MA looks to set up new rules for home births

[Austin]

The prevailing problem with OB-attended births in the U.S. is not that OBs and their nurses are assholes, although the pitocin-punishers do exist. It's that they are ignorant. Dangerously so.

This problem stems from the medical model of birth vs. the midwifery model of birth.

The midwifery model--which, BTW, used to be the medical model back when GPs attended births at home--assumes that the overwhelming majority of women and fetuses are fit for labor without intervention. Fat women. Small women. Women over age 30, or 35, or 37. Teenaged women. Twin fetuses. Fetuses that don't settle low in the pelvis several weeks before the EDD. Fetuses larger or smaller than average. Fetuses that don't trip the labor process until the end of the EDD bell curve. All of these categories come in for intervention under the medical model simply because they are who they are, before there is any sign whatsoever that mother or fetus is in medical distress. The medical model assumes that all women and fetuses are a hairsbreadth away from danger at all times and must be "delivered" from being not like the ideal in the textbooks. OBs and nurses who don't act like this are bucking the overwhelming trend. Remember that obstetrics used to be the branch of medicine that dealt with labors that really had gone wrong. When all you have is a hammer . . .

The midwifery model also assumes that normal labor can exhibit an enormous range of variations that are cues for intervention under the medical model. Women can fall asleep in labor; labor can start, stop, and restart; labor can stall due to the mother being scared, cold, or intruded on by strangers; labor can be "precipitous" and still be perfectly okay (I had two of those); labor can start well after the EDD and if there is no sign that the mother and baby are actually in danger--a real, tangible, physical sign, not just the date on the calendar--that's okay too. The midwife's job is to be the spotter, stepping in when labor does depart from this normal course and staying the hell out of the way the rest of the time. And the midwife's first response is to guide the labor back into this broad channel of normalcy--not decide to depart from it entirely and extract the baby some other way. The real emergencies--a transverse lay that won't shift, for example--are the OB's business, of course, and also there are lousy midwives who are worse than no help at all, but that doesn't invalidate the model.

Finally, the medical model ossified when most women were knocked out, manipulated physically while unconscious and supine, and handed a baby after they woke up. So the idea that the woman is conscious, even mentally competent to make decisions, and not only able to move around but probably better off doing so--many OBs treat this as crazy talk. The midwifery model encourages women to assume the positions that seem best to them because they are laboring the baby out. The midwifery model adjusts monitoring to the need of the mother for unrestricted movement and comfortable positions. And midwives, the overwhelming majority, do not strip a woman's membranes without telling or asking, or cut an episiotomy while the woman is shouting "I do not consent," or tell women that they are too stupid or incompetent to understand the process of labor. Again, the woman is the person doing the work; the birth attendant stays out of the way.

The midwifery model is also called "evidence-based care." Midwives present evidence gathered from attending hundreds of births; OBs dismiss it because midwives don't have the right letters after their names, so evidently they don't know what they are talking about. Not all OBs. But that is the overwhelming trend.

Well, I see you are on the extreme side of things because you seem to imply that all medical professionals who tend to women during deliveries are dangerously ignorant (I note that you did not say "some"). So I now realize that no matter how many women tell you that their hospital births were perfectly fine, you won't believe them because you KNOW that doctors and nurses are dangerously ignorant. I guess we weren't there and our experiences are not equally as valid as yours. Whatever - I try not to argue with extremists as it's rarely productive, so adios.

[valsa]

"I am the nurse. I don't like your attitude. I am going to punish you by turning up the pitocin. Even if you are saying no."

While this might happen once in awhile, unless that nurse has a doctor's order allowing her to turn on the pit rate, she cannot do it. Just remember, even if something looks a certain way to the patient ("my nurse doesn't like me so she turned up my pit"), there's usually a lot going on behind the scenes that the patient never even knows about.

[lilah]

IME, what women whine about is:

"I am the OB. I don't want to wait around for you to go into labor naturally because I have other things to do, so I will make up some nonsensical reason to induce. Or, my education was so lousy that I don't realize that the estimated due date has the word "estimate" in there, and I will actually panic if your labor doesn't begin "on schedule." Or I will declare from your ultrasound that your baby is 'too big.' In any case, induction time! Oh, your body is 'failing' to produce the baby on my schedule? And now it's time for a C-section? And the baby turns out to be small and premature? :hand: You have a healthy baby! And once the surgical wounds heal, you'll be a healthy mom!"

