a midwife?

· More effective labor when women are in the comfort of their own home

While this is difficult to quantify in studies it does seem to be suggested by the lower rates of interventions that are used in home births. Is Pitocin used so much more often in hospitals because the new, possibly scary, hospital atmosphere isn’t conducive to birthing?

Where will I feel most comfortable giving birth?
Do I feel comfortable in hospitals?

· Less medical intervention

Midwives try to use the most gentle ways possible to help mothers cope with labor and to encourage progress. These positional, psychological and otherwise less intrusive interventions carry far less risk to both mother and child and achieve excellent results.

What kind of interventions do I prefer?
What if I do need medical help?

· Lower cost[xv]

Who doesn’t want to pay less for more personal, dedicated attention? Often insurance covers a larger percentage of hospital birth, but because it is significantly more expensive the families out of pocket costs are about the same for both options.

What will my costs be for home birth?
What will my costs be for hospital birth?

· No arbitrary time limits are put on the progress of labor.

Hospitals and doctors use guidelines that establish what is a “normal” labor pattern and are often compelled to intervene with a labor when it does not follow the averages. Midwives do not consider there to be a normal time-frame for labor and will allow labor to determine its own course, only intervening if the health of the mother or baby are in jeopardy.

What are my provider’s beliefs about how long labor should last?

· Less separation of baby and mother

At home babies are placed in their mother’s arms and are almost never taken out of them. Hospitals generally have a ‘nursery’ nurse who’s job it is to take care of the baby as soon as it is born, when she is called to a delivery she isn’t able to go back to the nursery until the baby has been assessed, footprints have been made, hospital bracelets attached and paperwork is done. Often mothers receive their babies into their arms, but they nurse generally doesn’t want to wait for them to bond for an hour before she can get her “job” done. The baby is whisked off to the warmer and the procedures are done. Some hospitals and providers do better at facilitating the bonding process than others, but hospital patients have no choice about whom their nursery nurse will be and how this process will be handled. Midwives are only caring for one person and have no reason to rush the bonding process in order to get to the next baby. They are very conscientious of the importance of this bonding process for mother and baby and will do all the assessment of the newborn while the baby is in his mother’s arms. Weighing, measuring, and paperwork can all wait until hours after the birth and is then done at the mother’s bedside.

· Higher breastfeeding rates

This is due in part to the people who choose to birth at home and the increased likelihood that they are very committed to breastfeeding, but also because there are few disruptions to the bonding process at home and midwives have a lot of knowledge that can help mothers to be successful at breastfeeding.

Risks to home birth:

· Some emergency equipment is not available at home

This will vary depending on what your midwife carries, but obviously they cannot carry everything that is available in a hospital. Most midwives are qualified to perform both neonatal and adult CPR and carry the equipment to do so, including oxygen.

What equipment does your midwife carry?
Is she certified in CPR?
How often are emergency measures necessary in childbirth?

· No immediate availability of a cesarean section

Again, if a midwife has determined that there is a need for an immediate cesarean, a call is made to the nearest hospital alerting them to prepare for the woman’s arrival and a transfer is made as quickly as possible. Some midwives will not attend births at homes that are further than a half hour from a hospital.

How often is a cesarean needed immediately?
Are they truly going to be immediate even if you are in the hospital?)
What emergency techniques is your midwife trained in?

The choice of birthplace is an individual one, each woman brings her own history and desires to the situation. Each woman must decide what is right for her. She needs to know that she has choices, and that all are valid and deserve support. Every choice has benefits and risks. In all likelihood the birthplace that is the most safe is the one in which the woman feels the most comfortable. In an environment where a woman feels safe, relaxed and well cared for her body will release the optimal hormones for birthing, she and her baby will experience the least amount of stress and everyone will emerge from the birth healthier and happier.

