Belly Tales

Let’s face it: the economy sucks right now.  We haven’t yet hit rock bottom, and it’s going to be awhile (probably a long while) before things begin to recover.  In the midst of this harsh financial reality, companies and industries are scrambling to find ways to save money.  Birth activists have been trying for decades to convince this country of the benefits of midwifery based on its safety and track record of better outcomes, not to mention improved client satisfaction, but hey, this is America—the only thing people really pay attention to in this country is the bottom line.  So maybe midwifery has finally found the argument it needs to affect actual change.  In the midst of one of the worst recessions since the Great Depression, NOW is the time to increase access to midwifery care because it’s excellent care for a heck of a lot less than what we’re currently spending on maternity care.

In early December, shortly after the nomination of Tom Daschle as Secretary of Health and Human Services (HHS), the Big Push for Midwives launched a campaign to get Mr. Daschle to attend a community meeting on midwifery and its advantages.  Per the change.gov initiative, discussions on healthcare reform will be occurring around the country between 12/15 - 12/31, and Senator Daschle has promised to attend a few of them in person.  Thanks to the Big Push for Midwives, he was invited to several heartland discussions, including this one in Lees Summit, MO.  I haven’t been able to find any updates or reports from this meeting yet.  I’m not sure if Senator Daschle was able to attend, but it’s definitley the sort of discussion he (and the Obama administration) should be listening to. (Was anyone actually able to attend that meeting?  If so, give us an update, please!!  I’ve been searching the internet for reports on the meeting, but I haven’t found any yet.)

As this excellent recent article in the LA Times (Midwives Deliver by Jennifer Block) points out, midwives deliver much safer care for much lower cost:

The most cost-effective, health-promoting maternity care for normal, healthy women is midwife led and out of hospital. Hospitals charge from $7,000 to $16,000, depending on the type and complexity of the birth. The average birth-center fee is only $1,600 because high-tech medical intervention is rarely applied and stays are shorter. This model of care is not just cheaper; decades of medical research show that it’s better. Mother and baby are more likely to have a normal, vaginal birth; less likely to experience trauma, such as a bad vaginal tear or a surgical delivery; and more likely to breast feed. In other words, less is actually more.The Obama administration could save the country billions by overhauling the American way of birth.

It seems like instead of encouraging midwifery care, the opposite is happening.  Birth Centers around the country are closing at a rapid pace, and Medicaid has recently started to resfuse to fund birth center care:

Over the past few years, CMS (the federal agency that runs Medicaid/Medicare) has begun disallowing federal matching funds for state Medicaid payments for freestanding birth centers services. Birth centers have been recognized by CMS (and earlier, by HCFA) as a Medicaid provider type in State Medicaid Plans since 1987. Recently, however, CMS has disallowed such payment by several state Medicaid Agencies, including Alaska, South Carolina, Texas, and Washington State, claiming that it lacks clear statutory authority and direction to do so. CMS has directed its regional offices to stop federal payments to any state for birth center services.

As this article points out, this is going to cause a huge squeeze on birth centers around the country, and we’ll soon be seeing even more of them close unless something is done.  This is an urgent call to action.  The AACB has several resources on their website listing ways to contact your senators and let them know about this issue, including using this lovely flyer which lists all of the important talking points you’ll need when composing your e-mail or making your phone call (calls are preferrable, apparently, since e-mail is more likely to be lost in the midst of all the e-mails on the federal bail-out).  The reason this is so important is that Medicaid generally sets the standard for insurers.  If Medicaid stops insuring birth center care, other insurance companies will follow suit.  Birth centers are a crucial link in many communities, providing quality health care to diverse populations (including women on Medicaid - you only have to look at the work of Ruth Lubic and the Morris Heights birth center to appreciate that), and we need to keep as many of them open as possible.  Not only does it make great health sense, but it saves money too.

And here’s another great cost-saving suggestion: stop insuring preterm elective cesareans.  When I read this article I just about choked.  I can’t believe insurance companies are willing to pay for this when research has consistently shown that there are still a lot of complications with “near-term” infants (babies born between 34 - 36 wks) such as respiratory distress, jaundice, temperature instability (hypothermia), delayed brain development and feeding difficulties.  Forget the fact that a cesarean delivery is several thousands of dollars more expensive than a vaginal delivery; the real damage in this practice is caused by the increased number of preterm babies and the burden of care they demand.  Prematurity and NICU care accounts for one of the largest chunks of healthcare expenditure.  Even the March of Dimes is calling for a decrease in preterm cesareans.

I’ve always been consistently amazed that HMOs, managed care systems and Medicaid haven’t latched onto midwifery with more enthusiasm.  I wonder sometimes if this is because ACOG and the AMA are able to counteract the economic practicality of midwifery care with a tons of lobby money.  The economic angle isn’t anything new.  The Business of Being Born said the same thing in 2007, and Michel Odent, Ina May, Naomi Wolf, Suzanne Arms, Robbie Davis-Floyd etc. etc. have been saying the same thing for decades.  Maybe in the midst of the recession, the message will finally get through: midwifery care is better AND cheaper.