"I am the OB. I am such a control freak that the possibility of having to stitch an irregular perineal tear frightens me. So I will cut an episiotomy so that I can be sure of stitching a nice straight surgical wound. Even though you might not tear at all if I just back off. Even though you are shouting 'I do not consent.' "

"I am the nurse. I don't like your attitude. I am going to punish you by turning up the pitocin. Even if you are saying no."

My OB/GYN has stopped delivering babies b/c her insurance premiums had gone thru the roof

I know of at least two OB's who did this because they couldn't afford to pay their malpractice insurance. And a third who wanted to leave his practice and move to a different state but couldn't because his tail (the money paid to his malpractice to cover any suits potential that followed him living the state) was too high.

I would argue again that most OBs are not evil control freak snidely whiplashes twirling their mustaches. They want to do right by their patients, both mother and baby. But as long as they are paying through the nose for malpractice they are going to practice a lot of defense medicine to ensure that they don't get sued for malpractice. I'd argue again and again that a lot of the reasons why midwives can practice more evidence based care is because they don't have sky-high malpractice issuance to cover. Obstetrics isn't the only medical field where doctors don't follow evidence based medicine because of fears of being sued but it certainly one where the patients have been able to find another game in town.

[emmiedahl]

This is one I hear a lot: "Evil doctor told me he wanted to do a c-section because I had a one out of three chance of developing whatever life-threatening complication. So I gave birth at home and nothing happened. He lied to me!"

No, you came out lucky in the gamble. You gambled your child's life and won. It doesn't mean the doctor knew nothing or was an asshole, it means you were lucky.

[nutella addict]

I agree that people can be extreme on one side or the other, and I think it is incredibly frustrating for those women who are forced into medical interventions that may not be necessary, even given malpractice concerns, although of course I haven't had any kids, so I can't share my own story. However, a woman I know was telling us about her pregnancy and digressed to talking about a friend. Said friend (in Canada, if anyone's curious), required a c-section for her first baby, and was then told that VBACs were not allowed and neither was a 4th c-section, so even though she and her husband wanted four kids, they would have to have three (well, yes, they could adopt and all, but that's a different discussion). Now, considering that I was a c-section, and my 15-months-younger sister was a VBAC, I thought this was rather extreme on the part of the doctors. I then looked into it, and the general consensus I found (no, I can't remember the medical papers now, this was over a year ago), was that an ultrasound should be done to make sure that the uterus was not thinned because of the c-section, and if not, then a VBAC is actually the safer option. I don't know how many doctors actually weigh the risks, rather than jumping to a c-section, but I think that a lot of people who are wary of hospital births might be more open to medical intervention if the doctor had the time to clearly state the risks and benefits of each, and if he/she were to actually weigh them him/herself. I don't actually know the numbers of scalpel-ready doctors vs willing-to-try doctors, but I reckon everyone would benefit if each mother was taken as an individual, case-by-case basis.

I also don't think that anyone should take away the rights for women to have a home birth, although I do think it's very wise to be ready/able to transfer to the hospital if necessary, and to have at least someone properly trained (not a friend or a lay midwife) around for the birth, and also for the women to listen to the doctor recommendations during their prenatal care. Surely then if the women would rather be comfortably at home, at least they're reasonably safe.

And I do feel like c-section risks are de-emphasized. Women can just as easily die from a blood clot caused by the surgery as they can by complications in delivery. Rather than extremely sticking to one side or the other, I wish people would weigh evidence and risks for both sides.

[lizzy]

It all boils down to money.

Hospitals don't like natural births because there is less money they can bill insurance providers for. IVs, pitocin, c-sections, episiotomies, all those interventions spell cha-ching. Plus, there is the fact that medical assisted births go a lot faster than normal births in the main, so that way they can get women in and out quickly and the next patient in.

That said, there are genuine reasons women should be given interventions. Pre-eclampsia, unresolved breach presentations, plevis deformaties, etc. all are legitimate reasons for medical assistance. But keep in mind that the vast majority of the women on this planet has non-medical assisted births and the death rate is really not that high. The United States is in the global minority, including most first world industrialized countries, where a doctor assisted birth is the primary method.

In any case, it is good that women who do plan a home birth (and not a last second one like Josh/Anna) should have a plan in place if something goes wrong. Furthermore, I do believe that midwives should be adequately trained and licensed so that they are better able to recognize these situations.