[i] ACOG Practice Bulletin No. 5, July 1999
[ii] http://www.cdc.gov/ncidod/dhqp/healthDis.html
[iii] Health Grades Inc. "Patient Safety in American Hospitals," July 27, 2004. News release, Health Grades Inc. Institute of Medicine, "To Err Is Human," Sept. 1, 1999.
[iv] Declercq ER, Sakala C et al. Listening to Mothers II: Report of the Second National US Survey of Women’s Childbearing Experiences: October 2006
[v] Koehler MS, Solomon DA et al. Outcomes of a rural Sonoma County home birth practice: 1976-1982. Birth 1984; 11(3): 165-169.
Mehl, LE et al. Outcomes of elective home births: a series of 1146 cases. J Reprod Med 1977
Duran AM. The safety of home birth: the Farm study. Am. J Public Health 1992; 82(3): 450-453
[vi] Shy KK, Larson EB et al. Evaluating a new technology: the effectiveness of electronic fetal monitoring. Ann Rev Public Health 1987; 8: 165-190
Nelson KB, Emery ES. Birth asphyxia and the neonatal brain: what do we know and when do we know it? Clin Perinatol 1993; 20(2): 327-344
Albers, Leah and C. J. Krulewitch. 1993. "Electronic fetal monitoring in the United States in the 1980s." Obstetrics & Gynecology 82:8-10.
[vii] Deneux-Tharaux C. Carmona E. et al. Postpartum Maternal Mortality and Cesarean Delivery. Obstetrics and Gynecology. 2006
[viii] Carmona F, Martinez-Roman S, Manau D, et al: Immediate maternal and neonatal effects of low-forceps delivery according to the new criteria of The American College of Obstetricians and Gynecologists compared with spontaneous vaginal delivery in term pregnancies. Am J Obstet Gynecol 1995 Jul; 173(1): 55-9.
[ix] Akoury HA et al. Oxytocin augmentation of labor and perinatal outcome in nulliparas. Obstet Gynecol 1991; 78(2): 227-230
Satin AJ et al. High- versus low-dose oxytocin for labor stimulation. Obstet Gynecol1992; 80(1): 111-116. (U.S.)
http://www.drugs.com/cons/Pitocin.html
[x] Tipton DJ, Giannetti VJ, Kristofik JM. Managing the aftermath of medication errors: managed care’s role. J Am Pharm Assoc. 2003; 43:622-9
[xi] The Academy of Managed Care Pharmacy website: http://www.amcp.org/. Medication errors
[xii] Avard DM. Nimrod CM. Risks and benefits of obstetric epidural analgesia: a review. Birth 1985; 12(4): 215-225
Studd JWW et al. The effect of lumbar epidural analgesia on the rate of cervical dilatation and the outcome of labour of spontaneous onset. Br J Obstet Gynaecol 1980; 87:1015-1021.
[xiii] Graham, I., Birth, September 2005; vol 32: pp 219-223.
[xiv] World Factbook Estimates https://www.cia.gov/cia/publications/factbook/rankorder/2091rank.html
Madrona, Lewis & Morgaine, “The Future of Midwifery in the United States,” NAPSAC News, Fall-Winter, 1993, p. 30
[xv] Anderson RE. Anderson DA. [Dept. of Economics, Centre College, Danville, KY 40422, USA. ] The cost-effectiveness of home birth. Journal of Nurse-Midwifery. 44(1):30-5, 1999 Jan-Feb.

Arguing with myself

2008-03-12T15:19:00.004-06:00

So I’m on an email list for a website called Mamasource. It is a clever idea, women, mostly mothers, send in questions. The website sends an email every day to all the women who are signed up with them with a sampling of some that day’s posted questions. Also it is setup based on your local community so the questions actually go out to women who live near you, which is nice because you can get some actual recommendations for a good pediatrician or whatever.

There are lots of questions about babies sleeping through the night, potty training, discipline, all the myriad things that women often want advice about. I’m not a big contributor but the format of the emails and website makes it really easy to just click once and give another woman your $0.02 worth of advice. It seems great to me, I know I used my other women’s email groups in a similar fashion when I was a new mom and still do when life throws a challenge at me.

So obviously I couldn’t resist sending in a response when I saw the following question in the daily Mamasource email:

im not really asking for advice im more curious on the opinion about this subject since its an interesting one. i have been having some conversations with a friend about having home births. i know people have strong feelings about this and many people would never consider it because the hospital seems like the best place right? but im starting to wonder why people are so against having a baby at home with a midwife? or if there not. I think people think that women who want to have their baby at home are crazy. i don't see why. i probably would never do a home birth but i know people who would like to. I think it sounds interesting and i can see why some people would prefer to have a birth where they are able to do things more naturally and have a little more choice in how they want to have their baby. anyways just wondering on what the opinion of parents are about this subject.
A little about me:
i have had two babies (yes at hospitals)and no im not pregnant or thinking about having a home birth, but dont see anything wrong with it.

Well that is an easy question for me to answer so I posted the following response:

I have had both a home and a hospital birth. The decision to choose home birth for my second child was made over a very long period of time after an EXTENSIVE amount of research. My first birth was traumatic for me, it was so different than what I had hoped for, even though the hospital gave me good care. The reading that I did trying to understand and process that birth led me to a new way of thinking about birth and changed the way I wanted to handle my second birth. I became aware of the risk that came with hospital interventions and I knew that at the very least I would have to have continuous monitoring at the hospital (women having a VBAC are required to) and I didn't want that. I found a midwife who was extensively trained and extremely competent, the studies all said that homebirth is just as safe as the hospital, but only with a well trained midwife. In the end my home birth was a deeply healing experience and truly one of the best days of my life. I suffered with the pain of labor in the hospital with no support and the feeling that I had to stay in bed, which was extremely painful. In my homebirth I never laid down at all and used water for comfort. It wasn't painful for me (I used self-hypnosis techniques), but it was intense and powerful.

Well I’m not dumb, I know that these sorts of discussions on the internet are always ridiculous, but I went ahead and started reading the other responses anyway. It was the usual mix of about half home birth advocates or supporters and half posts from women who ‘surely would have died had they been at home’. These messages are frustrating because you don’t want to discount an experience that may have been serious and traumatic to them, but really most of them are totally bogus. True life and death emergencies during childbirth are pretty rare.

Many of the problems that these women experienced were caused by the things that were being done to them at the hospital. Yes, epidurals do cause extreme drops in blood pressure and babies go into distress, yes they will die if you don’t intervene. But that is why we don’t do epidurals at home! A lot of these women just don’t really understand all the repercussions of medical management and how different things are at home.

Some of the women also don’t understand they had truly high risk births that sensible midwives and home birth advocates would never attempt at home either.

