About the Ann Althouse Blog
"Formidable law blogger Ann Althouse." – Slate
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Comments below are in reply to and cross talk to a blog by Ann Althouse, in which she comments on the NY Times article on the arrest and prosecution of Indiana midwife Jennifer Williams, CPM.

NY Times story on Indiana prosecution of home birth midwife

Link to Ann Althouse Blog, midwife topic    Link to Ann Althouse Blog, NIH topic

Background info on CEO web site.  Link to "California Standard of Care for Licensed Midwives

Reply    #1 faith     #2 Elfanie    #3 Cherrie      #4 faith      #5 Cherrie     #6 Ann Althouse

#7 faith   #8 Jennifer    #9 haloJonesFan    #10 Cherrie   #11 Cherrie    #12 Cherrie     

#13 haloJonesFan   #14 Cherrie   #15  faith 

Ms Althouse's blog was dated for April 3, 2006 at 8:48 AM 58 comments

"It was the most cozy, lovely, lush experience."

That's a description of childbirth, accomplished at home, by candlelight, with the help of a midwife. It's pretty when it's pretty, but what if the baby dies, and it wouldn't have died in the hospital?

What a vaginal birth does to a baby's head -- if you did anything like that to your child after it was born -- with your hands, I mean, not your vagina -- it would be horrific child abuse. You can say it's "natural" -- but it's an extreme thing to do to a baby and it can cause permanent damage. To treat it as a spiritual experience for the adults is creepy.

Every birth is a potential disaster! So is every car trip. Lots of us assume we will be lucky, especially when the odds are in our favor. That's why when we lose we say "Why me?" We rarely think to say "Why not me?"

The question is whether the state ought to save us -- and our children -- from our relentless optimism.


April 3, 2006 faith gibson said ... 

re: The question is whether the state ought to save us -- and our children -- from our relentless optimism.

I started my professional life relentlessly optimistic about the benefits of hospital-based medical care for normal childbirth.  I was an L&D nurse in a big busy hospital and it was a fact of everyday life that complications could and did suddenly occur. My opinion about planned home birth mirrored all the derogatory comments read here and elsewhere – mainly that it was “only for idiots”. However, working for two decades in the hospital-based obstetrical system relentlessly stripped me of optimism about ‘modern’ obstetrics. The public’s perception about medicalized childbirth in hospitals is wrong. It is TV obstetrics and not real life.

 After just a few years in a high-volume L&D I began to see the connection between obstetrical interventions routinely applied to healthy laboring woman (70% of all pregnancies) and a steep increase in the need for additional interventions, unexpected complications, operative deliveries and breathing difficulties for the baby. Immobilizing a laboring woman in bed in anti-gravitational positions, hooked up to IVs and electronic fetal monitors, is not a biologically-effective way to facilitate normal childbirth.

I remember only to well racing down the hall with a stretcher, frantically trying to get a patient with a ruptured uterus to the operating room before she died. Eventually an emergency hysterectomy was necessary to save her life. As a young and inexperienced nurse, I initially thought this disaster proved that the biology of normal childbirth was dangerously defective. Afterward the older nurses talked about this ‘accident’ of childbirth, privately admitting among themselves that the Pitocin electively used to speed up her labor is what caused her uterus to rupture. I saw similar situations in which it was the baby who suffered permanent disability. However, all the families would ever learn was that the mother or baby was the victim of a life-threatening obstetrical emergency and that the quick response of the medical team had saved their life. Even though these emergencies were a known side-effect of obstetrical intervention, no acknowledgment of that important fact was made to the family.

I began to wonder if other things that we all took for granted were also causing iatrogenic complications. By paying close attention I soon noticed a direct correlation between the use of drugs and anesthesia and the need for assisted delivery (episiotomy, forceps or Cesarean section). I saw a direct correlation between the use of Pitocin to speed up labor, fetal distress in the baby and excessive maternal bleeding or even hemorrhage after the birth. I also saw a big spike in babies who had trouble breathing when their moms had narcotics during labor or other interventions such prolonged pushing (due to anesthesia) and /or delivery by forceps or C-section. All of these personal observations were also acknowledged in the drug company inserts or confirmed in the scientific literature.

My efforts to change the hospital culture failed miserably so I eventually cross-trained into community-based direct-entry midwifery. Counting my experience in both home and hospital, I have been present at approximately 3,500 births over the 40 years of my professional life. I can testify to the improved safety for both mothers and babies of physiological (vs. medical) management. Physiological management refers to care in accord with, or characteristic of the normal functioning of a living organism”. This non-medical, non-interventive form of care depends on continuous one-to-one social support, ‘patience with nature’, the right use of gravity and a commitment not to disturb the natural process. Presently, physiological management is only available in an out-of-hospital setting and midwives are the only caregivers a mother can turn to for non-interventive maternity care. Planned home birth (PHB) always includes a skilled birth attendant and appropriate access to medical services when indicated or requested by the mother. 

Midwifery as an organized body of knowledge preceded the modern discipline of medicine by more than 5,000 years. Midwifery principles recognized as effective and still valid in our own time were found among ancient Egyptian hieroglyphics dating back to 3,000 BC. Today, physiological management is the scientific backbone or evidence-based model of maternity care used world wide by midwives, except in the US where medicalized care eclipses all else. Physiological management is actually protective for both mothers and babies. Nationally certified direct-entry midwives (CPMs) using physiologic management in a domiciliary setting, reduced the episiotomy / operative delivery rate (and associated complications) from approximately 72% to approximately 5%, with an identical or even slightly improved perinatal mortality rate. It is efficacious -- that is, both safe and cost effective.

