From JW:
That our AMA develop model legislation in support of the concept that the safest setting for labor, delivery, and the immediate post-partum period is in the hospital, or a birthing center within a hospital...
What sort of legislation do you think can achieve these aims and also avoid either banning health professionals from attending home births or banning women from purposely attempting a home birth?
From Sailorman:
Didn't you read the rest of the post?
One way to do it is to deal with licensing requirements for DEMs.
From Alexis:
Except in some states, CNMs attend home birth as well. Do they intend to strip them of that right?
(IMO, the opposite should be done and CNMs should be permitted to attend home birth in every state. Not because I believe in an expansion of home birth, but because if you're going to have it, you should have someone qualified present.)
From Jenn:
I was just going to post and say essentially what JW said...if AMA wants to say that they only support hospital birth, that is their perogative. But to say that they are going to pursue legislation about birth only being safe in hospital settings is a round about way of saying they are going to look to ban homebirth.
From JW:
Didn't you read the rest of the post?
One way to do it is to deal with licensing requirements for DEMs.
But this wouldn't achieve what they are setting out to achieve in resolution 205 (develop model legislation in support of the concept that the safest setting for labor, delivery, and the immediate post-partum period is in the hospital, or a birthing center within a hospital complex). Does resolution 204 have anything directly to do with resolution 205? It seems to me that the two are independent and I do not see resolution 204 (which is about the scope of practice and licensure of midwives) as a suggested solution to resolution 205.
From Amy Tuteur, MD:
Jenn:
"But to say that they are going to pursue legislation about birth only being safe in hospital settings is a round about way of saying they are going to look to ban homebirth."
No, absolutely not.
There are licensing requirements for all sorts of professions and there are requirements about where the practice of professsions can take place. These range from regulations of hair stylists to teachers to dentists to midwives. I can't think of any legislation or even any effort to pass legislation that imposes criminal penalties on people who choose to get their hair cut by a friend, pull their own tooth, or attend a school where the teacher turns out to not have a valid license.
This is deliberate attempt on the part of homebirth advocates to divert attention from the real issue. NO ONE is trying to "outlaw" or criminalize homebirth, nor could they if they wanted to. The REAL issue is licensing standards for birth attendants and birth facilities.
Homebirth advocates are constantly pointing to industrialized countries that rely on midwifery. In those countries midwifery is HEAVILY REGULATED. There are elaborate rules about suitability for homebirth. Every midwife in the industrialized world has strict education and training standards and strict standards of practice. American DEMs are deliberately trying to evade those standards because they cannot meet them.
Why shouldn't American DEMs have to meet the SAME standards as any other midwife in the industrialized world?
From JW:
Amy,
I see no problem with midwives being regulated. Indeed, I've been shocked at the lack of regulation in the US. But resolution 205 has nothing to do with regulation of midwives. It relates just to Home Deliveries and talks of developing model legislation to support birth in hospitals.
From Esther:
Legislation to support birth in hospital is not, however, the equivalent of outlawing homebirth.
From Jenn:
Jenn:
"But to say that they are going to pursue legislation about birth only being safe in hospital settings is a round about way of saying they are going to look to ban homebirth."
No, absolutely not.
Really? So then abortion was not illegal prior to Roe v. Wade, if a woman just had her best friend perform the procedure? (well, I know that in some states it *was* legal...but not in all of the US)
Somehow I think that if something bad in the way of medical outcomes happened to the woman, the "best friend" would have gotten brought up on criminal charges.
Making it illegal for a licensed medical provider to provide abortion certainly did make it "illegal" for women to have them...and unsafe.
Likewise, making it illegal for any licensed medical provider to attend homebirths will have the trickle down effect of making it "illegal" for women to have homebirths. I'm pretty sure I've read that in some states it already *is* illegal for women to have anyone attend her in a planned homebirth--even her husband can be brought up on charges. My understanding is that it's not technically illegal for the woman to birth at home...its just illegal for ANYONE to attend her. Wish I had a reference for you on this, but I'll admit that I don't.
I can't believe I'm making this arguement...as I'm VERY much pro-life.
From Tracy:
Dr. Tuteur,
I would first of all like to say that I had heard about you, in a very negative way, from the women on my parenting forum. And I was very ignorant of the dangers of homebirthing or ignoring standard medical practice for the sake of avoiding "unnecessary" medical interventions.