Other women had true problems with their births that either the midwives would have been able to solve themselves or that they would have transferred the woman to the hospital for, but really are not life threatening. A lot of times women don’t understand that people attempting a home birth don’t just stay home and die if they aren’t able to deliver the babies, they actually go the hospital and get help when they need it.

It is impossible to respond to each and every woman, you just have to hope that the collective responses of the home birth advocates will penetrate a few people’s consciousness and open their minds a bit.

This one response though, boy it really got to me. I actually felt like crying after I read it, the sentiment was so hateful. So here is what I read that got me so upset:

Why would anyone who cared about their unborn child even consider doing a home birth??? Even if you have had a routine pregnancy, given birth before, or any other reason that people will give you...there is ALWAYS the chance of complications. And no midwife, no matter how experienced can give your child the care that they would recieve in an NICU where they have machines, and medications, and serveral staff to take care of them. Plus, what if you needed an emergency C-section? Do you think a midwife is just gonna cut you open? Nope!

Okay, deep breathing. This person is obviously pretty ignorant about birth, but boy was that judgmental. I pondered it for awhile, but I just couldn’t stop thinking about it, so I sent the woman the following private response:

Your response was pretty insulting to those of us who did massive amounts of research before we choose home birth? How much research did you do about the hospital you went to? Do you know their rates of medical mistakes? What about hospital acquired infection? Do you realize that women have lost uteruses, limbs, their babies and their own lives after acquiring antibiotic-resistant infections at hospitals? There is no way to eliminate all risks from life. Statistics show that both home and hospital are both very safe, but there is no way to guarantee that everyone will have a perfect outcome in either setting. I'm sorry if this is harsh, but it is extremely upsetting when people insinuate that I don't care about my baby because I chose a different set of risks than you did.

Ugh, I even had typos I was so mad! But I felt better. I thought well at least this person has been called on her nasty comments. Maybe she would think differently, maybe she would realize that I am a human being and a mother just like her- that I love my baby just as much.

*sigh*

No. Today I received the following response:

if you want to live the way of the third world, perhaps you should move to africa, live in the bush, a starve. You have been blessed to live in a time and place where you can benefit from a great advancement in medicine, and its ungrateful to throw that out the window. If your baby HAD needed medical intervention, how would you feel today, if she/he had died because you wanted to be at home instead of a hospital where thet could be properly cared for?

I didn’t get anywhere with her did I? Well I’m steaming mad that someone could be so hateful. She didn’t address any of the questions I had in my response to her, so she obviously isn’t really educated or wanting to engage in a real dialogue. I don’t really see the point in continuing to engage her, but really I want her to get her head screwed on straight! Instead of responding to her I figured I’d just rant on my blog.

First of all she doesn’t understand the difference between the choice to have a home birth here in the United States where I am well-nourished and healthy and choosing to live the life of someone in the third world. She basically tells me that I should think like her or I deserve to starve to death! Wow!

She assumes that just because I chose to give birth at home that I am not grateful for medical advancements! How presumptuous! I love medical technology when it is used appropriately. I’m thrilled that we have so many options. But I’m also quite aware that medical technology is not perfect that there are false positives, misuses, side effects and some downright serious dangers that come with them. We need to remember that a woman is three times more likely to die from a caesarean birth than a vaginal birth. That is not an amusing statistic when you live in a country with skyrocketing c-section rates.

And finally the big thing that really makes me nuts. “how would you feel today, if she/he had died because you wanted to be at home instead of a hospital where thet could be properly cared for?” Why is it that if a baby dies in the hospital it is ‘an act of god’ or ‘it wasn’t meant to be’, but if the baby dies at home then it is all the mother’s fault? I know a woman who lost her baby days after he was born in the hospital from an infection in his bloodstream. Nobody blamed her for going to the hospital where there are antibiotic resistant infections. Maybe her baby would have died either way but the point is that there are bad outcomes in both cases. Occasionally making a different decision might have changed the outcomes, but without a crystal ball who can know for sure? Most of the time the factors involved are complex and oftentimes there is nothing that ANYONE could have done to change the outcome.

I tried to make that point in my first response to this nasty woman. She is naïve for believing that being in a hospital guarantees a good outcome. She is naïve to think that being connected to an electronic fetal monitor, receiving Pitocin, not eating or drinking, getting an epidural in your back or forceps on your baby’s head is without risk. And even if she doesn’t do a single intervention in the hospital (which is bloody unlikely) just walking in the door increases the risk of getting yourself or your baby infected with something life threatening. Just driving the hospital and back home with your newborn could have a bad outcome, but no one would ever blame you for having driven there. Why is your choice protected, but mine is not?

It makes me so mad that I probably sound like I think people are bad for choosing to go the hospital for their births, but the point is that each choice has risk and each choice has benefits, none have guarantees. I understand that people are just doing the best that thing for themselves in light of their own circumstances. I really wish that people like this could be understanding about my choices.

Compromise Passes

2008-03-06T09:29:00.003-07:00

With only minutes to spare the compromise bill passed through the Senate and on to the governor for his signature. There is always the potential for him to veto it, but at this point that is highly unlikely.