Nothing that modern allopathic medicine has to offer – no routine use of drugs or surgical procedures, no electronic devise such as continuous electronic fetal monitoring, no ‘preemptive strike’ such as universal hospitalization or the routine elective use of Cesarean section, has been able to create a system that is better or safer than the routine use physiological management for healthy childbearing women. However, these methods don’t belong to midwives per se. They belong to science and to society, to be used by anyone regardless of professional affiliation, including physicians.  

One must question how the ancient and honorable tradition of midwifery came to be obliterated almost to the vanishing point by the medical profession and then claimed by the medical profession to be an illegal practice of medicine? What brought about the wide-spread but uncritical acceptance of an unscientific method such as interventionist obstetrics for healthy women? In the last 30 years, despite all the new computer technologies and other ‘improvements’ in obstetrical medicine, the cerebral palsy rate has not dropped one itty-bitty, teeny-tiny little smidgen. Zip. Zilch. Nada. Even the American College of Obstetricians and Gynecologists (ACOG) had to admit that electronic fetal monitoring has made no difference in perinatal outcomes but its use does significantly increase the Cesarean section rate. The routine use of the medical model has produced a 31% cesarean rate without any improvement in perinatal outcome for normal pregnancies, while exponentially increasing the rate (3 to 10 times greater) and the severity of medical and surgical interventions visited on these same healthy women.

A survey conducted in 2002 on healthy childbearing women who had given birth in the previous 24 months revealed that 72% of these mothers had some kind of surgical procedure performed during delivery (35% episiotomy, 25% Cesarean section and 12% forceps/vacuum extraction). In spite of this, there is a gathering movement within the obstetrical profession to replace normal birth with a medically unnecessary or “patient choice” Cesarean section as the 21st century ‘standard’ of care. Under these circumstances, women who insisted on having a vaginal birth would be required to sign informed refusal documents, the equivalent of ‘normal birth against medical advice’.   

The medicalization of normal labor triggers a chain of inevitability that starts with the ‘domino-effect’, in which the unintended consequences of routine interventions make childbirth progressively more complex, eventually requiring the use of injurious interventions and sometimes progressing on to serious complications. When injury to mother or baby does occur, the biology of normal birth gets the blame. The complications of these obstetrical interventions are often cited as proof that “I would have died if I hadn’t given birth in the hospital”. This chain of inevitability, multiplied by forth years, has ended in an ever sky-rocking Cesarean section rate, which was a 30% for 2004 and is projected to be 34% by 2006. This is the disheartening background of most midwife/home birth prosecutions, which are inevitably based on medical politics instead of credible scientific evidence.

Like the midwife in the Indiana prosecution, I am a CPM, that is, a nationally certified professional midwife. CPMs are experienced direct-entry midwives who trained directly in midwifery instead of becoming a nurse first or becoming certified as a nurse-midwife. The statistics from the CPM study published in the British Medical Journal (June 2005), include those from my own home-based practice, as well as Indiana CPM Jennifer Williams and 500 other CPMs in the US and Canada . The BMJ study confirmed again the consensus of the scientific literature, which consistently identifies that planned home birth, when compared to hospital-based care for healthy women, is equally safe for the baby and reduces maternal interventions by as much as ten times.

Unlike the recently arrested Indiana midwife, I am also licensed in my state of California but only because mothers and midwives in our state spent 30 years fighting an uphill battle against organized medicine to get midwifery decriminalized. Finally, in 1993, the California Legislature passed the Licensed Midwifery Practice Act. The LMPA officially recognized that the greatest safety for healthy mothers with normal pregnancies is to provide them with access to professionally-trained and licensed midwives. 

In my opinion, the relentless optimism that needs to be addressed in America is not false optimism about normal birth but the unfounded idea that the current obstetrical model is the most appropriate one for healthy childbearing women. Most important, everybody in society, even those who would never use a midwife or plan a home birth, benefits from preserving and promoting physiological management. In a perfect system, medical educators would learn and teach the principles of physiological management to medical students. Practicing physicians would utilize physiological management as the standard of care for healthy childbearing women. Hospital labor & delivery units would be primarily staffed by professional midwives, with incentives for current L&D nurses who wish to retrain as hospital-based midwives to do so at minimal expense to themselves.  This would dramatically reduce rate of injurious interventions and the cost of maternity care while increasing good outcomes and satisfaction of families served.

In a rehabilitated maternity care system, professional midwives, family practice physicians and obstetricians would all enjoy a mutually respectful, non-controversial relationship. Appropriate maternity care would be provided by all three categories of professionals in all three birth settings as appropriate – hospital, home and birth center – without prejudice, controversy or retaliation against the childbearing family or against other care providers. By making maternity care in all settings equally safe and equally satisfactory, families would not be forced to submit to forms of care that are not appropriate for their needs or that waste our economic resources. 

In the meantime, community-based midwifery needs to be legal for both mothers and midwives. If the problem is the law, then the law needs to be changed, as it must be kept in mind that the basic purpose of medical practice legislation is consumer safety, not as a political tool for promoting a medical monopoly. Enforcing medical practice laws in a manner contradictory to common sense and the well being of the public is not in the interest of childbearing families or a civil society.

#2 ~ 4:16 AM, April 06, 2006  elfanie said...

One reason I believe in hospital deliveries is that you never know. One kid I know went into distress during her delivery. It was, of course, picked up immediately on the fetal monitor, and was solved by giving her mother oxygen. If that had not worked, they were ready for a C-section. But in most home deliveries, it would have gone unnoticed, and the baby born with potentially some brain damage. Most likely not noticable, but there.

Ok...first off...you seem to think that homebirths are unmonitored. Homebirth midwives monitor the baby and DO catch the same "distress" that you are referring to.

secondly..you mention that it was "solved" by giving the mother oxygen. Bull. Homebirth midwives carry oxygen - but that in no way saved this baby, I assure you. If the mom's pulse ox was 98-100% (which it almost universally is), what benefit do you think putting oxygen on her did? nothing...just made the mother feel like they were doing something.

you said that if it didn't resolve they would have done a cesarean. Same thing with a homebirth. Something starts to look funky, you transport. Not a big deal.