The American College of Obstetricians and Gynecologists (ACOG) recently issued a Statement on Homebirth which condemns homebirth and all those who are willing to attend homebirth (aka midwives), concluding that only “…the safest setting for labor, delivery, and the immediate postpartum period is in the hospital, or a birthing center within a hospital complex, that meets the standards jointly outlined by the American Academy of Pediatrics (AAP) and ACOG, or in a freestanding birthing center that meets the standards of the Accreditation Association for Ambulatory Health Care, The Joint Commission, or the American Association of Birth Centers.”

Many other websites have covered this topic in exhaustive detail, so I’ll refer you to them in just a moment, but first a few comments of my own. As Rixa rightly pointed out on her blog The True Face of Birth, ACOG’s sudden acceptance of out-of-hospital birth facilities (i.e. freestanding birth centers) flies directly in the face of their earlier November, 2006 Statement on the subject, where they were adamant that the hospital “is the safest setting for labor, delivery, and the immediate postpartum period,” and that “ACOG strongly opposes out-of-hospital births.” I wonder what caused the sudden change of heart? If you recall, during the time, ACOG and the American Association of Birth Centers (AABC) were not on such buddy-buddy terms. In fact, the AACB wrote a scathing denouncement of ACOG’s statement. Opposing out of hospital birth included births that occurred in freestanding birth centers as well as in homes. I guess in deciding to attack homebirth directly, maybe ACOG decided that it would be better off having the AACB as an ally rather than an enemy, and included freestanding birth centers in its list of “acceptable birthing places” this time around. Who knows. There has got to be so much back-room wheeling and dealing and politics involved in all of this that one can only wonder at the motives. But crucially, why must support of freestanding birth centers be at the expense of homebirth?

It’s also interesting to note that the ACNM has yet to issue a response to this. Is that because they’re partly mollified by ACOG’s acceptance of certified nurse-midwives to the exclusion of all other midwives? From the ACOG statement: “For women who choose a midwife to help deliver their baby, it is critical that they choose only ACNM-certified or AMCB-certified midwives that collaborate with a physician to deliver their baby in a hospital, hospital-based birthing center, or properly accredited freestanding birth center.” Making distinctions like that among midwives in our country (CNMs v. CPMs) only hurts our profession as a whole and is going to get the overall profession of midwifery absolutely no where, but I’ve already written about this ad nauseum. And what about the hundreds of Certified-Nurse Midwives/ Certified Midwives who attend homebirths? Dear ACNM: Just because the majority fo CNMs/CMs work in hospitals doesn’t mean that those who work in homes don’t need a response statement from you. You’re still the professional organization for ALL Certified Nurse Midwives and Certified Midwives—even those who perform homebirth. If you won’t stand up for a woman’s right to give birth in a home, at least stand up for the midwives you represent who deliver in homes….even if it means butting heads with your beloved ACOG.

As Rixa conjectured, maybe all of this is indeed in response to Ricki Lake and Abby Epstein’s documentary The Business of Being Born, which has done a terrific job of raising awareness regarding homebirth. The real question we need to continue to ask ourselves is this: Why is it that America, with all of it’s insistence on hospital birth and safety, still has one of the highest rates of neonatal and maternal mortality among developed countries? That question lies at the heart of The Business of Being Born, and clearly, the American way of doing birth, for all its emphasis on hospitals and safety, has not adequately addressed this. What we need is a statement from ACOG more along the lines of the Royal College of Obstetricians and Gynaecologists (RCOG) and the Royal College of Midwives (RCM), which both jointly support homebirth, in sharp contrast to what ACOG has churned out (kudos to Rixa for finding and posting this in its entirety). Just read the first few lines of the document:

The Royal College of Midwives (RCM) and the Royal College of Obstetricians and Gynaecologists (RCOG) support home birth for women with uncomplicated pregnancies. There is no reason why home birth should not be offered to women at low risk of complications and it may confer considerable benefits for them and their families. There is ample evidence showing that labouring at home increases a woman’s likelihood of a birth that is both satisfying and safe, with implications for her health and that of her baby.^1–3

What a refreshingly different point of view. Surely American women aren’t that different from British women? Surely our healthcare systems are not that different? Why can homebirth be safe on one side of the pond, and unsafe on the other? Yeah, you guessed it: one side is actually basing its policy on research and fact, while the other is pandering in fear, uncertainty and doubt. And don’t forget the economics at work here. ACOG is a professional organization supporting and marketing the services of its members: obstetricians. In other words, a lobby. Again as the Business of Being Born points out, the bottom line is always the bottom line. If we had a national healthcare system like the NHS, where homebirth actually translates to increased savings, rather than a competitive profit-driven healthcare system and a surplus of obstetricians, we’d probably be seeing a lot more governtment-funded support for homebirth.

This is the line that really sticks in my craw: “The main goal should be a healthy and safe outcome for both mother and baby. Choosing to deliver a baby at home, however, is to place the process of giving birth over the goal of having a healthy baby.” You selfish, selfish mothers, trying to enjoy your relaxing, all-natural births at the expense of your babies! The mother and the baby have become hopelessly estranged in the minds of American medicine, and the emphasis (and increasingly, the legal rights) of the baby are always seen as more important than those of the mother. Rather than motherbaby, where the two are linked and the health and wellbeing (physical, mental and emotional) of one is dependent on the other, we have fetal rights outstripping maternal rights, in courts as well as in hospitals. Why can’t modern medicine seem to get it through its skull: what’s good for the mother is ALSO GOOD FOR THE BABY. The two are not diametrically opposed. When a woman feels safe, supported and relaxed, she’s able to sink into her labor and allow her birth to unfold in the manner that’s best for the baby, without all of the stress hormones and cortisol, without all of the fear….and more often than not, with stunningly good outcomes.