Someone on the Utah Friends of Midwives message board pointed out that you know it is a truly good compromise when both sides are angry. Well I guess it was a great compromise! The docs are upset that the midwives will still attend VBAC births. The homebirth community is outraged that anyone gets to tell them what they can and cannot do for their births.

The homebirth community in general does not take their choices lightly, many have not had cesareans but they still fought long and hard to preserve the options of their VBAC sisters. Many will not ever have breech babies or twins, but they fought hard to protect women who will. They are angry that any woman may have lost the birth of her choice due to this bill, but most are aware that we were at risk of losing a lot more if we didn't accept the compromise.

The midwives and home birth community will continue to try and educate the community at large about home birth, their excellent outcomes and the enhanced experience of families who choose home birth. The licensed midwives will continue to practice carefully and accumulate more excellent statistics. Hopefully in 2011 we can win back some of the ground we lost this year.

Something has actually happened:

2008-02-27T09:10:00.004-07:00

Sadly, I couldn't even be there! The Licensed Direct Entry Midwife Amendments (SB93) was the only thing on the agenda for the House Health and Human Services Committee this morning, but I had to get Roxy to school so I was listening online to the action.

When the committee convened apparently the two parties felt like they just needed a brief meeting to finalize a true compromise bill, so the committee 'sauntered' so they could try to finish it. (I love that they use the term 'saunter' instead of just taking a break or having a recess). At 8:30 they reconvened and the 7th (!!) substitute bill was entered for the committee to rule on. Both sides testified that this bill was a true compromise and that they would NOT be back to ask for further legislation until 2011 when their had been time for the LDEMs to gather statistics on their births.

With no argument from either side, the bill passed unanimously.

So I waited with baited breath for the new bill to be posted online and in a few minutes it was posted, and well, it is definitely a compromise.

I am very disappointed with what the LDEMs have given up. I don't know if I can really support this version of the bill. But at the same time I really do believe that if the midwives don't give up something that the Utah Medical Association will be back at this every legislative session trying to change what they are allowed to do. That is a frustrating idea, it takes such a huge amount of effort to hold our ground at all. Maybe the best thing really is give up a little so that they stop attacking us. I really am not sure what the best thing to do is at this point. (and frankly I'm not in charge anyway)

The one big redeeming factor, in my mind, is that the unlicensed midwives have been removed from the equation and will continue to be able to practice without any meddling from the state. That is all they ever wanted, and I am glad about that.

If you want to read on about my specific issues with the current bill, by all means do so, otherwise stay tuned for more information when it becomes available.

Substitute 7 requires a mandatory transfer when a mother has been pushing for 3 hours and birth is not imminent. I don't see the problem of continuing to push as long as the mother and baby are tolerating it well. I also think there is the potential for problems if the parents don't want to transport after three hours, what is the midwife to do? Abandon them? Call 911?

Women with prior c-sections become ineligible after 42 weeks gestation. That could be a real concern as these mothers will then be facing c-sections or inductions, which increase the risks to mother and baby.

It also mandates that women with prior c-sections have an ultrasound to determine the location of the placenta. I don't exactly disagree with the idea of that, it is something I did in my own pregnancy, but it is a scary concept that they the midwives will have to require the VBAC moms to have ultrasounds. Some people really don't want an ultrasound, don't feel it is safe or necessary, and this is just a little too ' big brother' to require tests of people. (they should at least pay for it if they are want to require it!)

It also puts in guidelines saying that VBAC moms must have a prescribed rate of dilation or they have to be transferred, which gets scarier the more I think about it. It isn't at all uncommon for moms to start labor and progress for a while, then reach a plateau where they need to rest or her baby needs time to rotate and she won't make progress for awhile. If a midwife checks you at 10 am and you are 5 cm but for whatever reason you haven't progressed at 2 pm then she has to transport you. Even if there isn't any real reason to believe something is wrong.

And of course two big restrictions, twins and breech. I have written before on this blog about breech birth, I stand by those statements and feel like it is a real shame that LDEMs are losing the ability to attend those births. The midwife that in my mind has more experience than anyone in this whole state with breech birth (doctors included) is licensed and will no longer be allowed to attend women who choose to stay home.

Twins is another sad thing to lose. I have personally attended a twin birth at home and it was an amazing experience. The mother was very motivated to stay home for her birth and she took seriously the extra risks involved with twins, but she also knew that the risks would not be eliminated by going to the hospital. She met with hospital providers and had arrangements to use their services if at some point she felt that the birth was too risky to be at home (for example if the babies weren't in good positions when labor came). She was relieved when she carried the babies to term and remained low risk as she really did not agree with the way the hospital providers wanted to handle her birth. The birth was attended by 3 midwives, with 45 years combined experience, and handled with extreme care. In the end it was a beautiful and healthy birth experience for the whole family.

Having sat through enough committee meetings to know full well what the opposition would say to my little anecdote (and that is all it is, hardly scientific, but still an experience to learn from). The opposition would say that this mother got lucky, that it could have turned into a disaster at any moment, she could have needed a c-section that the midwives could not have given her.