You don't mention WHY the baby was in distress. Was mom being induced? (not happening at a homebirth) Was her water broken for her? (not happening routinely at a homebirth) Did she have anesthesia - an epidural? (not happening at a homebirth)

You say this baby was at risk...but how do you know that baby wasn't at risk BECAUSE of the hospital and the things we do to to them.
I see a lot of fear of homebirths based on the proverbial "what if"...but I also fear the "what if" of hospitals, since the #1 cause of complications is iatrogenic! We start messing with mom (inducing, strapping to monitors, restricting movement, restricting food/fluids, giving analgesics, giving anesthesia, breaking her water...) and then a complication occurs that wouldn't have otherwise.

THAT is what I think more people should find scary.

#3 ~ 1:46 PM, April 07, 2006 Cherrie said...

Thanks Faith, for a really well thought out post. I appreciate seeing all the accurate info you took the time to write down.

I think it's amazing how we all form such strong opinions on things we know so little about. We can't each be experts in everything, of course. And knowing this, we have to take somebody's word as the expert we choose to believe. Something like childbirth is so socialized, we tend to align our belief system with, say, our sister or neighbor, rather than take the time to educate ourselves. The evidence is out there, folks. But each of us has to choose to dig it up, read it, and then be able to critically examine what that means to us.

The fear about the baby's head being a 'battering ram' originated long ago when mothers were out cold when giving birth. It has long since been proven over and over again that a vaginal birth has many benifits for the baby in prepairing it for those first breaths, and life outside the uterus.

Home or hospital isn't the question so much as what 'style' care your provider is going to give you. Expectant management? Agressive treatment? Defensive Decisions? There are so many decisions in the many months of pregnancy and childbirth, each practitioner has their own paradigm from which they make decisions for your care. And each decision has a big impact on the safety of both mother and child. Each birthing woman and her family should take the time to educate themselves just enough to at LEAST know which style of management they want, and find a provider who'll give it to them.

#4 ~ 3:10 PM, April 07, 2006  faith gibson said...

I am impressed by the thoughtful, informed and informing responses to my April 4th comments. Usually I am talking to myself when addressing any aspect of this unpopular topic. I have to admit that this is the first time I’ve ever posted anything to a blog, as my handlers usually keep me chained up in the basement, nose to the grindstone, and won’t let me ‘waste’ time with such foolishness. But the NYT article on the Indiana midwife had a link to Ann Althouse’s blog and I clicked just to see what it was all about. Imagine my surprise! Cherrie and Elfanie’s replies are so good and worthy of being quoted. So I’m officially asking – may I quote you both?

The actual hot issue of the day is not the prosecuted midwife in Indiana but the draft report by the National Institute of Health subsequent to their “State-of-the-Science Conference on Cesarean Delivery on Maternal Request” (which they kindly reduced to ‘CSMR’ for the keyboard challenged). The conference was held March 27-29 in Bethesda. One of the most interesting aspects is that a government agency officially released a report at 5pm on March 29th, the last day and last minute of a conference. [www.consensus.nih.gov] Obviously, the report had already been written, which means the input of the participants was just a feel good move and window dressing for a predetermined agenda.

The NIH draft report concluded that mothers are demanding C-sections in greater numbers (good data says not true!), which ‘explains’ the 29% percent C-section rate for 2004 (and the projected 33% C-section rate for 2005!). The report went on to infer that there isn’t really any good data to determine if C-sections are better or worse than vaginal birth, but if you’re only planning one or two children, the odds are about even.

The illogical conclusion was that if you want to, go ahead and have all your babies by scheduled C-section (something about consumer convenience and giving mothers ‘control’ over their birth), never mind that it doubles maternal mortality and costs twice as much. Rumor has it that one of the things fueling this conference was a push for a CPT code (Current Procedural Terminology) for patient choice CS. This would permit them to hide a lot of poor obstetrical practices under the banner of women’s reproductive freedom and a woman’s ‘right to choose’. How poetic.

The NIH’s official conclusions are a great way to distract the American public from the real issue, which is physician fear of normal birth, spurred on by lack of education or experience in physiological management of spontaneous labor and birth, hospital policies that make physiologic process hard or impossible for either mother or physician to use in an institution, run away litigation, pressure on doctors from malpractice insurance carriers not to ‘allow’ mothers with VBAC, breech and twin pregnancy to deliver vaginally (docs get a ‘good driver’ discount if they agree) and astronomical malpractice premiums. This is all wrapped up in the notion that Cesareans (referred to as ‘vaginal by-pass surgery') are safer and better than normal birth (referred to as “delivery from below” – uck!). All these spurious ideas come to us courtesy of a dis-information campaign by many spokespersons within the obstetrical profession, who go on the Today show and NRP and assure us that vaginal birth is very bad for the mother’s pelvic floor (under anti-gravitational obstetrical management I agree!) and the baby and that “Cesarean is safer for the baby”.

Mind you, I’m not anti-obstetrician or anti-hospital. I have several physician friends that are obstetricians, even ones that are politically active in ACOG. They are all honest dedicated people. I am however ‘anti’ the politics of organized medicine, which includes methods of mass deception and the ill-informed idea that the best way to prevent complications is the “pre-emptive strike” -- routine use of potentially injurious interventions on healthy women and a form of malpractice insurance referred to by OBs as “when in doubt, cut it out”.

American mothers don’t have a “C-section deficiency”. The most important issue is not maternal choice Cesarean, it is how and why the mismanagement of normal birth has been systemized by the entire obstetrical profession to become the 20th century ‘standard of care’. Abandonment by the medical profession of physiological management in 1910 has brought us, in 2006, to the brink of the “tipping point”. For the lay public, post 9-11 political & economic overload, normal human inertia and the blind spot and prejudiced reporting that the media treats this topic with, combined with the relentless lobbying pressure of ‘special interests’ groups and especially the loss of ‘institutional memory’ within the medical profession for normal birth management, has us tittering on the brink of a precipice. In some ways, the NIH document represents that exact point of the “tip-over” into no man’s land.