In any case, you should go read the rest of Rixa’s post on The True Face of Birth ASAP: 10 Responses to ACOG’s statement on homebirth, as well as the other responses cropping up around the blogosphere.

The other day I discovered a postcard at my local yoga center urging women to participate in a birth survey, which instantly piqued my interest; apparently this survey has already been going on for some time, although I have only now heard about it. A little research has revealed that the Coalition for Improving Maternity Services (CIMS) has launched a new program entitled The Transparency in Maternity Care Project, which is intended to research and explore maternity care in this country, with an emphasis on improving the transparency of maternity care. Unlike other areas of medicine, hospitals and maternity care providers are still pretty cagey when it comes to being open with their numbers. What is the c-section rate for specific doctors or hospitals? What is the VBAC rate? How many providers perform episiotomies? How many elective cesareans or inductions occur annually? Hard numbers like this are always notoriously hard to come by. And of coruse, beyond the actual numbers themselves, women’s experiences with maternity care providers and services and overall satisfaction is often something which is overlooked. It seems like The Transparency in Maternity Care Project is trying to fix all of that, and is acting as a follow-up to the Listening to Mothers surveys which occurred in 2002 and 2006. Like Listening to Mothers I and II, a survey lies at the heart of The Transparency in Maternity Care Project, which can be found at the following website: www.TheBirthSurvey.com. The pilot survey is occurring in New York City right now, between July 2007 and July 2008.

There were many reasons to choose New York City as our pilot site.

First: New York is a large, high profile city offering a wide variety of birth options.

It is a densely populated and well-networked urban center. There is easy access to multiple press/media outlets. Approximately 125,000 births occur in NYC per year. Forty-four hospitals provide maternity care services. The majority of the country’s obstetricians are trained in NYC. Two Free-standing Birth Centers are in operation. An established homebirth community thrives. Nearly 10% of births in NY are attended by midwives.

Second: The Grassroots Advocates Committee will be piloting the project in partnership with Choices in Childbirth (CIC), an active grassroots organization based in NYC.

CIC is well connected with the NYC birth community. CIC publishes The New York Guide to a Healthy Birth – in 2007, 20,000 copies advertising The Birth Survey will be distributed free to the public. A member of the GAC and CIC is based in NYC and will be engaged in the day-to-day oversight of the pilot.

Third: New York State is one of only two states with a Maternity Information Act.

The MIA provides the public with legal access to intervention rates at the facility level. Choices in Childbirth is connected with the NYS Department of Health and has already collected the intervention rates for all New York hospitals.

So, if you live in NYC and have given birth in NYC, here’s your chance to discuss your experience and provide valuable information and feedback about birth in our country. Please participate in the birth survey ASAP. As for the rest of the country, the project plans to unveil a national survey next summer, but if you’re super motivated, you can provide feedback about your birth experience at www.drscore.com.

Last Friday I was a very lucky duck: I was able to attend a screening of The Business of Being Born at the Tribeca Film Festival, hosted by Friends of the Birth Center, along with a post-show talkbalk with the Abby Epstein, the director of the movie, and Ricki Lake, the producer, followed by a cocktail reception. Given that the tickets to the screening (with proceeds going to Friends of the Birth Center) had sold out in less than 24 hours, and the line waiting to get in was a roll-call of who’s who in the New York City birthing community, I felt very lucky and very privileged to be part of this experience.

Most of the early press on the film has been encouraging rather than caustic, and everything I had heard by word-of-mouth was nothing but positive. I actually know many of the midwives and nurses and one or two of the doctors that are feautured in it, and I trusted their voices and their ability to speak accurately about birth and midwifery. Even so, I must admit I’m always a bit trepidatious when it comes to anything about midwives in the mainstream media. I’m always worried that somehow the media will get it wrong—they won’t get the full picture, they won’t understand the smaller details, they’ll paint our profession in broad, misinformed strokes, or they’ll fall back on stereotypes—with the end result being that the much-needed media attention, instead of being a welcome and helpful boon, actually does nothing more than continue to misinform and confuse the public about exactly what it is we do. It’s often a mixed blessing. I was also concerned that this film might be disregarded as too far out on the fringe—that it would come across like a very slanted Michael Moore documentary and therefore not have the universal appeal needed in order for it to be taken seriously by the mainstream public.

These fears were somewhat allayed when the announcer for the film—a man—came out and assured the men in the audience that if they were expecting to suffer through a “chick flick”, they were in for a very pleasant surprise. Apparently he had been on the Tribeca Film Festival selection committee, and it was one of the other men on the committee who had first approached him about the film, saying that he had really kind of liked it and needed a second opinion. As it turns out, the film’s biggest supporterters on the selection committee were these two men, both of whom had known absolutely nothing about birth prior to watching the film, but had found it to be a very fascinating, informative and well-researched documentary. The announcer kept it short and sweet, and then, without further adieu, the lights went down, and the film began.