I have read ALL of your posts, including the related links to the information you based your opinion on, and can say that I am shocked that I never did any research of my own before the births of my two children! I did not homebirth because I was "paranoid" about things going wrong and there not being a doctor, trained medical staff, or proper equipment, and apparently my instinct to NOT trust my instincts was a good thing. There was meconium present in my second birth, and it there hadn't been constant fetal monitoring, how would anyone have been able to tell my baby was in distress? (yes, this is anecdotal, and doesn't "prove" anything, just relating my own personal experience)
I used to have a very cavalier attitude about women having the "right" to choose and plan how and where they want to deliver, but now I'm not sure... I think a line needs to be drawn somewhere...
Thank you for taking the time to write about this subject, for not merely stating just your opinion, providing links to sources of information, and intelligently debating. I hope more women read this and can make an EDUCATED decision about their deliveries, with full knowledge of the risks involved.
From JR:
I don't think DEMs should practice unless they're licensed, held to an acceptable standard, and there's a system for reporting professional misconduct or malpractice. Of course, the definition of DEM would seem to defy that.
There are downsides to being regulated - lack of flexibility and ability to individuate care is certainly one of them. But there are much greater and more important benefits - clarity, professional standards, accountability.
I would prefer if all homebirth midwives were CNMs - mine was. But failing that, I've also supported legislation to license and regulate CPMs so that at least there are standards and accountability for practitioners. This underground nonsense is dangerous for everyone and results in multiple kinds of harm and abuse.
IMO, mother and baby-friendly care in the hospital, and greater respect for patient dignity and autonomy, are far more important than preserving homebirth. So many women seek homebirth not because they feel that is where they need or want to give birth, but because they were disrespected and/or mistreated while birthing in a hospital. It shouldn't have to be that way.
From Dearme:
So, Amy, the end result of all of this is...more of the same of all of this? 1% of American women will continue to have homebirths, for whatever reason they always have, attended by unregulated, possibly unqualified midwives. Is that the goal? To maintain the situation as it is now?
From Amy Tuteur, MD:
Tracey,
Thank you for your kind words. Every woman has the right to make her own choices about any aspect of healthcare. In order to make informed choices, though, she must have access to accurate information. That's why this website exists.
From Amy Tuteur, MD:
Dearme:
"1% of American women will continue to have homebirths, for whatever reason they always have, attended by unregulated, possibly unqualified midwives. Is that the goal? To maintain the situation as it is now?
Less than one quarter of one percent of women will have homebirth with a DEM. I'm doing my level best to lower that number. However, there is only so much I can do to reduce ignorance. They are free to expose their babies to the danger of death. I just want them to know that that is what they are doing.
From angela:
For me, the "danger" of homebirth is not just restricted to that fringe few who do it. It is the philosophy behind it (and its umbrella philosophy "natural" birth) that is pervasive in our (privileged, first-world) culture today: the wide-spread (unquestioned) belief that doctors "intervene too much," that avoiding a CS is something to be "proud of" (God, A Sarah, I want to hear that song you mentioned in one of the previous threads!), that a woman's birth experience is somehow lesser valued the more needles and drugs she gets like it's some kind of reverse first-world competition (and the thinnest lady wins, too!).
People talk about "natural" birth as if it's something they need to protect from the "medical establishment," and I don't think most people know what they're talking about. It has become a fad, an accepted "truth" that nobody questions. There are very, very, very few people informed by the points of view raised on this blog. For instance, that childbirth is "inherently dangerous." Who would ever say that? What woman amongst our friends would acknowledge that (unless she was an OB)? People have just gone absolutely ga-ga over the "fashionable-ness" of certain ways to give birth. It has been a long time since babies and mothers died from things that are easily preventable today, and we (as a society) have completely forgotten; we have lost our perspective, in some ways shamefully; and happily (and cattily) engage in a false sense of security that is much more dangerous to more people (emotionally as well as physically) than the fringe homebirth crowd.
The philosophical footprint is much larger than one quarter of one percent and way more entrenched IMO.
From onesmallvoice:
You say that your intention is to educate women about the dangers of homebirth so they can make informed decisions - but what about the dangers of hospital birth? What about the (even by AMA standards) excessive rates of cesarean births? What about all of the interventions (labor inducement being a prime example) routinely practiced by hospitals that have nothing to do with the health of the mother or baby, but are a convenience for the doctor and staff?