[formergothardite]

Isn't the Business of Being Born the movie that has Dr. Odent in it and he claimed women who had c-sections didn't really bond and love their babies like women who had natural births did? And also that men shouldn't be present during births (except him of course)?

This guy:

http://www.thecowgoddess.com/michel-odent/

[fundiefan]

I really am glad that giving birth has never been part of my life and never will be.

It's enough of an emotional roller coaster for most mothers to make life affecting decisions, even in the best of circumstances. To be fed worst case scenario stories, medical system conspiracies, and everything else that comes into these types of 'arguments' is, to me, a total and complete disservice to woman and to those in the business of caring for women.

[TVR]

Although I'm very very pro homebirth for those who are not high risk and although I have some reservations and issues with how some medical practitioners view and deal with birth, I did not enjoy the Business of Being Born. I didn't find it factual enough and I found it was very emotionally loaded.

[valsa]

But keep in mind that the vast majority of the women on this planet has non-medical assisted births and the death rate is really not that high.

You have got to be kidding me. You do realize that dying in childbirth used to be not all that uncommon, right? In some places in the developing world, today, the lifetime risk of dying is childbirth is as high as 1 in 14 women.

Yes, it's true that the United States has some twisted views when it comes to pregnancy and childbirth and it could stand to do things differently. However, childbirth is, and has always been, a risky undertaking.

[TVR]

Lizzy, have you ever seen how women in some of those countries birth? It is not a joke and I can assure you that the romantizing of childbirth and attachment parenting in places like Africa really is not okay.

[Deleted03]

Well, I see you are on the extreme side of things because you seem to imply that all medical professionals who tend to women during deliveries are dangerously ignorant (I note that you did not say "some"). So I now realize that no matter how many women tell you that their hospital births were perfectly fine, you won't believe them because you KNOW that doctors and nurses are dangerously ignorant. I guess we weren't there and our experiences are not equally as valid as yours. Whatever - I try not to argue with extremists as it's rarely productive, so adios.

Austin, I read this differently: the system in itself leads to some doctors taking it the extreme way. So yes some doctors can be more thoughtful or even present ideas that most midwives would agree on, but historically what has been described is true. I really think the homebirth movement made a lot of progress in the last decade in particular. But you still have old school doctors - old school insurance companies - old school professor. Things are changing, I am sure it's unequal depending on the geographical area, and not all women have the luxury to go somewhere else.

There are many examples of patients being treated unfairly - I know one woman whose nurse just plain refused to tell her how many stitches she got. What do you do? Your husband's working, you're exhausted, and the only thing you want is to finally go home... The main point of the homebirths advocate is that you are not necessarily in a state to argue about you want to be treated hence the birthplans. I'm sure some hospitals have teams of better doctors, just like some doctors are more friendly than others, some doctors are more understanding, some are more attached to regulatory codes, etc.

Anyway just to say that I don't think the profession in itself is the one that is denounced, but the system of knowledge that is associated with it, is.

[Childless]

My hospital experience was just fine. I went overdue and was then given the choice whether to jump start labor with pitocin (which I did). I pretty much labored without being bothered. The doc came in to check my dilation 3 times and every once in a while a nurse would come in, look at the baby's heart rate and ask me if I needed anything. That's about it. When it came time to push, I did so for 3 hours with no progress (he was sunny side up and caught on my pelvic bone). They gave me the choice to either keep going, use the vacuum to get him out, or do a c-section. We asked the doc's opinion, and he voted for c-section based on what he saw and how the delivery had gone thus far. We decided to go with the c-section. We were in no way forced to make that decision and the doctor never even offered an opinion until he was asked. And you know what? He was right. Once they got me open, it was clear that he was so jammed in there that he was never coming out vaginally. When they doctor pulled him out, there was an actual sucking sound and pop as his head disengaged from my pelvis.

I was so happy that I chose to go ahead with the c-section. My son's life would have been in danger if I had kept going. As it was, he had a bruise that spanned his entire forehead, a black eye, a bruise on his cheek, and an open sore on the back of his head. He looked like he'd been in a bar fight. If you so much as brushed a finger across his forehead for the three days following the delivery, he would scream because it hurt. My husband and I are planning on trying for another child soon. When I do have that child, I will have a scheduled c-section. I cannot put another baby through what my son went through. I know he won't remember any of it, but I just can't do it. Furthermore, he's currently in orthotic equipment to correct an issue that stemmed from the difficult delivery. So, nope. No more vaginal deliveries for me and I'm neither upset nor ashamed of that fact.