The NIH’s went off track because they started with the idea that the ‘normal’ CS rate is and should be one out of three or higher. Since no one can tell which one of the three patients will have a C-section and since the other two mothers will be subjected to so many injurious interventions that the rate of sequelae will be as high as it is for scheduled C-sections, then why shouldn’t we retool the behemoth of obstetrical care into a 9-5 M-F walk in C-section assembly line, which is already how its done in Mexico City (95% CS rate, with surgery scheduled at 15 minute intervals).

Throughout the entire 20th century, organized medicine has been free to build a relentlessly ambitious system to replace normal childbearing with a new and improved version, orchestrated by institutional medicine but never exposed to scientific methods. This unofficial medical experiment required that the principles of physiologic process be ridiculed and discredited and that infrastructure for physiological management dismantled. In the obstetrical model the integrity of childbirth is broken up into two separate sub-systems. Normal labor is conducted as a medical condition managed by nurses (no directly billable units, just routine hospital charges). Normal birth is renamed as the ‘delivery’ and given its own special professional status and economic base. Delivery is considered to be a surgical procedure that can only be ‘performed’ by a physician-surgeon in an institutional setting and which generates an itemized professional fee to be billed on top of normal hospital charges.

After 96 years of this new world order, physiological management has become invisible, a total non-entity (aside from the practice of community midwives) and was of course, missing-in-action in the 2006 NIH scheme of things. The federal government’s rubber stamp for maternal choice cesarean simply gives the obstetrical profession the green light to continue on with business as usual. That business is the death of normal birth via the total replacement of spontaneous vaginal birth with various forms of Pitocin accelerated labors and assisted vaginal delivery under epidural anesthesia and what they'd like us to think of as the Rolls Royce of OB care -- Cesarean surgery. The ultimate goal is the obstetrical dream machine – 9 to 5, Monday thru Friday walk-in assembly line C-section as the 21century standard of care.

The NIH panel did not report anything that is technically in conflict with "the literature" at the most base level of interpretation. Its faults, of which there are many, are subtle instead of simple and easily apparent. What that means is the scientific facts must be explained one by one; those explanations requires several sequential steps, which of course, means the listener has to care enough to pay attention long enough to get the point. The bottom line seems to be that nobody cares enough about this topic to find out the facts and/or knows enough about the issues to hold the obstetrical profession accountable. Like the popular perceptions of Enron and Arthur Anderson, we all just assume that ‘they’ know what they’re doing and of course, ‘they’ have our best interest at heart. I wish it were true.

#5 ~ 6:59 PM, April 07, 2006 Cherrie said...

What that means is the scientific facts must be explained one by one; those explanations requires several sequential steps, which of course, means the listener has to care enough to pay attention long enough to get the point. The bottom line seems to be that nobody cares enough about this topic to find out the facts and/or knows enough about the issues to hold the obstetrical profession accountable. Like the popular perceptions of Enron and Arthur Anderson, we all just assume that ‘they’ know what they’re doing and of course, ‘they’ have our best interest at heart.


#6 ~ 7:25 PM, April 07, 2006 Ann Althouse said...

Faith: We discussed the NIH study here.

Thanks to all who are bringing the pro-midwife perspective.

Personally, I'm skeptical of everyone, not just midwives. Being pregnant is quite a predicament, and you need someone to help you out of that jam. I didn't like anyone I had to deal with. But the reality was, with modern nutrition, the babies' heads were completely out of proportion to the pelvis. I had no real choice.

Good luck to all. I don't have the answer myself, other than to say I'm glad I lived through the supposedly "natural" phenomenon of childbirth. Millions of my sisters did not.

#7 April 9th 2006 - faith said .....@ 3:55am

Ann, thank you for the kind words and the link to your blog on the NIH draft report. I wish I’d read it before my own post; I feel a bit foolish now.

I’d feel even worse if anything I said about the politics of physiological childbearing and the need to reform our national maternity policies that were interpreted by you or your readers as a criticism of your informed choices or birth-related medical necessities. Nor do I mean to ignore real dangers such as maternal mortality. My objection is only to the systemized and often non-consensual use of potentially dangerous drugs, interventions and operative delivery in the absence of a medical necessity, without first employing science-based physiological principles and without first obtaining true informed consent.

I do not mean to cast aspersions on any of the lovely women who require or desire medically appropriate interventions or make light of the ability of modern obstetrics to successfully treat life and limb-threatening complications. My eldest grandson was born by Cesarean. It never occurred to me to judge his mother (my beloved first daughter) based on an accident of biology or the route of delivery.

As a young married woman, I was diagnosed with Stein-Leventhal syndrome (polycystic ovaries). At that time the only treatment required major abdominal surgery. I was and still am eternally grateful to my wonderful OB doctor, who made such an astute diagnosis more than 40 years ago (before modern infertility technologies) and skillfully performed surgery that permitted me to have 3 lovely children and 2 grandchildren. I love obstetricians and continue to grieve that they no longer love me. 

However, I also remember waking up in the recovery room after abdominal surgery, feeling like I had been kicked in the stomach by someone wearing a pair of ice skates, retching and desperately in pain. I pondered long and hard on what such intense pain and prolonged debilitation would be like as a new mother also trying to meet, get to know, breastfeed and care for a newborn. Thus was born my dedication to preventing *unnecessary* cesareans.