And as for the "lies" of the DEMs and homebirth community - we look at the recent statements from the AMA and doctors such as yourself and see the definition of "normal" birth being ever-narrowed and the medical lobby ever-strengthened and have to worry for the day when DEM will be illegal entirely (as it already is in some states), any birth that occurs outside of a hospital (or AMA approved birth facility) will be suspect, or even criminal, and we see a need to fight against that eventuality. It is not a lie to project the consequences of a policy to its intended and desired end.
My son was born at home, 18 days post-date, under the care of a Certified Professional Midwife. My daughter was born 11 days late under the care of a direct-entry midwife, in a birth center. Both were perfectly healthy. But the AMA's definition of "normal" would have strapped me down for a pit drip and who-knows-what-else. When a liability-conscious hospital can offer me the same freedom to birth my children as my body is made to (we joke "I just cook 'em longer"), then hospital birth might be the safer choice for me. But not until.
From Susanne:
Angela: "It has been a long time since babies and mothers died from things that are easily preventable today, and we (as a society) have completely forgotten; we have lost our perspective, in some ways shamefully; and happily (and cattily) engage in a false sense of security that is much more dangerous to more people (emotionally as well as physically) than the fringe homebirth crowd."
Brava. The polio vaccine is a perfect example. It's easy today to worry about the "interventions" of vaccines, because we don't have the fears that our grandparents did that our children would wind up in iron lungs.
From Alexis:
Sigh. Once again, I despair.
Ladies, if you want to argue with Dr. Amy, you need to know how. The plural of anecdote is not data, and your personal desires or experiences are not the foundations of research or policy.
All you are achieving is a deeper impression that all NCBs/HBAs care about is warm fuzzy feelings. And that won't work.
From Alexis:
Of course, if all you want to do is prove her point, you're doing an excellent job--and don't tell me it's because she censors comments, because I've seen the same hand-wringing and whining over plenty of blogs and forums.
From Amy Tuteur, MD:
onesmallvoice:
"but what about the dangers of hospital birth?"
The point is that the dangers of homebirth EXCEED the dangers of hospital birth.
No one is claiming that hospital birth doesn't have specific dangers. No one is claiming that there are no iatrogenic diseases. No one is claiming that there is no malpractice.
Even when you include the complications of hospital births, even when you include iatrogenic diseases, even when you include malpractice, homebirth is EVEN MORE dangerous!
From Susanne:
onesmallvoice: "What about the (even by AMA standards) excessive rates of cesarean births? "
What about them? Do you understand that they're driven by better-safe-than-sorry?
"What about all of the interventions (labor inducement being a prime example) routinely practiced by hospitals that have nothing to do with the health of the mother or baby, but are a convenience for the doctor and staff?"
Inducement or augmentation? Big difference, IMO.
"And as for the "lies" of the DEMs and homebirth community - we look at the recent statements from the AMA and doctors such as yourself and see the definition of "normal" birth being ever-narrowed and the medical lobby ever-strengthened and have to worry for the day when DEM will be illegal entirely"
Definition of "normal" birth being ever-narrowed? WE'RE not the side that portrays any birth other than out of an unanesthetized woman's vagina as somehow "lesser." WE'RE not the ones making women feel bad about having CS.
"My son was born at home, 18 days post-date, under the care of a Certified Professional Midwife. My daughter was born 11 days late under the care of a direct-entry midwife, in a birth center. Both were perfectly healthy. But the AMA's definition of "normal" would have strapped me down for a pit drip and who-knows-what-else. When a liability-conscious hospital can offer me the same freedom to birth my children as my body is made to (we joke "I just cook 'em longer"), then hospital birth might be the safer choice for me. But not until."
You only know that your body "cooks them longer" in retrospect. Surely you've seen how stillbirth rates do rise after the 41/42nd week? What distinguishes you, who "cooks them longer," from the women whose bodies cook them too much and they die from post-date complications? How are you so sure you're one of the "long cooks"? More importantly, how were you so sure ahead of the fact?
From onesmallvoice:
Suzanne: "What about them? Do you understand that they're driven by better-safe-than-sorry?"
Or they're driven by convenience. If the AMA says the c-section rates are too high (and they have), it's not about safety.