[valsa]

As it was, he had a bruise that spanned his entire forehead, a black eye, a bruise on his cheek, and an open sore on the back of his head. He looked like he'd been in a bar fight.

What your poor little guy went through reminded me of something else. Even the women in developing countries who are lucky enough to not have serious, life-threatening complications can still have to deal with long-term, less serious complications like fistulas (which result from the baby being in the birth canal too long and putting pressure on the tissue there, which blocks blood flow to said tissue and makes it break down) This, in turn, leads to problems like incontinence and infections (ususally from fecal matter getting into the vagina)

[Black Aliss]

It depends on a lot of things, including the type of c-section, the conditions under which it was performed like what happened to necessitate it, the conditions of the current pregnancy, etc. There are so many variables that I would find a doctor I trust and ask their personal opinion on it.

One reason that many doctors and hospitals are against VBACs in many cases is because of insurance. If insurance has to pay out enough money for adverse events, they will start asking for changes in policy. Thank your local malpractice lawyer for that one. The doctors and hospitals have their hands tied. If you perform a somewhat risky procedure at the mother's insistence and it goes bad, then she will sue you.

The risk I think is 7 or 8 out of 1000. That is huge if we are talking about my life and my baby.

And you are absolutely right to make the decision NOT to have a home VBAC. For yourself, that is. For other women, well, a certified nurse-midwife IS a trained medical professional and is capable of recognizing and addressing the risks of VBAC as well as a bunch of other risk factors. A competent nurse-midwife will recognize complications before they become life-threatening and arrange for transport to hospital. After all, how many obstetricians sit with their patient through active labor. More typically, they show up when it's time to catch the baby, or perform a caesarian.

[valsa]

For other women, well, a certified nurse-midwife IS a trained medical professional and is capable of recognizing and addressing the risks of VBAC as well as a bunch of other risk factors. A competent nurse-midwife will recognize complications before they become life-threatening and arrange for transport to hospital. After all, how many obstetricians sit with their patient through active labor. More typically, they show up when it's time to catch the baby, or perform a caesarian.

The problem is that not all women go to a certified nurse-midwife. Bills like the one in the original post seem to formalize the requirement for competent midwives.

[Kaylee]

The problem is that not all women go to a certified nurse-midwife. Bills like the one in the original post seem to formalize the requirement for competent midwives.

Not really, the just tend to make it harder for some women to birth at home with competent midwives (I would say or doctors, but I don't know of any OBs whose insurance would allow them to do home births, even if they wanted to). So, it increases that chances that women who choose to give birth at home will have to take the risk of hiring a somewhat anonymous and almost certainly unlicensed "midwife" for the birth or going for an unassisted birth, perhaps relying on internet sources like Candy's homebirth e-book.

[valsa]

Not really, the just tend to make it harder for some women to birth at home with competent midwives (I would say or doctors, but I don't know of any OBs whose insurance would allow them to do home births, even if they wanted to). So, it increases that chances that women who choose to give birth at home will have to take the risk of hiring a somewhat anonymous and almost certainly unlicensed "midwife" for the birth or going for an unassisted birth, perhaps relying on internet sources like Candy's homebirth e-book.

Since I don't know much about bills like this, would you mind explaining how so? The article mentioned that midwives would have to be certified and the bill would require a certain level of training. I'm having a hard time seeing how that would be a bad thing.

[treemom]

I don't think regulation of midwifery standards from within their groups, or through the law, or indirectly from high insurance costs, takes away the right to home birth.

+1

Regulation is not some secret thing that strips away rights

[treemom]

There absolutely is a middle ground. You just don't hear about those middle-ground births because there is nothing exciting, risky or controversial about them.

Unfortunately, the fact that the medical establishment insists on the extreme of interevened birth in virtually all cases (if they have the opportunity) forces some people out of the middle ground into the extreme.

Don't you think you sound like someone who is being extremely hyperbolic. I know lots of women. And no, not virtually all of those cases have the extreme of intervened birth

[Kaylee]

Since I don't know much about bills like this, would you mind explaining how so? The article mentioned that midwives would have to be certified and the bill would require a certain level of training. I'm having a hard time seeing how that would be a bad thing.