I have been an advocate for childbearing women since I was an 18 year old nursing student. I define that as meeting the mother’s practical needs with the right amount and right kind of care – timely, not too little, not too much. I was taught to baby the new mother so that she was empowered to mother the new baby. My entire professional life has been a quest to secure the right of healthy, mentally-competent women to have control over the manner and circumstance of their normal childbirth.

My father, my husband and more recently my son were all in the armed forces, fighting (and risk dying) for our democratic way of life. But despite my ability to vote for the politician of my choice, my mother, myself and now my daughters, did not / do not have the ability to say no to medically unnecessary obstetrical procedures we didn’t want or need. Obstetrical care is often provided on a basis similar to pediatric care, in which the adult experts make the fundamental decisions while the childlike patient is expected to be good and to be grateful.

I know of these realities because I was the labor room nurse who carried out the doctor’s orders and the hospital policies, whether or not the mother wanted or needed or even legally consented. This is still as immutable for the majority of childbearing women in America today as it is for woman living in third world countries who can be forced as children to submit to female circumcision and required as a married woman to submit to unwanted sexual encounters.

Only in America, if a pregnant woman in a hospital should object to a treatment perceived by the staff as ‘necessary’ or refuse to cooperate, the obstetrical version of unwelcome bodily invasion will be accompanied by threats to call a juvenal court judge for a court order. If the baby is already born, the non-compliant mother will be told that if she doesn’t quickly agree to the proposed medical procedure for her newborn, Child Protective Services will be contacted.

Occasionally this is justified for an acting-out teenager on crack cocaine or mentally ill adult woman, but ask around and you will find many reports of being coerced into treatments because mothers couldn’t hold out against the sustained professional pressure or they feared retaliation. The prestigious Maternity Center Association of NYC just published their second “Listening to Mothers Survey” conducted by Harris Interactive of 1,500 healthy women with a single fetus who gave birth in the last 12 months. Only 1 mother identified herself as voluntarily (with true informed consent) choosing an elective Cesarean, but 9% of women described being ‘talked into’ a cesarean which they didn’t believe was medically necessary and didn’t want. (www.maternitywise.org)

True mastery in normal childbirth services means bringing about a good outcome without introducing any unnecessary harm. Interventionist obstetrics is an “expert” system that has failed most in the very area it was supposed to have the most mastery and expertise -- "the optimal conduct of the many normal cases".  This dysfunctional system creates an asymmetrical burden of that risks falls unfairly on the childbearing woman, in which the mother is exposed to the actual pain and potential harm of medical and surgical interventions in order to reduce the risk of litigation for the obstetrician and hospital.     

As a mother myself, this breaks my heart. But one of the most intractable issues I face as a birth activist (second only to the vitriolic rhetoric of lobbyists) is that attempts to widen and deepen the public discourse on this topic inevitably triggers an avalanche of protests from (yes, you guessed it) other mothers. Usually these women needed or wanted medical interventions and feel that I am judging their use of medical procedures as unnecessary, and inferring that they are bad. Most people I talk to are also misinformed about physiological care, believing that it means NOT doing anything at all, denying the laboring woman access to effective pain management, putting the baby at risk because no one is monitoring its well-being, refusing to offer medical help if labor stalls or gravity fails to bring about a spontaneous birth.

This instantly negative reaction specifically applies to career women,  many of whom are the movers and shakers in my political world -- women legislators, members of the medical board, attorneys, members of NOW, newspaper reporters, TV journalists, etc. This is a major, if not insurmountable, stumbling block to effective political action. America needs to question the fundamental premise of a surgical specialist routinely using a medically and surgically interventive model to provide care to healthy childbearing women with normal pregnancies (70%). There is real danger in permitting obstetrics to adopt Cesarean section as the 21st century standard of care. Already the new maternity unit at the Ann Harbor University Hospital ( Michigan ), scheduled to open in 2011, is replacing 50% of its LDR with ORs in anticipation of a 50% C-section rate by 2010. It is “build it and they will have no other choice”.

Heaven help us all if there were to be a dirty boom, bio-terrorism or a pandemic of the avian flu. Precious hospital services would have to be divided between the gravely injured or the contagious, critically ill AND providing customary but medically unnecessary high tech interventions to healthy pregnancy women because none of our OB doctors know how to physiologically manage a normal birth any more (the midwives will all be in jail). I Googled the words “obstetrical research on normal childbirth” on March 31, 2006. The search results said it all in a single digit:  Number of results: zero. Sorry, your search for Obstetrical Research on Normal Birth has found no results. 

So my question for you lovely women is what can I and other birth activist say or do that would not inadvertently insult the 99% of the childbearing public that did not have un-intervened with childbirth and among that cohort, the 30% who had a Cesarean? Unless we can avoid this pitfall, it will be impossible to would elevate the public discourse and reform our national maternity care policies. A rehabilitated system would integrate the classic and scientifically sound principles of physiological management with the best advances in obstetrical medicine, to create a single, evidence-based standard for all healthy women used by all maternity care providers and in all birth settings -- family practice physicians, obstetricians, and professional midwives, providing care in hospitals, independent birth centers and homes.

But without rigorous public debate, we will never have maternity care that is safe, cost-effective, family-friendly, physiologically-sound and able to keep on keeping on, even during a Katrina-like civil disruption.

Any constructive feedback would be most welcome…. Faith ^O^

#8  April 09, 2006  Jennifer said...@ 8:47 pm

Faith: I don't know how you frame the debate without seeming to disparage those who choose differently. Babies and mothering are touchy subjects.

Just look at breastfeeding. Try to put out a factual message like "breast is best" and automatically you set anyone who chooses bottle on the defensive. But how else do you advocate for breastfeeding without pointing out its inherent advantages?

My only guess is to frame the debate in terms of new information that most of us don't have access to. Most people are unaware of the evidence supporting home births.