Not all women have low-risk pregnancies and can opt for homebirth, out-of-hospital birth, or even vaginal birth. Not all women want the experience. That's cool with me. My desire to preserve the option of out-of-hospital birth for myself and others who would choose it has absolutely nothing to do with anyone else's guilt about having a c-section.
After 14 days post-date I had ultrasounds every 3 days (meaning I had 2) to check the levels of amniotic fluid and make sure baby was doing okay. There were absolutely no indications that I was putting me or my baby in danger by waiting.
From Amy Tuteur, MD:
onesmallvoice:
"There were absolutely no indications that I was putting me or my baby in danger by waiting."
Really?
Do you know what the stillbirth rate is at 40 weeks? Do you know what the stillbirth rate is at 41 weeks? Do you know what the stillbirth rate is at 42 weeks? If you don't know these things, and I'm sure you don't, then how can you possibly determine the risk?
From Kneelingwoman:
Amy, she was being monitored; if she was having US done, it was through an OB--CPM's cannot "order" an ultrasound without an OB on board; you know that. While your data on the elevation of risk of stillbirth after 41.5 weeks is accurate it is still a very small number....most babies who are "post dates" are not "dysmature"; there's a difference and it is also one that you know well. It's exactly this "hair splitting" and the complete inability to give credit where it's due ( except to me; LOL, and thank you ) that I think creates the difficulty women have accepting your information; its the packaging, frankly. It doesn't take your argument down to concede the fact that someone who chose homebirth with a midwife actually did the "right "thing, in this case, get appropriate monitoring and FYI, most of the OB's around here are still o.k. with monitoring through 42 weeks; a few years ago, it was through 43! I know because I referred women for monitoring. I also know, as I've written here before, that most women who appear to have a post due pregnancy actually have very long menstrual cycles that most Physicians do not ask about, primarily because they can't document what a woman tells them about that; women, of course, not being in any way trustworthy about their bodies ( a-hem...). As to the whole "due date" thing; I've ben spitting nails, lately, over the several friends and family members who are having their due dates revised "back" to an earlier date with US in the third trimester; notoriously innaccurate and in every case, completely off the wall in terms of mother's menstrual history and the earlier, first trimester dating US....My niece, who's husband is in the Marine's, knows, catogorically, that it is impossible for her to have conieved at the time the "new date" would have it; her husband was in Iraq! Her OB had the temerity to suggest that "maybe she's just forgotten a few things". Come on....and we're seeing much more of this kind of highly suspect "testing". Changing the due date in the third trimester, often by as much as 2 or 3 weeks is just crazy and only done so someone can have a ready made excuse to induce. I've read the last few threads here with mounting dismay; you seem to be relying more and more on sarcasm, angry retort and some blown out "facts" that, in most cases, I've decided not to argue out ( I'm tired; almost vacation time ) but, I've also noticed that people are walking away very unconvinced and I thought convincing them was the objective? No? Maybe I've misunderstood.
From Alexis:
I have to agree here--stillbirth may increase markedly at 42 weeks, but monitoring and waiting is not outside the realm of what an OB or CNM might do. It's not an example of irresponsibility at all.
And I agree with KW; there are practices, including the due date revision she mentions, which are just not defensible. Maybe someone can explain this to me because I don't get it--why do OBs put so much stock in late u/s for size and dates when it's been demonstrated to be unreliable and when ACOG (IIRC) recommends against CS for suspected macrosomia based on u/s? Heck, even mine was off. (At 36 weeks, they said I was looking at having a 7 lb'er. At 38 I delivered an 8 lb, 1 oz baby.)
From JW:
Maybe someone can explain this to me because I don't get it--why do OBs put so much stock in late u/s for size and dates when it's been demonstrated to be unreliable and when ACOG (IIRC) recommends against CS for suspected macrosomia based on u/s?
More evidence that US OBs routinely ignore evidence based medicine?
From Antigonos:
(At 36 weeks, they said I was looking at having a 7 lb'er. At 38 I delivered an 8 lb, 1 oz baby.)
~~~~That's enough time for the baby to put on a pound. Babies gain 30 gm a day, or 200 gm a week. 400 gm is roughly a pound.
From Amy Tuteur, MD:
Ultrasound is currently the ONLY method for estimating fetal weight. Doctors are well aware of its limitations and its limitations are integral to the way that the calculations are made. The limitations are greatest at the end of pregnancy and greatest for large babies.