I would have to read the whole bill to compare it to the situations I'm familiar with. In North Carolina, the licensing required is pretty specific, and midwives practicing under that license must be working under an OB. That seems to be typical of state regulations, and of many licensing standards. The problem is that it can create issues with the OB's insurance which result in home births not being allowed to be attended by the certified/licensed midwives. Since many women do still want to birth at home, what happens is a midwifery system divided between licensed/certified/legal midwives that do hospital births and unlicensed/underground midwives that do home births. Hopefully, the law will be structured to avoid that problem, but it is what similar laws in other states have resulted in.

[aelar]

I think I've mentioned before that I just recently gave birth, and my insurance/hospital system is Kaiser, which to me does a pretty good job of straddling the patient safety/patient autonomy line.

No routine interventions, no predetermined timeline for labor, no scheduled c-sections for non-medical reasons, VBAC is supported as long as there aren't serious additional risk factors, certified nurse midwives are available in some hospitals (I chose to labor at a hospital with midwives).

Everyone is given the opportunity, during prenatal care and again when they come in for labor, to specify their wishes on a standard birth plan. The birth plan form includes things like whether you want to be offered pain medication, whether you want everything explained to you before it is done or not (I guess some women just want the medical staff to 'handle it'), how you want to labor (if walking around, trying natural methods first, etc. is important to you, if pain management is your priority, etc.), whether you want your baby to get the HepB vaccination or not, and even whether you want them to wash your baby before you hold her or not (they are pretty messy, but I took her with cord still attached, slime and all).

Unless there is a medical reason, babies never leave the moms, especially not during the first couple hours (I was in the hospital two days and the only time my daughter left my sight was five minutes for her hearing test), and breastfeeding is so encouraged it's almost oppressive.

All that said, I still had to be my own advocate, and have my husband and best friend be my advocates when I couldn't, to ensure that I got as close to the experience I wanted as was medically feasible. I think this is normal, if you aren't willing to educate yourself, and speak for yourself, then of course the medical staff is going to use their judgment, what else do they have to go on.

I wanted as close to the crunchy natural experience as I could get while being in a hospital setting (unwilling to risk harm to my child with a non-hospital birth) but I developed pre-eclampsia right at the end of my pregnancy, 37 weeks, basically went in for a non-stress test because I had a lot of swelling and my labs were looking a little sketchy, and ended up with the staff wanting to induce me right that day. But because I had studied up on pre-E, I was able to take my bad lab results, and put them in perspective, and decide that the stress of rushing into an induction would be more of a risk to me (baby was perfectly fine) than waiting a little while, and getting myself psychologically prepared to deliver early. The doctors weren't happy that I decided to ignore their recommendation, but I got sent home with a blood pressure monitor, and came back in a couple days for more tests, and at that point, calmer and ready, and with my results still not great, agreed to an induction.

During the induction process, my experience was that I was given the minimum amount of intervention at each stage, and while when I first went in the doctors warned me that I would probably be stuck in bed, laboring on my back, on magnesium, they took things slow, and I ended up with some medical help to get the contractions started, and I had to stay in bed a lot to keep my blood pressure down, but I was allowed to move around once active labor started, find good positions to labor in, and push squatting, and even got to have a midwife deliver me, with no episiotomy, no pitocin, no magnesium, and only a dose of pain meds to take the edge off and keep my BP from spiking too high. We did switch at one point to an internal fetal monitor, because that way they could keep an eye on my baby, and not do more interventions on me when they weren't needed to keep her safe. I didn't even notice, honestly, and it didn't hurt her at all. And the important thing is that I had a healthy baby, I had a safe delivery, and my experience after the birth was supportive of bonding with my baby too.

TLDR: There are reasons for interventions, and interventions do tend to lead to more interventions, but it doesn't have to become a roller coaster that ends in c-section. The trend toward more natural childbirth, midwives, labor as normal, not medicalized, is a really great thing, and -some hospital systems have listened-. It doesn't have to be homebirth or c-section, there are a lot of gradations of experience, even for someone like me that had complications and would not have been safe to labor at home. Don't assume the doctors and hospitals in your area are backward and paternalistic, I know Kaiser has improved dramatically over the last few years, and some hospitals are crunchier than others. If you can't find someone who will listen and work with you, then investigate other options, but remember that no one can guarantee your birth experience.