The Business of Being Born sets out to explore the business of maternity care in our country. Along the way, the film raises a lot of difficult questions, which it then attempts to answer: why are the infant and maternal mortality rates in the US the second worst in the world when compared to other developed countries? Why do midwives deliver 60-80% of all births in other developed countries, but only 8% here? Why is our cesarean rate so high, especially when compared to other countries which have a much lower cesarean rate but much better overall outcomes? Why are so many mothers so disatisfied with their birth experience or maternity care? Why do so many of our births occur in hospitals? Why is the prevailing attitude towards birth one of fear, rather than of trust and normalcy? You know, just the sort of complicated questions which keep midwives up at night, but which very few other people ever stop to think about (I’m pretty sure it was Pat Burkhardt, director of the NYU Midwifery program, who rightly points out that most people do more research on buying a new car or appliance or camera than they do on their choices and options when it comes to birth). The film tackles these complicated questions from several angles, including the vicious circle of medicated birth (epidural leading to pitocin leading to more epidural leading to nonreassuring fetal status leading to cesarean, all done in cute cartoon format), the pervasive fear-mongering of birth on TV and in the media, the status symbol of “too posh to push” and “designer deliveries”, insurance issues, malpractice issues, even touching upon possible implications of disturbing the delicate “love cocktail” of hormones present in unmedicated births which facilitates bonding and maternal instinct. Quite a big mouthful to bite off for one small film.

The opening sequence of the film begins at 3:25 am, as a homebirth midwife (Cara Muhlhahn) prepares her birth bag before heading out to a birth. This footage is interspersed with people discussing their initial perceptions of midwifery and midwives. Not surprisingly, many of the people being questioned have either never heard of midwives before, or assumed that they were untrained granny-midwife types. A few people express disbelief that anyone would choose to have birth somewhere other than a hospital, or with someone other than a doctor. One man says something like “I didn’t even know midwives still existed”. We cut back to the homebirth midwife in her apartment, packing her bag. The idea that midwives are untrained grannies more likely to treat you with herbs than a prescription is quietly challenged by her preparations: we see her checking her oxygen tank, preparing her suture and syringes, counting vials of pitocin and other medicines, packing liters of IV fluid still neatly sealed in their bags, along with IV tubing, and then setting off to the birth.

Without a doubt, one of the best things about this film is the sheer number of unmedicated births that it shows. While attending and seeing births was something that was familiar and commonplace to many people at the turn of the century, in its move from the home to the hospital, birth has become isolated from everyday life, no longer thought of as a routine, normal occurrence. Today, most people have never been to a birth prior to having their own baby. What few births people do see are usually on TV, where they’re either wildly dramatic, such as the screaming, frantic woman on ER, or complicated and scary, such as on A Baby Story, where it seems like routine, normal vaginal births are often passed over in favor of dramatic life-and-death births, which probably garner much better ratings. Also, whenever birth is seen on TV, it is unfailingly (inevitably) set in the hospital. However, The Business of Being Born thankfully turns all of this on its head, showing what real, normal, uncomplicated, unmedicated birth actually looks like—something most people have probably never seen before. The audience is exposed, perhaps for the first time, to the sights and sounds of unmedicated labor. Instead of screaming and drama, women are shown rocking and swaying, moaning and grunting and sweating. Instead of beeping machines and alarms sounding, heads emerge from between legs in relative silence as the mothers are left undisturbed, pushing with quiet concentration and determination. We’re shown births attended by midwives in homes and birthing centers, births in tubs and pools, births squatting and standing; we even see Ricki Lake’s homebirth, in a bathtub.

While many famous, leading authorities (Michel Odent, Marsden Wagner, Ina May Gaskin, Robbie Davis-Floyd, to name a few) and many leaders in the New York City birthing community spend a lot of time discussing the issues behind the business of birth in the film, it’s often the images themselves which speak the loudest. Forget what the experts are saying: the audience is actually able to see it, with their own eyes. The images of women concentrating and pushing with power and strength, in tubs, kneeling on beds, supported by their partners, squatting or rocking, versus the images of women flat on their backs in the hospital, covered in tubes and oxygen masks, being told to “push!”, their legs in stirrups or held by staff, supine on gurneys being wheeled to the operating room, provides a message far more clear and visceral than any book or 5-hour lecture on the subject could manage. This, more than any other aspect of the film, probably provides the greatest education to the audience.

One of the issues raised at the talk-back session after the show was the decision to include director Abby Epstein’s birth in the film. Although she was planning on having a homebirth with Cara Muhlhahn, she went into labor at 35 weeks, and because her baby was breech, she needed a cesarean. While including this birth at the end of the film does put a bit of a damper on the natural-birth/homebirth high of the film, at the same time it demonstrates a very crucial point: homebirth and midwifery care is safe care. Midwives don’t take stupid risks, they have good clinical judgement, and they make good calls; they’re not going to try to deliver a premature breech baby at home. I also think it’s important for the audience to see that birth doesn’t always go according to plan, and that flexibiilty and the ability to roll with a change in circumstance is one of the most important aspects of a successful birth experience, and that support during these difficult transitions is also key. This birth also shows the system working exactly the way it should: the midwife takes care of the low-risk patient, but when low-risk becomes high-risk, the patient is transferred to the back-up doctor, and seamless, excellent healthcare is provided to the woman.