The solution for the KNOWN limitations of ultrasound is not to ignore the ultrasound results and pretend that everything is fine.
From JW:
Amy said,
The solution for the KNOWN limitations of ultrasound is not to ignore the ultrasound results and pretend that everything is fine.
but kneelingwoman said,
I've ben spitting nails, lately, over the several friends and family members who are having their due dates revised "back" to an earlier date with US in the third trimester; notoriously innaccurate and in every case, completely off the wall in terms of mother's menstrual history and the earlier, first trimester dating US...
I was under the impression that a first trimester dating scan is much more accurate than a third trimester scan. Is this wrong, or are these doctors making a mistake when they revise dates based on the later of two scans?
From Amy Tuteur, MD:
JW:
"are these doctors making a mistake"
They are making a mistake. Obstetric textbooks are clear on this point.
From JW:
And, going back to the topic of this article and my first post, has anyone thought of any form of legislation, short of banning midwives from attending women in labour at home, that would achieve the AMA stated aim of supporting the "concept that the safest setting for labor, delivery, and the immediate post-partum period is in the hospital, or a birthing center within a hospital..."
From Alexis:
Antigonos, I mean that they estimated that the baby was going to be 7 lbs at birth. Not that she was 7 lb at the time. Of course I know she could/would have gained a pound in the intervening 2 weeks. (And I know I didn't misunderstand, either.)
From Antigonos:
From JW:
And, going back to the topic of this article and my first post, has anyone thought of any form of legislation, short of banning midwives from attending women in labour at home, that would achieve the AMA stated aim of supporting the "concept that the safest setting for labor, delivery, and the immediate post-partum period is in the hospital, or a birthing center within a hospital..."
~~~No matter what the safest way to have a baby is, you will ALWAYS have some people who will deliberately choose a less safe way to do it, and there's really no way to COMPEL a woman to deliver in a specific venue or with a specific type of birth attendant. [and, has been noted, there are precipitate deliveries even in the population which ardently desires hospital birth with all the bells and whistles]
We talk all the time about the "educated consumer" but I deal daily with women, who've got 12 or more years of formal education who haven't got a CLUE about anything relating to birth and are therefore are completely vulnerable to the misinformation bandied about on HB/NCB sites [if they bother to look] or from friends who have an agenda. Just today I had a "I've been given sure-fire exercises to prevent a breech birth" and a "the only form of induction I'll agree to is a dose of castor oil". In the first case, the baby was noted to be breech at 31 weeks, not surprisingly, and AMAZINGLY turned two weeks later, due of course to these miraculous exercises [most fetuses are breech prior to 32 weeks anyway] and as for the castor oil...well, the lady in question had been glugging it for several days and couldn't understand why she was having diarrhea...there was no medical reason for induction, but she was tired of waiting.
From Jenn:
Ultrasound is currently the ONLY method for estimating fetal weight.
Really? Because the research I read (presented in a journal for American Family Physicians, so perhaps you haven't read it) indicated that manual palpatation of the belly provided more accurate results than ultrasound. Previous birth history coupled with the mother's thoughts about the baby's size was also more accurate than ultrasound.
I never had a late pregnancy ultrasound to predict weight, but in my two homebirths my midwife did palpatate my belly and predict weight...and she was right on both times.
From JW:
No matter what the safest way to have a baby is, you will ALWAYS have some people who will deliberately choose a less safe way to do it, and there's really no way to COMPEL a woman to deliver in a specific venue or with a specific type of birth attendant.
Antigonos,
Not sure why you quoted my question above your post? It doesn't seem to address my question at all. I didn't mention compelling a woman to deliver anywhere, I asked what legislation could be introduced that would achieve the resolutions stated aims, short of banning midwives or anyone else from attending a woman in labour at home.
From Susanne:
"are these doctors making a mistake"
They are making a mistake. Obstetric textbooks are clear on this point.>>
This is a pet peeve of mine as well - to revise a due date based on a 3rd trim scan. Amy, why do you think doctors do this? It really is more widespread than one might hope. (And yes, the OB textbooks do make it clear that it's not the right practice.)