Well, the irony is that if she had been in the hospital she would have had a c-section. The midwives monitored her and the babies carefully and waited patiently for her second baby to be born. The hospital never would have been willing to allow nature to take it's course, not because they are bad people, but because that is how hospitals work. You can't just sit and let a women nurse and bond with her new baby while you're occupying an operating room and you have 10 staff members standing by waiting for the other baby to be born. The way the hospital views that birth every minute that you are in that room you are open to liability and it is costing you money.

Mothers with twins will still choose to stay home and they will be forced to use unlicensed midwives for their births. Some of those women will experience bleeding that could easily be managed with a shot of Pitocin, but because the unlicensed midwives can't carry Pitocin those moms will have to go the hospital after the birth just for one shot.

Part of me wants to say just screw licensure, just be midwives and skip the medications and the hassles. But another part of me thinks that licensure has been such a wonderful thing. Having just a few medications available can save women a lot of hassle. Some women really do have completely normal pregnancies and labor but need just a shot of RhoGam. It has been so wonderful with LDEM care that women in that situation don't have to give birth at home and then make the trek into a doctor just to receive that one medication that a midwife can very safely give her. The midwives really only use a very short list of medications, it is a shame that licensure is the only way to legally have acces to those medications. (none of the medications are 'controlled substances' by the way, just a few things for controlling bleeding, antibiotics, etc)

In case you care, here is the exact language for mandatory transfers in the bill:

(a) failure to deliver the infant after three hours of pushing unless birth is imminent;
158 (b) gestation beyond 42 weeks without consultation with a licensed health care
159 provider or with non-reassuring surveillance;
160 (c) gestation beyond 43 weeks;
161 (d) moderate, thick, or particulate meconium in the amniotic fluid unless birth is
162 imminent;
163 (e) non-reassuring fetal heart rate pattern indicative of fetal distress that does not
164 immediately respond to the licensed Direct-entry midwife's treatment, unless birth is imminent;
165 (f) a fetus in the breech presentation during labor unless birth is imminent;
166 (g) multiple gestation unless birth is imminent;
167 (h) more than two prior c-sections;
168 (i) prior c-section with a known classical or inverted-T or J incision;
169 (j) prior c-section without an ultrasound that rules out placental implantation over the
170 uterine scar;
171 (k) prior c-section without a signed informed consent document detailing the risks of
172 vaginal birth after caesarean;
173 (l) prior c-section with cervical dilation progress in the current labor of less than 1 cm
174 in three hours once labor is active;
175 (m) prior c-section with a gestation greater than 42 weeks; and
176 (n) Rh isoimmunization with an antibody titre of greater than 1:8 in a mother carrying
177 an Rh positive baby or a baby of unknown Rh type.

Read the whole bill here:

http://le.utah.gov/~2008/bills/sbillint/sb0093s07.pdf

Thursday nights action plan

2008-02-21T20:44:00.002-07:00

Hang on folks this is where it gets bumpy. The legislators who are on our side are helping us to find a solution:

A timeline to hopefully make this clear.

So this all began with SB93 - new and insanely restrictive laws to regulate midwives attending births at home (commonly called direct-entry midwives).

We say NO, don't vote for that will make it against the law for many of us to have our right to have a midwife at home.

The legislators say midwives you and the Utah Medical Association (UMA) need to go and negotiate this, we don' want to hear about this issue again so let's solve it once and for all.

(we all roll our eyes because we agree and thought it was solved in 2005 when we got the midwives legal and licensed)

The representative midwives and the UMA meet for many hours and start making headway pinning down the details.

The UMA says we will work on a new version of the bill and we'll show it to you before we put it back out for a vote.

Without telling the midwives they enter a new bill, we'll call it Sub1 (technically SB93S001). This bill does remove some of the insane restrictions but still has vague language and some unacceptable restrictions (including me, a mom with a prior c-section)

The bill sails through the Senate.

We work hard to get the bill killed in the House.

That brings us to now. The savvy people who know the best way to do things at the capital have a new strategy.

Tomorrow, our friend, Representative Jackie Biskupski will enter a new substitute bill. This bill was written by Representative Lockhart during the negotions between the UMA and midwives. Sub 2 will have a reasonable scope of practice for the midwives, similar to what they have now (that is working so well).

There are lots of things that can still happen, we just have to wait and see, but tomorrow we need to get a new message to the Representatives. Tell them that you have been asking them to vote against SB93 because it unfairly restricted women's rights, but now Representatives Biskupski and Lockhart have come up with a more reasonable bill and you would like them to support Sub 2.

Phew, I know this is painfully complicated. Isn't politics fun?

A poorly written article...

2008-02-20T15:21:00.000-07:00

But I'll share it anyway:

http://www.deseretnews.com/article/1,5143,695254580,00.html

I commented on it over on the Des News website, but I'll elaborate a little more here addressing some of the errors and agendas:

1st paragraph:
The bill does not affect only 16 midwives, it affects all the midwives and all of the women that they serve. The bill's sponsors are telling people that this bill only affects licensed midwives and they asked for it by licensing, but in reality the language of the bill is such that all midwives are affected.

3rd paragraph:
The writer says it is a veiled effort by the licensing division, but it actually has nothing to do with them. They are satisified with the rules that are already in place. He is right about the tacit approval of the medical establishment, since the Utah Medical Association is behind the bill.

4th paragraph:
Opponents say lots of things, but the fact that they are following pioneer-era traditions is not really the most important. More importantly opponents say that the bill eliminates women's rights.