Perhaps the only problem with this is the fact that the care is almost too seamless. When Abby Epstein mentioned to her doctor that she was planning a homebirth, his enthusiastic response is just a little too quick. You can’t help but wonder: if the camera hadn’t been there, capturing the moment, would he have so readily offered to serve as back-up, or would he have tried to talk her out of having a homebirth using scare tactics or punitive manipulation? (This is by no means a statement on this particular doctor in the film, whom I personally know to be very supportive of midwives and midwifery, but rather a statement on the larger, more generalized attitudes of doctors towards midwifery and homebirth). In reality, it’s rarely so smooth a transition, and doctors are rarely so enthusiastic when they hear that their patients are planning a homebirth. While the film touches briefly on the competition between doctors and midwives and the fact that many doctors are vehemently anti-homebirth, the smooth transition of care between Abby Epstein’s homebirth midwife and back-up doctor is potentially misleading. The audience can walk away from the film thinking that this is a very easy thing to arrange, when actually, one of the biggest barriers to providing homebirth as a viable option to more women in this country is the lack of back-up providers and the challenges faced in trying to arrange appropriate back-up; rather than being smooth and easy, it’s often complex, frustrating and fraught with politics.

My only other critique of the film is that it is perhaps a bit too black and white: homebirth v. hospital, midwife v. doctor, unmedicated, natural childbirth v. monstrosity of tubes and terror. While the film did follow a hospital-based midwife (Catherine Tanksley), and showed midwives in hospitals, the emphasis seemed to be on homebirth. The truth is that in this country far more midwives practice in hospitals than they do in homes, and the word “midwife” is not synonymous with “unmedicated childbirth”. While midwives are experts in normal, unmedicated births, we’re not anti-epidural or anti-hospital. We can prescribe narcotics and pain relief in labor, we can order epidurals, we can support a woman through a medicated birth experience just as easily as an unmedicated birth—it really just boils down to the desires, needs and expectations of the woman and her family. Unfortunately, I can very easily see a woman walking away from this film and thinking “well, midwives are great for natural childbirth, but I want an epidural, so I guess that means I’ve got to go to a doctor”. While all of the beautiful, natural homebirths in this film are a joy and privilege to watch, I think one or two equally beautiful and joyous hospital births attended by midwives might have added a more balanced perspective to the film.

Nevertheless, overall I thought the film was truly amazing; it brought tears to my eyes on several occassions. Rather than being far out on the left fringe as I had feared, I was actually blown away by how mainstream and accessible it was. It begins with the assumption that the audience knows absolutely nothing about birth and the business of birth in this country, and then moves on from there, using a simple and easy-to-understand, yet powerful and engrossing format and narrative. Forget the Ricki Lake Show; I think this film will be a new highlight in her career, and I’m very grateful that a film like this has finally been made. I want all of my friends, my beloved boy, my family, my peers, to see this film so that they can finally see and understand exactly what it is that I do, and why I do it, and what I believe in. Hopefully this film will be picked up by a national distributor and shown in cities all over the country; hopefully soon it will be playing at a theater near you. If it is, you’ll have to go and see it—and bring all of your friends with you!

Dear American Association of Birth Centers:

I have a lot of respect for you. I feel that you’re a very informed and informative organization, providing countless resources for both families seeking a birth center experience, and for midwives, doctors, nurses and other care providers and community advocates who are interested in opening up birth centers around our country. Your response to ACOG’s misguided new policy on out-of-hospital birth was particularly brilliant: well researched, well stated, and just spot-on. And trust me, I wholly agree with your mission statement: we need more birth centers in this country! The work you do is crucial and very much needed and appreciated.

However, I just recently discovered that you’re planning on having your annual meeting in Anchorage Alaska this year. Midwives, nurses, doulas, doctors and other birth workers tend to be very busy people. We tend to be stretched in many different directions at once, and we tend to have our fingers in several pots at the same time. We’re dedicated, but we’re not rich. We get time off, every now and then, but not heaps of it, especially for those who’re living the on-call lifestyle. We’re presented with many conference opportunities throughout the year, and because our finances, budgets and work schedules are often prohibitive in the number of days off we can obtain, and our ability to attend a conference is often a luxury and not a mandate, our conference choices must be made very carefully.

There are already several large and popular conferences hosted on an annual basis on midwifery and birth related topics, such as the ACNM National Convention, Contraceptive Technology, MANA conferences and Midwifery Today conferences. There are probably many of us who are very interested in promoting and enhancing access to birth centers in this country, and who are interested in attending your conference, but why Alaska?? While I am sure that Anchorage is a beautiful and vibrant city with much to offer to attendees, and Alaska is just as much a part of the birth center debate as the lower fifty states, the simple truth of the matter is this: hopping to Chicago for a long weekend is probably much more do-able and affordable for many people, while Alaska is much less so. Very few of the busy and active workers, the ones who would benefit the most from your conference, and the ones who you probably most want to attend, are going to be able to make it—at least, not in the numbers that you are probably hoping for, and not in the numbers that we need in order to really begin to make positive change in this country regarding the promotion of birth centers.

By hosting your conference and annual meeting in a remote location, you are ensuring that birth centers remain remote from the national debate on birth in this country. In fact, as birth centers continue to close and become marginalized in this current unfavorable climate, hosting a conference in Alaska seems to sadly epitiomize where birth centers stand in this debate. I strongly urge you to consider a more central and easily accessible location for your conference next year, so that your urgent work and mission can receive the attendance and attention it deserves.