From Miss Belle:
Susanne,
It's a huge pet peeve of mine but I don't see it as doc who revise the due date. The woman gets the 3rd trimester scan for whatever indication and it is usually ( where I work ) that the machine spits out a new due date and the tech who ignorantly tells the woman this date. Since babies are so often larger than average the new date is sooner and the mom latches onto that date and won't let go. I have explained it so many times to mothers but they really want to believe their due date is a little sooner because they want it to be true. But I actually have not seen an OB actually change the due date on the prenatal based on the scan. This is in my region. I think the techs need the education not to tell that false date to the mother. The only time it is helpful at all ( and not VERY helpful at that ) is with a woman with no prenatal care who comes in in labor...even so it is very inaccurate and I think a Dubowitz is a better assessment of maturity after a birth with no prenatal care.
From Alexis:
Well, given that 50% of babies will be larger than average....
From newhere:
"It's exactly this "hair splitting" and the complete inability to give credit where it's due ( except to me; LOL, and thank you ) that I think creates the difficulty women have accepting your information; its the packaging, frankly."
I couldn't agree more.
I first started reading this blog a few weeks ago and will admit, I have learned quite a bit about homebirth that I didn't know before. I wouldn't say it's changed my stance that all women deserve a choice in their birth options/locations, but I will say I have learned a thing or two, which I believe is a good thing.
However-if the intent of this blog is to convince women that might be contemplating a homebirth to think again, I'm not sure it's going to achieve that goal based on some of the posts of late.
Using MDC as a barometer of homebirth is a big mistake. The vast majority of women over there take massive risk and absolutely DO NOT represent most women seeking alternatives in birth.
Additionally, pigeon-holing every women that chooses something other than IV/EFM/Epidural/Pitocin/etc, even in a HOSPITAL setting is going to turn off a lot of people. Not every woman that questions or challenges her doctor is uninformed and stupid. Nor does she "not understand clinical or scientific information." It's the black/white labeling that is so troubling to me.
I cited my own example of my son ending up in the NICU for 12 hours as a result of a hospital policy that couldn't be changed-even though my OB and nurses didn't feel he needed that level of care. $8000 was spent to observe him. In an era of rising healthcare costs, a growing uninsured population, and Medicaid programs stretched to the limit, how in the world is that prudent use of scarce healthcare dollars?
This example is exactly why women look for alternatives.
On the use of epidurals and c-sections-I don't believe any woman should undergo pain if they don't want too. I also don't think women should be forced to VBAC of they don't feel comfortable doing so. However, many women are not educated by their healthcare providers that not having an epidural or a repeat c-section is even option. You talk about informed consent, but epidurals and c-sections are such common practice now that women don't know there are other options. There are many hospitals around here that offer VBAC and their success rates are pretty good. However, most women you meet on the street that had a primary c-section will tell you their only choice is a repeat c-section.
If women want epidurals they should have access-no question. But why is so strange and weird to OBs that some women wouldn't want them? I found the IV sticks and sitting through the contractions to get the epidural in much more painful then just going through labor and having the baby. I've done it both ways and prefer to do it without drugs. Why can't that choice be supported by the medical community? Don't tell me it is, because it's not. I had to research hospitals that were friendly to unmedicated births because it's known around here that some hospitals will make life quite miserable for you if you don't get an epidural.
Now I'm sure the response to this will be "this is ancedotal, show me the evidence hospitals treat women differently depending on their choices" and you know what, I can't show you that. No one has studied it. And why would they? What could come of it? There is the Mothers survey that is often quoted here but that is satisfaction, not a true representation of how women are treated across various institutions in this country.
Women make decisions based on evidence, fact, emotion, popular culture, family influence, friend influence, the list goes on. So if your goal is to reach those women that might be contemplating homebirth then you need to revise your packaging because all you are doing is reinforcing why women opt out of the system. Recently this blog has been downright nasty and that's truly unfortunate and ultimately going to drive away the very population you are attempting to sway.
From Li:
I suspect that some OB's prefer women to get epidurals because women who are in severe pain are harder to manage as patients. I had an epidural and when I got to the pushing stage it was removed and a (morphine?) drip put in, so I was able to feel the baby as he moved through the birth canal. I told the OB, "Wow, that hurts." She replied, "This is the point where women who haven't had the epidural are screaming." I'm guessing that a screaming patient is a lot less pleasant to deal with.
None of this is a justification for pressuring women to have an epidural, btw. If a woman wants an unmedicated birth, her wishes should be respected.