7th paragraph:
Senator Dayton says she wishes that the midwives had never asked for licensing, which is a true statement. She fought the bill that made midwifery legal and gave them licensing 3 years ago, because she doesn't think direct-entry midwives deserve licensure. She is a labor and delivery nurse and her husband is an OB/GYN, hospital birth is all she knows. Home birth and the midwives who attend them are something that she doesn't understand and doesn't believe in.
Also in that paragraph it says that the bill doesn't affect "certified midwives" which is an incorrect term. The writer means Certified Nurse Midwives, and he is right they are unaffected. Actually the licensed direct-entry midwives are also certified by their own organization.

12th paragraph:
Dayton says that licensed professionals must have practice parameters, which is true and it is why the midwives had a Rules process that determined their parameters 2 years ago. The UMedA had the opportunity to give input during this time, the midwives had more public hearings than any other profession has had before.

13th paragraph:
Yes, if this bill goes through I do have choices. I can go to the hospital, a place that they are right, I don't want to be. Or I can stay home alone. This bill takes away my preferred choice, which is to stay at home with a Certified Professional Midwife who was trained by both apprenticeship and study, and who passed a very rigorous exam proving her competence.

Begging via Email

2008-02-20T15:19:00.000-07:00

This is the email I sent out today:

I am asking for a favor on behalf of a cause that I feel very passionate about, the rights of women, specifically their right to choose how they want handle their births. I believe this is a deeply personal issue and the decisions about where to give birth and what care provider to use belong in the hands of the woman giving birth.

Right now there is a bill in the Utah House of Representatives that, if passed, would eliminate the choice of giving birth at home for myself and many women like me. This bill is sponsored by Senator Margaret Dayton of Provo and backed by the Utah Medical Association, who feel it is their duty to protect women and babies by making it illegal for midwives to attend certain births at home, even though the home birth outcomes are already excellent and there is not any scientific evidence to support their views.

One type of birth that will be illegal for midwives to attend are the births of women like me who have had a prior caesarean section. The bill's sponsors have decided on my behalf that I am too 'high risk' to have my baby at home. I do not share their view (because the science does not support it) and I believe it should be up to each woman to make these decisions based on their own personal situation and medical risk factors.

I believe that it is a slippery slope when we allow our government to make laws dictating how we must handle what should be personal medical/life decisions.

You can help me by taking just a moment to contact your own representative and ask them to oppose this bill and protect women's rights!

Go to this website to find your districts if you don't already know them - enter your address into the left hand side:

http://www.le.state.ut.us/maps/amap.html

If you don't like that one try this one:
http://www.le.state.ut.us/house/DistrictInfo/NewMaps/State.htm

You can send them just a one line email asking them to oppose SB93S1 the Licensed Direct Entry Midwife Amendments. Tell them to protect women's rights to make their own decisions!

I wouldn't ask if I didn't believe that every single email matters, the representative are listening and they take constituents requests seriously. I have been told by my own legislator that just a few emails have made the difference in how he votes. Please forward my request on to anyone that you think might help.

Through the Senate

2008-02-19T15:18:00.000-07:00

The bill went through the senate with only 3 nays. ***insert swearing here***

Time to stop it in the house. Contact your representatives!!!

Here is what I sent to mine:

Dear Representative Hughes,

I am emailing you in regards to SB 93 Sub1 the Direct Entry Midwives bill. I am extremely angry about this bill and the audacious way in which it violates my right to choose where and with whom I can give birth. This bill would make it against the law for any midwife to attend my birth at home because I have had a prior caesarean section. Senator Dayton and the Utah Medical Association have no right to make the important personal and private decision of where to give birth on my behalf.

The bill's sponsors are claiming to be protecting the citizens of Utah, but that is a false claim that they cannot back up with any solid evidence. The reality is that both hospital and home are basically safe places to give birth, but life is never risk free and there are some very real risks that exist only in the hospital (life threatening antibiotic-resistant bacteria are one very good example). It should be up to the woman who faces the risks of giving birth to decide which ones she chooses to assume.

Please fight this unjust bill by holding it in Rules committee. As my representative I am asking you to please protect my rights!

Sincerely,

Heidi Sylvester

Another article

2008-02-19T13:50:00.001-07:00

Right to the point:

http://www.heraldextra.com/content/view/255734/155/

More on the substitute bill

2008-02-19T10:39:00.000-07:00

Boy what a bunch of garbage...

All along Senator Dayton has been saying that this bill only affects the licensed midwives, they asked for licensure and it is the state's responsibility to regulate them.

Well first of all the state is regulating them, through DOPL, just as they do other licensed professionals.

Second of all the new substitute bill is definitely written so that all the restrictions are placed on both licensed and unlicensed midwives. This is unfuriating, because they are making it against the law for me to have a midwife attend my birth, no matter if she license or not, there are no options for me.

I have a scar on my uterus and because of that the Utah Medical Association believes they have a right to make my medical decisions for me! They are writing a law that makes it so that my only options are to give birth alone at home or in a hospital. Neither of those options are as safe as being at home with a trained, experiened midiwfe.

I am so mad I could spit.