#  9  April 09, 2006  HaloJonesFan said...@ 8:53 pm

I don't think that there are "roadblocks to having this conversation". Mostly because you're trying to have about six different conversations in one. What are you arguing about? Home birth? Standing birth? Midwifery versus nursing? Mechanically-assisted birth? A narrower range of C-section initiation criteria?

As far as PHB goes, I'd judge it by two statistics. (And I should have been asking about them all along, but I hadn't fully understood it until just now.)

First: What is the percentage (overall, PHB or in-hospital or wherever, any birth) of "low-risk" births that end up requiring intervention? Because that is where PHB falls down. We've used statistics to prove that births which don't require intervention...don't require intervention. The reason you'd go to a hospital is in the rare instance that the birth does require intervention. What happens when a low-risk home birth has complications? You send mother and baby to the hospital--adding that much time before treatment is possible.

Also, one big part of your argument in favor of PHB is the lower rate of medical intervention. But what are the criteria for medical intervention in the case of PHB? Are they less stringent than those in a hospital birth? As I've said earlier, if a hospital would call for a C-section but a PHB would just roll with it, that means that you aren't comparing statistics in a meaningful way.

If you're arguing that a clinical approach to childbirth is associated with a lot of un-necessary medical issues and may cause great pain to the mother, that I can agree with, but I'm not sure that is what the home-delivery debate is all about. The debate is typically framed, from both sides, as women wanting to do whatever they like and expecting their insurance to pay for it. They aren't saying "I think that the medical practice surrounding childbirth results in a needlessly traumatic experience, but I understand the need for having the resources of a hospital immediately available", they're saying "women should be allowed to do whatever they want".

#10  April 09, 2006 Cherrie said...@ 9:47 pm

A couple of us might know you from Adam's house cat, Faith. I, for one. And let me take this moment to publically thank you for all the years you've spent clearing the trail for women like myself, who had the option of picking up a few books and thinking for myself when I became pregnant. Then I had the further option of choosing a CPM in my midwifery legal state and having the most incredible birth, spending the next week sky high on my own opiates. Was I lucky? YES! I was lucky to have both the information AND practicing caregivers available in my area.

A couple requests have been posted to quote. Anyone has permission to quote me, but I'm just an ordinary girl, not terribly worthy of quoting. But I'd like to quote YOU Faith, if I may. That J discription is the best I've seen. And I'd love to get my hands on those two volumes you've put together.

Faith said:
So I’m asking again if anyone out there can articulate for me what the road blocks are, at least as they see them, to having this type of conversation in a public forum without making women feel unduly anxious (or judged) and cutting off debate.

I'm one of the 1% who didn't birth in a hospital, so I'll share what I've interpreted from those 99% around me.

First, I think women who've had a bad hospital experience have a psycological need to protect themselves from believing that it was all unnecessary. That would make them victims. Nobody wants to be a victim. And when a woman DOES admit to herself that she was victimized, she may struggle from post-tramatic stress disorder (diagnosed or not). How many women put aside their complaints after being told for the 12th time 'but at least you have a healthy baby!'
As if the alternative was the opposite. And we women do this to each other. Was anybody here told horror stories when you were pregnant?

Women also have a hard time trusting themselves. If our decisions are questioned by loved ones, we cave.

I honestly have no idea why women feel judged or pushed by 'natural birthers'. I know that on a number of occations I've had to cut a conversation short when the people I'm talking to get defensive. The thing is, how do I share what I know, from facts about what anesthesia does to the baby (which most hospital personel do NOT disclose), to what my natural hormones (resulting only from a completely unmedicated birth) did for me. I'm immediatly met with comments like, 'I'd like a natural birth, but I bled after the last one, being in the hosptial saved my life'. How can I present to this woman the fact that most hemmorages result from 'aggressive management of third stage', when they don't know what that means, and they think I'm making a comment about their personal circumstances. We have a language barrier, and I'm not a midwife, or a health care professional!

Somebody reciently pointed out that the language of the press release required in depth discription of each item, and people's attention spans just aren't that great. And they get confused too, and then give up listening.

halojonesfan is right, the topic seems too large, too encompassing. What ARE we discussing? From my perspective, you can't discuss one part separately. It's all tied up together.

And too often in these attempted discussions I come across as being anti-doctor or anti-hospital. But that's not it at all.

Faith uses the term physiologically managed care. That's an excellent discription, IF you know what it means. But lay people don't know the difference between it and medical management, and it's too difficult to describe in a casual conversation.

So my answer is; not enough information available to the average person. (although the info is there, it's interpreted as 'militant' or 'judgemental') And, we have a language barrier.

#11  April 09, 2006 Cherrie said @ 10:44 pm 

halojonesfan said:
What is the percentage (overall, PHB or in-hospital or wherever, any birth) of "low-risk" births that end up requiring intervention?

The reason I find this impossible to answer is that 'intervention' is a collective term that means anything anybody does to change the course of the labor/birth.

some common interventions are: restricting food/drink, any kind of drug, rupturing the waters, directing the woman to lay in bed, strapping on a monitor or listening with a fetoscope.

Each intervention carries it's own set of risks/benifits and needs to be carried out on a basis that takes the INDIVIDUAL labor into account.

intervention isn't bad. it's the routine application of the intervention that leads to further problems in an individual labor/birth.

You can't have a hospital birth without interventions of one variety or another. I suppose it is theoretically possible, but not very probable to have one at home either.

halojonesfan said: The reason you'd go to a hospital is in the rare instance that the birth does require intervention. What happens when a low-risk home birth has complications? You send mother and baby to the hospital--adding that much time before treatment is possible.

Intervention happens in and out of hospital. Some interventions are so risky however that they can not happen out of hospital. c-section being an obvious one. Epidurals, for instance, can not be administered out of hospital because of very serious and life-threatning risks for both baby and mother accompany them.