From Alexis:
So, what IS the point of the legislation if it's not to restrict the availability of home birth? (Notice I don't say ban, since you can't really ban it.)
Preventing women from having a skilled attendant present is not the solution to the problem. If it were just about keeping out unskilled DEMs, ACOG/AMA would not also prevent CNMs from attending home births. I think ACOG and the AMA have scored an own goal with this approach. Trying to force a woman to give birth in the hospital by only offering her the choice of UC or hospital is not going to work. It increases suspicion of ACOG/AMA's motives, and it does nothing to address real concerns that pregnant women have.
From Susanne:
"I suspect that some OB's prefer women to get epidurals because women who are in severe pain are harder to manage as patients."
I suspect that some OB's and L&D nurses prefer women to get epidurals because kind people don't like to see others in pain if it can easily and safely be avoided.
From Alexis:
They're not the ones in pain, though. If the woman wants to be in pain, that's her choice. The OB shouldn't need to have an opinion or push his POV one way or the other. (Same argument often used against NCBers.)
From Alexis:
BTW, navelgazing midwife has a good post on what hospitals need to do if they want a constructive method of discouraging women from home birth:
http://observantmidwife.blogspot...resolve-
to.html
I think she draws on an important distinction between a desire for a "birth experience" and the desire to be treated with compassion, as an intelligent individual who is capable of making informed decisions.
From Li:
I had a weird experience today. I went to see my OB-gyn, who as it turns out is on a reality TV show. I've never seen it because I don't have cable TV, so I googled the show and found a bunch of blog posts from NCB advocates excoriating the show and blasting her for being an evil interventionist, greedy, only interested in getting home on time, etc. I got really angry because she is a warm, caring and competent doctor, one of the best practicing in our city. She absolutely does not fit the stereotype of the greedy OB who wants to do c/s so she can go play golf. The attitude seems to be "all doctors are evil, all interventions are evil."
BTW, Susanne, I agree with you that interventions is a loaded word. What we're really talking about are medical treatments, so why not call them that?
From Susanne:
Alexis: "They're not the ones in pain, though. If the woman wants to be in pain, that's her choice. The OB shouldn't need to have an opinion or push his POV one way or the other. (Same argument often used against NCBers.)"
I agree with you that the OB shouldn't have a preference one way or the other (aside from medical considerations, of course).
From Li:
Alexis, I read that post and while I like a lot of what NGM says, I'm rolling my eyes right now:
"Stop de-personalizing women by putting them all in hideous hospital gowns."
Most women do not give a shit what they're wearing in the hospital. Anything of your own will have to be thrown away after the birth, so why not wear a hospital gown?
"Stop calling women “Momma,” “Mom,” “Mother,” and use her name."
Plenty of doulas and midwives also call women Momma. And really, is being called Momma such a tragedy? Big whoop.
"Since birth plans are so similar, perhaps listening to what the majority of them ask for would be prudent."
Interesting that birth plans are supposed to communicate what you want as an individual, yet they are so similar. Why is that?
"Stop offering medications when women ask for them not to be mentioned."
This goes to Susanne's point above. Plus, you can say no.
"Stop using your status as a means to manipulate or lie to women when they ask you questions."
What evidence does she have that large numbers of doctors are lying to women?
"Find a way to open your hearts to the pain and sadness in women whose births don’t go the way they expected."
My OB delivered her baby at 30 weeks, so when I was having contractions at 28 weeks, she was extremely sympathetic and empathetic. Why assume that doctors don't open their hearts?
"Demand more (compassionately-trained) nursing staff in Labor & Delivery units."
Again, the assumption that nurses aren't compassionate. Wonder how the nurses who post here feel about that?
"Remember that birth is unpredictable."
Because OB's have never had any experiences to teach them that birth is unpredictable. Oy.
From Alexis:
I certainly don't wish to be called mama by my midwife, doula, or indeed anyone other than my daughter (my husband can get away with it if she's present). I have a name. Please use it.
I don't think she's making a blanket statement about all OBs or all nurses. But it is true that SOME L&D nurses are rude and unhelpful, and given the role they play, a lousy nurse is a potential major problem.