Sincerely,

The Student

This is in follow-up to last week’s post about ACOG’s recent new policy on out-of-hospital birth. The American Association of Birth Centers wrote a detailed and very well researched response, and included a 2 page selected bibliography on the safety and efficacy of birth centers at the end of the letter. I thought I’d just post the bibliography here, for all of us to peruse in our spare time (you know, that mythical thing where in theory you have the freedom and liesure and ability to pursue areas of intellectual interest and research to you). More importantly, maybe this bibliography will come in handy to any fellow students out there who’re up against deadlines and frantically working on their research projects on birth centers. Enjoy!

Albers, L.l. & Katz, V. L. (1991). Birth setting for low-risk pregnancies: An analysis of the current literature. Journal of Nurse-Midwifery, 36(4),215-220.

American Public Health Association (1983). 8209 (PP): Guidelines for licensing and regulating birth centers. American Journal of Public Health, 73(3), 331-334.

Ballard, R.A. (1979). Changing the environment for birth, an alternative birth center in the hospital. In Lindheim, R. (Ed.), Environments for humanized health care (pp. 83-89). Berkeley, CA: University of California.

Ballard, RA, Ferris, C, & Clyman, RI (1985). The hospital alternative birth center: is it safe? Experience in 1000 cases from 1976 to 1980. Journal of Perinatology, 5(61-64).

Bennetts, A. (1982). The first national collaborative study of birth centers. Cooperative Birth Center Network News, (February/May), 12-13.

Bennetts, A.B. & Lubic, R.W. (1982). The free-standing birth centre. The Lancet, February 13, 378-380.

Campbell, R. & MacFarlane, A. (1986). Place of delivery: a review. British Journal of Obstetrics and Gynecology, 93, 675-683.

(Read on …)

A few weeks ago, the American College of Obstetricians and Gynecologists released the following policy on out-of-hospital birth:

Out of Hospital Births in the United States

Labor and delivery is a physiologic process that most women experience without complications. Ongoing surveillance of the mother and fetus is essential because serious intrapartum complications may arise with little or no warning, even in low risk pregnancies. In some of these instances, the availability of expertise and interventions on an urgent or emergent basis may be life-saving for the mother, the fetus or the newborn and may reduce the likelihood of an adverse outcome. For these reasons, the American College of Obstetricians and Gynecologists (ACOG) believes that the hospital, including a birthing center within a hospital complex, that conforms to the standards outlined by American Academy of Pediatrics and ACOG,1 is the safest setting for labor, delivery, and the immediate postpartum period. ACOG also strongly supports providing conditions that will improve the birthing experience for women and their families without compromising safety.

Studies comparing the safety and outcome of U.S. births in the hospital with those occurring in other settings are limited and have not been scientifically rigorous. The development of well-designed research studies of sufficient size, prepared in consultation with obstetric departments and approved by institutional review boards, might clarify the comparative safety of births in different settings. Until the results of such studies are convincing, ACOG strongly opposes out-of-hospital births. Although ACOG acknowledges a woman’s right to make informed decisions regarding her delivery, ACOG does not support programs or individuals that advocate for or who provide out-of-hospital births.

1 American Academy of Pediatrics and American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care, 5th Edition. Elk Grove Village, IL, AAP/ACOG, 2002.

Approved by the Executive Board October 2006

“…ACOG does not support programs or individuals that advocate for or who provide out-of-hospital births.” In other words, homebirth CNMs/CMs and CPMs? And what about last year’s large, peer-reviewed, prospective cohort study in the BMJ? That study certainly didn’t strike me as particularly “limited” and “not…scientifically rigorous.”

In response, the ACNM recently released the following statement, which was also signed and supported by eight other organizations, including the American Nurses Association, the Midwives Alliance of North America, Citizens for Midwifery, Lamaze International, the Coalition for Improving Maternity Services, the White Ribbon Alliance for Safe Motherhood, the American Association of Birth Centers and Birth Network National:

November 20, 2006
Douglas W. Laube, MD
President, ACOG
409 12th Street,
SW Washington, DC 20024-2188

Dear Dr. Laube,

Some families, after thoughtful consideration, choose home birth or birth in an out-of-hospital birth center. On behalf of those families, we are writing to express our concern about the recent ACOG Policy Statement, Out-of-Hospital Birth in the United States . The troubling nature of this statement places in jeopardy access to a valid, evidence-based system of care. Providers who support evidence-based care have an ethical responsibility to offer access to care at all levels and in all settings for these families.

The safety of birth in any setting is of utmost priority. Unfortunately, studies which have not differentiated between planned and unplanned home birth or attendance by qualified versus unqualified attendants, and/or that do not clearly define appropriate inclusion criteria, have been used to discredit all out of hospital birth.

The implication that there is insufficient evidence to support the safety of planned out-of-hospital birth is unsubstantiated. After a review of the evidence, ACNM published a position statement in 2005 in support of planned home birth under specific conditions. That statement is reflective of similar interpretations of the evidence by national and international panels. Furthermore, we are not aware of evidence supporting the assertion that the hospital is the safest setting for labor, birth and the immediate postpartum period for low risk women.

Across health care disciplines, it is well documented that safety can be best assured when health care professionals and institutions collaborate to ensure that women have access to qualified providers. Indeed, many health care institutions and obstetrician-gynecologists support the right of women to choose out-of-hospital birth by actively working to maintain respectful collaborative relationships, provide expert consultation, and facilitate transfer of care.