I believe you may be asking how many PHBs need emergency transport? An emergency transport would be in case of an emergency (obviously) vs a transport that occurs because of a non-emergency situation. A non-emergency situation might be if a mother decides on an epidural, or baby is in a weird position and can't be born without further invasive help.

Many 'complications' can be delt with at home, with gentler methods. (and always the decision about what to do about a complication should be the mothers) Some can not. This is where we get into involved discussions about this situation, or that situation, and the statistics and evidence of care for each situation.

I don't know the statistics for emergency transport. I know they're low. Anybody here have a link, or stats available? I know the midwife I used had a 4% transfer rate total, and the emergency transfers were a small % of that.

halojonesfan said: Also, one big part of your argument in favor of PHB is the lower rate of medical intervention. But what are the criteria for medical intervention in the case of PHB? Are they less stringent than those in a hospital birth?

I'm not a medical professional, where's that apprentice who posted earlier? I believe the arguement is over the use of interventions in a hospital setting that are used strictly for cover-your-ass purposes. An intervention that may leave lasting harm to mother or baby in an individual case may be done anyway because it's 'standard of care'.

Each Out Of Hospital (OOH) midwife must have their own protocols, in which they have their own practice rules written down. That means they have to have written standards, I'll do x if y happens. I can't comment on how 'stringent' they are.

halojonesfan said: As I've said earlier, if a hospital would call for a C-section but a PHB would just roll with it, that means that you aren't comparing statistics in a meaningful way.

I think this is one reason it's difficult to use statistics alone for an arguement such as this. You can't untangle them to make logical sense. Just too many variables. An individual woman isn't simply a statistic. She's an individual and deserves to be treated that way. She deserves to be in charge of her own health care. She deserves a caregiver who will listen to her wishes and work with her as a partner in achieving that. She does not deserve to be subjected to completely unnecessary medical procedures, with all their accompanying risks to her health and well-being, just because it's hospital 'policy' or even 'standard of care'.

 #12  April 09, 2006 Cherrie said ....10:49 pm

strapping on a monitor or listening with a fetoscope

oops, that would fall under 'survalence'. It's the decision that comes as a result of listening with a fetoscope that is the intervention.

My mistake.

#13  April 10, 2006 HaloJonesFan said...@. 5:19 am
Cherrie: You're proving my point. Discussing statistics that "prove" home births are safer is useless, because the home-birth advocates don't use the same critera as hospital births. A proper study would have to look at home-births situation by situation and judge whether a hospital would have intervened(*). You can argue about whether or not the intervention was actually been necessary, but that isn't the argument that we're having.

As I've said earlier, I get the impression that most home-birth advocates aren't saying that home-birth is better, they're saying that the criteria for intervention should be relaxed, and that the birth process is needlessly clinical. That's fine, but it doesn't necessarily drive women towards home birth and midwifery.

(*) and I'd think that it was obvious, from the context of this discussion, what I mean by 'intervention'

 #14  April 10, 2006 Cherrie said...@ 10:26 am

halojonesfan said: You can argue about whether or not the intervention was actually been necessary, but that isn't the argument that we're having.

But I think that is the argument we're having. Lets take one example. If at home, a woman has a baby in an upright position, and because of her J shaped anatomy, baby comes without incident. In the hospital another woman who carries the same 'risk factors' (predetermined examination of her situation which anticipates complications during the birth process) lays in bed to give birth, and forceps are necessary because of gravity slowing the process, and baby's heart rate drops due to the strain of turning that 90 degree angle. The forceps require an epidural (with accompanying IV to keep blood pressure from plummeting), and an episiotomy, which then tears into the rectum upon insertion of the forceps. The epidural leaks just the tiniest amount resulting in a spinal headache that forces the woman to lie flat on her back for a week following birth. Any upright position, or even moving around too much causes an excrutiating headache. The episiotomy is sewn, but because of the extention into the rectum, bowel movements will be excrutiating for way longer than a week, and carries possibility of a fistula developing, where feces migrates into the vagina. The forceps create a tiny, yet perminant scar on the cheek of the baby. Later in life, the woman in at risk of developing bladder incontinence from the forceps damage, as well as a slight risk of vaginal prolapse, also from the forceps. The episiotomy, once healed, is always a source of pain and irratation, especially during sex.
Now, you tell me. Which birth was 'safer'?
It seems to me, that the argument hinges on home births being, as the BMJ study showed, 10 times safer for the mother, and just as safe for the baby. That's taking into account morbidity (that's my above example, damage that results from interventions) and mortality (death of either mother or baby). They take into account morbidity and mortality resulting from both necessary, and unnecessary interventions. No distinction can be made for purposes of a study, on if the intervention is necessary or not. The reason we then claim that home birth is as safe (mortality) or safer (morbidity) at home, is because fewer interventions with their lasting effects happen at home.
If the majority of interventions in a hospital were necessary, why wouldn't women at home be suffering from lack of these interventions? Because in the majority of cases, when a complication occurs, a midwife who has been at hundreds of labors from start to finish, has learned many non-surgical ways to resolve the complication. And because a hospital, if it becomes necessary, is hopefully right around the corner.
halojonesfan said: As I've said earlier, I get the impression that most home-birth advocates aren't saying that home-birth is better, they're saying that the criteria for intervention should be relaxed, and that the birth process is needlessly clinical. That's fine, but it doesn't necessarily drive women towards home birth and midwifery.

I agree with your point on this. The first birth in my example could have happened in a hospital. Why doesn't it happen very often? Yet it's not as simple as saying the criteria should be 'relaxed'. Because the forceps really were necessary in the hospital to get the baby out safely. The point is, the envionment in the hospital makes interventions such as forceps necessary more often. Something about being in your home makes it less necessary. A study can't possibly determine what it is that makes it this way. The studies are saying that births that happen in the home are as safe, or in some situations, safer than births at the hospital. Therefore, I believe home birth should be a legal option in every state. Faith thought the ideal would be to bring midwives into the hospital setting, where women could get OOH care, while in a hospital. I think the ideal would be to remove the antagonistic barriers between OOH and H birth. I think Holland is a great example of just such a system. 30% of births occur in the home, it's the woman's choice where to birth. If a H becomes necessary, she, and her caregivers transport to the H, and her caregivers continue care there. Statistics show that Holland is the safest place in the world to have a baby.