If you've offered the epidural and it's been refused, you don't need to keep asking. It's annoying, and makes the patient feel like they weren't listened to the first half a dozen times. I don't think NGM is saying never offer; I think she's saying "if the patient says no, believe her! if she wants it she can change her mind." There are nurses and hospitals that really push the epidural, and it's not just because they don't like seeing women in pain. You don't get a 95% epidural rate without pushing, and one hospital I know of with such a rate also has an extraordinarily high number of births so that's not what's skewing the figures.
Doctors do sometimes use their status as a way of being patronizing and avoiding having to explain themselves. Had it happen myself. As far as I know, there is no test in medical school for "people skills". (I always remember my old pediatrician, who was apparently a superb clinician, but regularly made children cry. To this day I do not know what made him choose pediatrics.)
As for birth plans, I think that it's simply that the women who have them tend to be similar. What they want is usually a common set of non-standard things, many of which are easily achievable.
From Amy Tuteur, MD:
newhere:
"However-if the intent of this blog is to convince women that might be contemplating a homebirth to think again, I'm not sure it's going to achieve that goal based on some of the posts of late."
The people who post are only a very small fraction of the people who read the blog. I get a lot of positive feedback privately.
"Using MDC as a barometer of homebirth is a big mistake. The vast majority of women over there take massive risk and absolutely DO NOT represent most women seeking alternatives in birth."
I used to think that, too, but I've come to understand that since homebirth is chosen by such a small number of women, MDC members represent a large proportion of women choosing homebirth.
From Li:
"You don't get a 95% epidural rate without pushing."
What's the percentage of people who get anesthesia for dental surgery? I'm guessing it's at least as high as the numer of women getting epidurals. Would you say dentists are "pushing" novacaine?
"As far as I know, there is no test in medical school for "people skills"."
There are now classes specifically to teach med students how to communication with patients, though I agree that more can be done to improve those skills. As for mean nurses, IME nurses are often the most compassionate people you'll meet at a hospital. I work at a hospital and former patients weep when they talk about how compassionate their nurses were. I don't know why the evil nurse stereotype comes up in OB.
"As for birth plans, I think that it's simply that the women who have them tend to be similar."
I think it's that within a certain cultural and educational class, there's a rigidly defined "right" way to birth, which is why the birth plans are so similar.
From Susanne:
Li: "You don't get a 95% epidural rate without pushing." "What's the percentage of people who get anesthesia for dental surgery? I'm guessing it's at least as high as the numer of women getting epidurals. Would you say dentists are "pushing" novacaine?"
Exactly. Jenn's ingoing assumption is that a 95% epidural rate at a given hospital is "bad." If it truly reflects women's preferences (and anyone who deals with mainstream American women knows that interest in unmedicated childbirth is fairly limited), then what's so bad about a 95% epidural rate?
YK, at least with CS, one can say that a 95% CS rate would be a Bad Thing. What's the difference in a world with 5% epidurals / 95% not, and a world with 95% epidurals / 5% not? It seems about as meaningless as whether ice cream sales are 5% choc / 95% vanilla or 95% choc / 5% vanilla. What is inherently superior about a low epidural rate, Jenn?
From Alexis:
It wasn't Jenn, it was me. My (completely anecdotal) experience is that there's usually a group of women who don't want an epidural for whatever reason, and this normally exceeds 5%. When you consider that you always have labors where the mother shows up pushing, a 95%+ rate means that nearly every woman who could have one, did.
More importantly, in the hospitals that do have such high rates, women tend to report that the doctors and nurses are aggressive in pushing an epidural. It also tends to indicate that the hospital in question is not big on other methods of pain relief. This is something which is not necessarily negative in itself, but would be for a woman who preferred those techniques.
So I don't regard a high epidural rate as a problem in and of itself. If it were truly indicative of women's desires, then that would just be something I'd have to suck up. However, based on what I've seen and heard, epidural rates exceeding 90% tend to have other causes as well.
From Susanne:
Sorry, Alexis and Jenn, for the misattribute.
From 5in9years:
"I suspect that some OB's prefer women to get epidurals because women who are in severe pain are harder to manage as patients."
I suspect that some OB's and L&D nurses prefer women to get epidurals because kind people don't like to see others in pain if it can easily and safely be avoided.
Both of you are correct. Pushing a woman to have an epidural she does not want for the caregiver's own comfort, however well intentioned, still violates the right to self determination.
From Susanne:
No one disagrees with that last point.
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