In contrast, the ACOG statement discourages collaborative practice and support for out-of-hospital birth providers. This position could potentially harm the culture of safety around birth, for patients and providers.

We agree that there is much to be learned from further studies. Research that focuses on the characteristics and management of normal birth, the impact of various care processes on morbidity, and variables that affect client satisfaction and experience as related to birth site are all necessary.

In order to ensure the provision of safe and appropriate care, research should be focused on the ways in which all health care providers and institutions can establish seamless systems of care when transfer is needed from the home or birth center to the hospital. The data needed for such research can only be provided if we continue to offer safe, comprehensive and appropriate care in all settings.

Finally, we are distressed that this statement is published at a time when the public health system is preparing for pandemic influenza. The National Pandemic Flu Plan calls for hospitals to develop ‘surge capacity’ plans to maximize their capability to care for seriously ill patients, and create alternative care sites for routine care. Specifically, the plan calls for health systems to explore ways of “increasing the role of home care, and developing off-site care facilities.” It seems likely that in an influenza pandemic, a hospital bed – in short supply and in close proximity to those ill with a virulent virus – may not be the safest place for healthy women to give birth.

In other disaster situations, access to care based on technology may not be available even in a hospital. Preserving our competencies in providing perinatal care in low resource settings is critical to adequate preparedness in the United States and our continued support of midwifery education and safe motherhood in the developing world.

Since potential necessity and strong patient desire by a small percentage of women assure that birth outside the hospital setting will likely persist, we encourage ACOG to partner with other health care providers to enhance the safety of birth in out-of-hospital settings by promoting an agenda for continued research, developing policies to ensure seamless coordination of care across settings, and encouraging collaborative management across disciplines. ACNM proposes the development of a joint task force to develop guidelines for out of hospital birth and to establish a research agenda to explore issues of safety across birth settings.

We look forward to our continuing dialogue and the opportunity to work collaboratively on this issue.

Sincerely,

Katherine Camacho Carr, CNM, PhD, FACNM
President, ACNM

Finally, the American Association of Birth Centers also released the following statement:

November 16, 2006
Douglas Laube, MD, MEd, President
American College of Obstetricians & Gynecologists
409 12th Street SW, PO Box 96920
Washington, DC 20090-6920
Fax: 202-863-4981

Dear Dr. Douglas Laube:

We are hereby responding to the recent ACOG Executive Committee Statement regarding out-of-hospital birth which we direct to each member of the Committee personally.

The statement does not appear to be evidence-based, and AABC has been unable to find a factual basis to support this sweeping pronouncement. To the contrary, the evidence demonstrates that birth center outcomes are at least equivalent to those in hospitals for low-risk women. Please refer to the attached reference list for examples of these studies from the U.S. and Europe. Your statement could have serious consequences for women choosing licensed birth centers, of which there are over 180 in number, particularly in areas where access to maternity and women’s health services is limited. As I’m sure your organization realizes, there is a growing crisis of access to obstetric care for women in rural and other medically underserved areas, and this is an unfortunate time to artificially further limit access to care by marginalizing fully licensed birth facilities.

Women choose out-of-hospital birth for a variety of reasons including desire to avoid intervention of hospital routines, previous unsatisfactory or untoward hospital experiences, desire for family participation, concern about possible exposure to hospital infections for healthy women and infants, and preference for midwifery care. Birth center providers, their consulting specialists and affiliated acute care services work very hard to prepare for any eventuality including a need for hospitalization and cesarean section, so that women can be assured of safe and satisfying outcomes. In many hospitals around the country in-house twenty-four hour availability of anesthesia or surgery to perform emergency cesareans does not exist. These services are available on call. Licensed birth centers operate by agreement with transfer facilities in the same way, and consultants are on call and immediately available when needed.

The fact that birth can become complicated is the reason the birth center was developed (and demonstrated first in 1975), as a point of entry to a continuum of care based on the medical, psychological, social and economic needs of the childbearing woman and her family. It is why AABC, as an organization, has worked very hard to develop a team approach to the care of women in childbirth - a team which includes obstetrical specialist consultation, acute care medical and nursing services, close follow-up of mother and baby, pediatric services, and the host of other social and community services that may be indicated for individual women and their families. It is why we have developed national standards and sought the assistance of the American Public Health Association to promulgate recommendations for licensure. It is why we have established a Commission for Accreditation of Birth Centers to provide assistance and oversight to birth center operations.

Childbirth is more than a physiological event, important as that is to the whole spectrum of care of the mother, baby and family. Surely your members are aware of the growing evidence to support not only the physiological, but also the psychological, social and emotional impact of the care afforded during the childbearing year and the impact on the mother, the infant and the family. Granted, these all need further study, as evidenced in the Institute of Medicine report entitled “Research Issues in Birth Settings”. That report spelled out the need for research in all birth settings. In the interim, we do need to allow low-risk normal birth to occur when possible in the family-centered, comfortable environment of the birth center, when that is the choice of the mother and her family.

We urge you to reconsider your statement on out-of -hospital birth. Although we strongly disagree with your position on the quality of existing studies, we do agree that more study is needed, and will continue to support study of all issues surrounding the preservation of access to normal birth. We suggest that the birth center model operating within an established network of consultation and referral can be an important factor in improving outcomes in this country.