Tribune article

2008-02-19T10:37:00.000-07:00

A really great article on the home birth legislation:

http://www.sltrib.com/News/ci_8286322

The cute mama in the article was a client of mine!

Legislative Update

2008-02-18T20:36:00.000-07:00

Senator Dayton has entered a substitute bill, supposedly a compromise between the Utah Medical Association and the midwives. Problem is, the midwives never signed off on it and the bill is not an acceptable compromise.

The new bill does remove some of the restrictions on the midwives, but the big sticking points remain. The home birth supporters are emphatic that the midwives retain the right to attend VBAC (vaginal births after cesarean), breech and twin births. The UMA is equally emphatic that those births take place in the hospital, they consider them too high risk to take place at home.

The irony is that the vast majority of women having VBAC, breech or twin births in the hospital will have a cesarean section. I don't know any doctors that will even allow a woman to attempt a breech birth, they simply don't know how to do them anymore, all these women will be sectioned.

Midwives know that these births are higher risk and they are never undertaken lightly. The midwives work very hard to maintain the skills necessary to manage these births and their clients are often able to give birth vaginally.

Cesarean section is not a risk free way to give birth. Women are three times more likely to die after a c-section then they are after a vaginal birth. Other risks include increased blood loss, increased rates of infection, increased risk of losing her uterus due to complications, the list goes on - and that is just the risks for the mother, there are additional risks to the baby.

Doctors dictating that a women must give birth in the hospital for a breech birth are dictating that the women must have a cesarean. Doing cesareans for all breech births doesn't improve the outcomes.

Basically, when the baby is breech the birth is slightly more risky, NO ONE can guarantee a perfect outcome. The same things are true with twins and VBAC. It should be up to the women to decide what is the best course of action, which set of risks she chooses to accept. This bill is an attempt by the Utah Medical Association to declare that they are the ones who should decide what women should do with their bodies. It is an infringment on our reproductive and civil rights and a step down a slippery slope that really frightens me.

Write your senators today. Tell them that they shouldn't allow a self-serving professional organization to run roughsod over our rights to make our own medical decisions.

Midwifery in the press...

2008-02-08T11:28:00.001-07:00

An article in the Tribune:

http://www.sltrib.com/utahpolitics/ci_8198859

(written by the fabulous Heather May)

And front page in the Deseret News:

http://www.deseretnews.com/article/1,5143,695251312,00.html

In the Daily Herald:
http://www.heraldextra.com/content/view/254628/155/

(cute picture of my friend Laura!)

And my letter to the editor in the Des News:

http://www.deseretnews.com/article/1,5143,695251231,00.html

And the Standard-Examiner:

http://www.standard.net/live/opinion/letterstotheeditor/125436/

And in the Salt Lake Tribune:

http://www.sltrib.com//ci_8210097

There are some great comments on the articles, it is great that more people are hearing about this!

Be aware

2008-02-08T09:03:00.000-07:00

Just an FYI on what is going on under the scenes...

http://www.thebigpushformidwives.org/amastmt.aspx

The ongoing battle...

2008-02-08T08:38:00.000-07:00

Our midwives met with the UMedA yesterday. They talked, but everyone knows a compromise is going to be difficult. They are both going to write acceptable versions of the bill over the weekend and meet again on Monday to see if an agreement can be reached. I think we are going to have to accept some sort of law if we hope to ever get them to leave us alone. I am very concerned with what we may have to give up though. Especially the right for the midwives to do VBACs, because of course that affects me very specifically. I don't expect to have another baby, but if I did the hospital is not an acceptable option.

I know the midwives will fight as hard as they can for us, but it is very frustrating to me to have a small group of doctors and lobbyists attempting to take away my rights, FORCE me to use their care and deal with the risks of the hospital. They will say that I can still choose to stay home and have my birth unattended or have an unlicensed midwife attend, but that also is not what I want. I want a midwife who carries Pitocin and can legally use it, I want a midwife who can legally use antibiotics if I need them. The science shows that the best outcomes for home birth are with qualified care, and I trust the Certified Professional Midwife credential (all licensed midwives are CPMs), as have many of the best studies on home birth.

I also firmly believe that because of the way that the bill has been worded removing their legal protection, that the unlicensed midwives are going to face legal battles. Their opposition will bide their time until they can prosecute one of them in an attempt to terrorize as many of them as possible out of practicing.

It is really kind of amazing to me that the doctors have the right to decide what the competition can and can not do. It is very much akin to the issues that I've heard about with real estate, where the real estate agents say that they are the only ones who should handle housing deals, and that sell-it-yourself types can't handle it on their own. The claim is that it is about protecting the citizens of Utah, but it is really about protecting ones territory and not allowing competition.

It stinks.

Start here...

2008-02-06T16:11:00.000-07:00

So I’ve decided to finally start up a blog. Everyone I know has one and I just feel left out! Just kidding a few people I know have them, but mostly I just feel like I do some major ranting on emails and such, I might as well put them out there on the blogosphere.

Right now most of my ranting relates to the legislative ‘battle’ going on over direct-entry midwifery.

First some history...

Midwives have existed for all of recorded human history. In Utah they were pivotal in the lives of the pioneer women and the ‘ancestors’ of those midwives continue to this day. 150 years ago everyone gave birth at home, midwives were still common, but doctors were attending more women each year. It was considered to be a sign of status in some ways to be attended by a physician. Around 1900 there started to be a shift towards hospitals, in large part for convenience of the medical staff, but also because more drugs were being used and it was safer and easier to use them in the hospital.