#15  April 10, 2006 faith said....@ 6:52pm

Wow, I’m impressed. This is public discourse at its best.  Everything I was going to say has been said eloquently by other knowledgeable and articulate souls.

HaloJonesFan said (and rightly so) that my original post was *not one* conversation but many. As pointed out by Cherrie, it is so hard to talk about just one circumscript aspect of this complex subject. But up front, I am NOT saying that “anything goes”. I am no more promoting irrational, “feel good” but potentially injurious choices by childbearing women than I am for the obstetrical profession.

The crux of my commentary is not even about midwives or home-based midwifery per se. This only gets into the fray because there is absolutely no place for physiological management in public consciousness or in mainstream obstetrics. Healthy childbearing women in the US are not suffering from an “obstetrical-intervention deficiency”; instead it is American obstetrics that suffers from a deficiency in its knowledge of and respect for and experience in physiological management. The powers-that-be would like to distract us from their unproven, unscientific practices (resulting in a 30% C-section rate!). So they turn the story around and make it about irresponsible midwives using false ideas about 'normal process' to lead gullible young women astray. Not true.

So here is the pearl of great price.

The main and the plain reading of the scientific literature brings one to the logical conclusion that physiological management is the safest and most cost-effective form of care for a healthy childbearing population. This leads to the natural and compelling conclusion that our current intervention-based maternity care system must be reexamined and rehabilitated.

A newly formulated national maternity care policy would integrate the standard, science-based physiological principles with the best advances in obstetrical medicine to create a single, evidence-based standard for all healthy women. That standard must be based on criteria arrived at through an interdisciplinary process that includes the all the stakeholders. 

In addition to obstetricians, public health experts and economists, the traditional discipline of midwifery as an independent profession and *the input of childbearing women and their families* must be integrated into the political process. 

Once identified as the foremost standard for normal maternity care, the principles of physiological management would apply equally to all birth attendants – physician, obstetricians and midwives – and in all maternity care setting – hospital, home and independent birth centers. Physiological care ALWAYS defaults to medical care whenever medical and surgical interventions become the *more appropriate* treatment for a complication or are requested by the childbearing woman.  

Reform of our national maternity policies is also vital to the ability of the US to maintain its place in a global economy. To meet the practical needs of childbearing families while remaining competitive in the world marketplace, the US must utilize the *same efficacious form of maternity care as the countries with the best, most cost-effective outcomes*.

Just from the standpoint of economics, that can never be a system based on escalating medical interventions and scheduled C-sections. Only an improved and cost-effective system can permit limited health care dollars to be properly used so as to meet the medical needs of the ill, injured and elderly. Effective and affordable maternity care based on scientific principle of physiological management is to the mutual benefit of mothers, babies, fathers, families and society in general. 

As a practical matter, most normal births would actually be best managed (from the doctor's and the mother's standpoint) by the professional midwives that would normally staff the L&D unit. This saves OB doctors all those sleep-destroying middle of the night trips to the hospital for a simple delivery, thus allowing obstetricians to do what they do best and are trained for – treat the diseases and disorders of reproduction and complications of pregnancy and birth.

Were our national maternity care polices to reflect this change, the unbelievable tension and acrimony between midwifery and medicine would be naturally resolve itself, based on the genuine merit of both disciplines. 

How could this happen? Actually, it is easy at the practical level but frankly unlikely at the political level. The answer is simply that ACOG itself acknowledges that physiological management is the appropriate standard for healthy women, that medical interventions should not be used “prophylactically” and instead be reserved for actual complications or if requested by the mother. The would instantly shift the landscape of our tort law in relationship to obstetrical "malpractice".

I have pasted in an operational definition of physiological management, since it is somewhat elusive in the minds of most people. Anyone who is also interest in how midwives apply these principles (at least as defined by the standard of care for members of the California College of Midwives). 

Here is the link to the "California Standard of Care for Licensed Midwives

Stedman’s Medical Dictionary definition of “physiological” – “…in accord with, or characteristic of, the normal functioning of a living organism” (1995) ©

The Principles of Physiologically-based Maternity Care* include:

Continuity of care
Patience with nature
Social and emotional support
Mother- controlled environment 
Provision for appropriate psychological privacy
Mother-directed activities, positions & postures for labor & birth 
Full-time presence of the primary caregiver during active labor
Recognition of the sexual nature of spontaneous labor
Upright and mobile mother during active labor
Non-pharmaceutical pain management such as showers & deep water tubs
Judicious use of drugs, anesthesia, medical and surgical procedures when needed
Absence of arbitrary time limits as long reasonable progress, mom & babe OK 
Vertical postures, pelvic mobility and the right use of gravity for pushing
Birth position by maternal choice unless medical factors require otherwise
Mother-directed pushing - no Valsalva Maneuver (prolonged breath-holding)
Physiological clamping of umbilical cord-- after circulation stopped (avg. 2 to 5 minutes)
Immediate possession and control of healthy newborn by mother and father
On-going & unified care and support of the mother-baby for postpartum
Access to appropriate social and psychological services for the 'second nine months' relative to breastfeeding advise, infant development, parenting and psychological adjustments to postpartum stresses, other children, spouse and employment outside the home, etc  

**One does not have to be a midwife to appropriately use physiological  management ("midwifery model of care")

Return to Home Page       Link to the "California Standard of Care for Licensed Midwives

For more info on CEO web site.

Critique of NIH report on Maternal Choice Cesarean Section March 29, 2006