Sincerely,

Jill Alliman, MSN, CNM
President, American Association of Birth Centers
American Association of Birth Centers

So, in a rather sweeping statement, ACOG is trying to say that the only safe births are those that happen in hospitals, and out-of-hospital birth is not something ACOG obstetricians should support. If you’re interested in signing the ACNM’s letter in response to ACOG’s new policy, you can visit the ACNM website and add your name to the open letter.

Funny how IP will just knock the wind out of you. You wake up on a Friday morning and realize that it’s been National Midwifery Week ALL week, and you haven’t said or done a thing about it. However, it’s not too late to celebrate! This year, like last year, our local NYC ACNM chapter, along with Friends of the Birth Center will be hosting the 4th annual Miles for Midwives, a 5K Run/Walk race around Prospect Park, this Sunday starting at 10:00 am, rain or shine. Registration costs $15, and all proceeds go to Friends of the Birth Center and the NYC ACNM Chapter. There are great pictures up from last year’s event, and I can’t even begin to tell you how much fun it was. This year is slated to be even bigger, with more people expected to participate (last year we had about 200), and maybe even a politician or two. The beloved boy and I, as well as many of my fellow sister students from midwifery school will all be there, so if you’re in the area and you’re not doing anything on Sunday, come for a jog! Bring your children, bring your dogs, bring rain gair if it’s raining, and come hug a midwife or two and learn more about the wonderful profession of midwifery, and everything we have to offer you.

If anyone is in New York in the next two weeks, be sure to check out Until the Violence Stops: NYC, a two week festival organized by playwright Eve Ensler to help educate and promote awareness about violence against women, with events and venues all over the 5 boroughs. Like V-Day, which uses creative events to increase awareness, raise money and revitalise the spirit of existing anti-violence organisations, this festival includes monologues, plays and spoken word performances by artists such as Rosario Dawson, Brittany Murphy, Cynthia Nixon, Isabella Rossellini, Kerry Washington, Selma Hayek, Rosie O’Donnell and more, workshops and forums to discuss the issue and ways to change the alarming statistics, and even a self-defense class. Topics include rape, domestic violence, incest, female genital mutilation (FGM) and sex trafficking, and even a panel discussion with women from global conflict zones. Read more about the festival over at Time Out New York (Antiviolent Femme)

And for those of you who are in town this weekend, come to Friends of the Birth Center’s 3rd Annual “Celebrate Birth” Picnic, which will be in Central Park this Sunday (June 18th). It should be a great afternoon, including birthday cake and lots of entertainment for the kiddies, and the $10 suggested donation goes towards (re-) opening a free-standing birth center in Manhattan after the tragic close of the Elizabeth Seton Childbearing Center. For more information, visit the link above. (Unfortunately, I’m going to be out of the city camping this weekend, but we get back on Sunday, and if we get back in time…I’ll be there).

We had a quick consultation yesterday with the professor who will be teaching us the pelvic part of our physical assessment class, which will begin in October. She had a three ring binder with her that was 4″ thick, filled to the brim with paper, and all of this was our pelvic unit. It was massive. You could kill someone with it if you accidentally dropped it on their heads. We were all a bit hushed and flabbergasted.

However, as she quickly (and correctly) pointed out, the pelvis is the foundation of our practice. We’re learning how to examine the heart and lungs, but truth be told, if we run into something seriously abnormal, we’re probably going to refer it out to another practitioner. Hearts and lungs will not be our specialty. The pelvis, on the other hand…we’ve got to know it inside out, all of its muscles, structures, ligaments, bones, how it works, how it feels, how it stretches, what a normal finding is, what an abnormal finding is, how to do a pap, wet mount and liquid slide, how to diagnose all the different variations of vaginal itch, and all sorts of amazing stuff that I don’t even know about yet.

To say that I’m excited is a bit of an understatement. I can’t wait! We’re finally getting to the good stuff. Although, looking out that 4″ binder…the good stuff is going to be a ton of work. But good work. Work I’ve been looking forward to for years and years.

In other news:

The Senate Judiciary committee has endorsed John G. Roberts as future Chief Justice, and the vote will go to the entire Senate next week. I’m still of a mixed opinion about this. On the one hand, he does seem like a very intelligent and judicious man, which is more than can be said about a lot of people, and he has repeated, on several occassions, that he doesn’t want to tamper with precedent, which you could possibly read as his way of saying that he doesn’t want to open the Roe v. Wade powder-keg without having to say it directly and piss off all of his right wing conservative supporters. Or maybe that’s just his way of skirting the issue and not answering directly, so that he can unload a bazooka gun at privacy rights just as soon as he’s nominated. He has been so ambiguous throughout this entire process, and infuriatingly indirect, and the uncoorperativeness of the White House has just been staggering. Honestly, you really don’t know what to think, because the entire thing has been so abstract and obfuscated. I can’t take the measure of the man. No one can. That’s been the problem. I have a sneaky suspicion we’re all going to have to find out the hard way on this.

A quick reminder: Miles for Midwives, the 5K run/walk that will jointly benefit the NYC Chapter of the ACNM and Friends of the Birth Center is next weekend. I’ve already signed my beloved boy and I up to run, and I know several of my fellow midwifery students and friends will also be going. If you live in the NYC area and are interested in attending, the registration form is here.

Finally, some adoreable shirts have been designed with the logo “Midwives Deliver” on them. Proceeds from the sales will also go to benefit Friends of the Birth Center, so if you’re at all interested in owning one, check them out here.