Maternal mortality rates rose as women moved to the hospitals, mostly because they were more likely to get infections in hospitals where the germs were unfamiliar and the women were more susceptible to them (still true today). The drugs were dangerous too and many women died from complications from ether and other early medication techniques.

Finally in the 1930s there were some real scientific breakthroughs in medications, specifically antibiotics for infections and the maternal mortality continued a downward trend for the next 40 years (it bottomed out in 1982, but it has risen every year since, which is quite frightening). More and more women switched to giving birth in hospitals and medical care is now considered normal for all women.

A few women still stayed home though, women in rural areas, blacks in the south, the Amish, polygamists, and a handful of others. The midwives never stopped attending them and fortunately their ways were never completely lost. They worked under the radar for the most part.

This is how it was in Utah, they were always there and nobody really minded. But in 2000 a midwife in St. George was prosecuted for practicing medicine without a license. There were no laws saying what a midwife could do and therefore she fell under the umbrella of the Medical Practice Act.

The midwifery community reacted by going to the legislature and asking for a change to the law that would define their livelihood as separate from medicine and give them legal status. The midwives did not want to be afraid that she could go to jail for providing care for a birthing woman.

Midwifery has changed and evolved over the years. For the most part midwives have continued to support women as they grow and give birth to their babies, just as they always did. But they also pursued education, they read studies, they learned what doctors did, and what science has proven to really help. Wisely, they learned more ways of helping women, incorporating some of the best and most effective tools into their practices. Some still use only traditional practices, using only herbs or hands-on tricks to deal with women who bleed too much or babies that need help transitioning. Some families do not want their midwives to carry or use any drugs or medical equipment. Other families and midwives wanted to have access to Pitocin (for treating postpartum bleeding), oxygen, antibiotics, etc. The vast majority of the time they don’t need these tools, but they wanted to have them available and the midwives wanted to have access to the things that would make their clients feel safe.

Federal law says that professionals must be licensed to use prescription medications, so they found a way to provide the most choices for all women and all midwives. A bill was created that gave midwives the option to license, using the same national standards as other states for defining what education was necessary for licensure. Midwives could also choose not to license, but now they would be able to practice without fear of prosecution for doing their jobs, although they could not carry or use any drugs.

This is where we are now; after years of effort, fought tooth and nail by the Utah Medical Association and others, compromises were made, the UMedA withdrew their opposition, and a wonderful bill was passed in 2005. Since then, as spelled out in the law, rules were defined governing the practice of the LDEMs (licensed direct-entry midwives). Happy midwives and happy families have gone on doing what they have always done, having babies at home. The licensed midwives have submitted statistics to the state each year and their outcomes are excellent, follow the links below to see for yourself:
Outcomes from 2006:http://dopl.utah.gov/licensing/forms/de_midwife_outcomes.pdfOutcomes from 2007:http://dopl.utah.gov/licensing/forms/LDEM_2007OutcomeReport.pdf

So, what is the problem then?
The Utah Medical Association isn’t satisfied with how the midwives defined ‘normal’ and wants to pass legislation to define it themselves. This in itself is an abnormal practice; no other profession has the rules of their practices dictated by their competitors! The UMedA and their bill’s sponsor are claiming that the bill comes from concerns over the safety of women and babies, but the rules set forth by the bill seem to be more concerned with eliminating all the midwives’ potential clients.

The bill is cleverly designed to fool uneducated legislators; it is a laundry list of conditions that define what makes a woman outside the range of normal, disqualifying them from midwifery care. Many are legitimate, like a heart condition or AIDS, things that are already covered in the existing rules. These women don’t belong at home and the midwives know it. Buried in the logical are the rules put forth by the UMedA that don't really make sense from a safety perspective. Some examples: a history of 3 or more miscarriages (that has no bearing on a current pregnancy that has been carried to term), a woman who has previously given birth to a baby larger than 9lb 13 oz (even when she may have had much larger babies with no difficulties in the past). Some of the new rules are just vague and broadly sweeping enough as to rule out women with only minor problems, or problems that have no bearing on her ability to give birth safely. Under the proposed rules, the midwives estimate that 10% or less of the clients they cared for last year (successfully I might add) would not have been eligible.

Probably the most concerning change with the new bill is removal of the language that protected the midwives who chose not to license. The midwives who just want to be left alone so that they can "catch" babies at home with only their ancient ‘bag of tricks’, just as they have always done. These women will continue regardless of whatever law is written on the books, but without the language that specifically protects them, they are vulnerable. Practicing medicine without a license is a felony, and these women could be prosecuted for as little as listening to the baby with a stethoscope. To me that is unacceptable, midwives have the right to exist and we shouldn’t allow their opposition to mount a modern day witch hunt against them.

So back to the hill we go, we may have little money or power, but we have a lot of passion and commitment. We believe in home birth and midwifery care and we won’t allow the choices to be taken away without a fight.

To find out what you can do to join support this cause, join the yahoo group and get involved:
http://health.groups.yahoo.com/group/UtahfriendsofMidwives/