Belly Tales

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.

A few weeks ago, Dark Daughta over at One Tenacious Baby Mama asked me for a contribution to her new weekly series entitled Reloaded, which happens every Sunday and features old posts that are worth posting and reading a second time (oldies but goodies, as she calls them). She wanted posts that I was particularly proud of, “something that really kicks ass analytically, politically” etc., and I quickly discovered when I was combing through my old posts that I don’t really have much in the analytical/ political/ highly opinionated/ kick-ass vein. It seems that my blogging style overall tends to be of the objective-news-reporting variety, or at best the highly-researched highly-factual variety; in other words, the variety that is so factual and evidence-based that no one can really argue or disagree with what you’re saying; in other words, the risk-free variety. Which is good to know about yourself, I guess, because it then prompts a bunch of really good questions, like: WHY AREN’T YOU TAKING MORE RISKS? Why aren’t there more highly opinionated, highly political, highly analytical, highly kick-ass posts on your blog? What are you scared of? Pissing someone off? Causing controversy? But really…is there any other point to a blog than opinion? If all we’re after is the news, we’ll read newpapers and news sources, thank you very much. Blogs are supposed to comment on things. So, good to know. Note to self: enough with the reporting on things. Get commenting instead. Go out on that limb. It’s about time, don’t you think?

Anyway, I sent Dark Daughta a few posts. One on the Keeper (still one of my proudest feminist and environmentalist statements), one on the UK’s new birth agenda (Maternity Matters), and two on female circumcision (Circumcision or Mutiliation? and Further Thoughts on FGM).

I was curious to see what Dark Daughta would think of them. Leave it to Dark Daughta to not only think about them, but to write an explosive 1000 word treatise as well. She picked my posts on female circumcision, of course, and then ran with them. Ran is a polite word for what she did. More like smacked the posts upside down, flipped them inside out, and then shook all of the loose change out of their pockets. She took everything I had thought after my first encounter with a circumcised woman, and all of the conclusions I had come to at that time (and this had involved a lot of thinking back then, trust me), and managed to turn all of those thoughts, all of those culminations of thought, absolutely, irrevocably, upside down. In the space of just one post. Leave it to Dark Daughta to challenge the hell out of you.

Just a few highlights, here:

Dear Student Midwife:I’m glad that you’re asking yourself questions about how best to proceed. …Maybe examining the culturally based and biased and ofttimes downright racist, response of many privileged feminists who were not born into cultures where genital circumcision is practiced might offer some much needed space inside which there might be less emotionally and politically charged room for a true examination of the issues.There is a power relation here. Are parents in western societies hunted down and denied access to safe male circumcision? Why is the WHO advocating for this procedure when there is a fast growing segment of the male population that is crying out against it?

When male circumcision of babies who can’t make the choice for themselves is enshrined as a part of at least major world religion, are health care practitioners strategizing about how best to stigmatize grown men who present penises that are mutilated? Are feminists of conscience refusing to sleep with men who are circumcized? Are we looking on them with pity and defining them as mutilated? Are we strategizing about how best to divest them of custodianship of their sons so that we can keep them safe from circumcision? Is anyone noticing that the actual side effects of male circumcision…besides those that go horribly wrong…are minimal because these surgeries are done by skilled practitioners in sterile settings?

I don’t agree with either kind of circumcision. But I can’t fail to notice that one is filled with shame and stigma heaped on those who experience it, while the other is thought of as a throwback that should be done away with but is still tolerated and executed in hospitals.

Being useful is definitely not going to include making any circumcized wimmin feel uncomfortable and on the spot about the decisions of their parents. So, labeling a woman’s cuts “mutilations” without checking to see what if anything she says about her own genitalia will go a long way to making a practitioner seem like a judge and not as someone a woman can potentially confide in or turn to.

Because really, the shock and the unfamiliarity with the view below is ours, not theirs. If we’re gonna pay lipservice to accepting the anatomy of the vulva, we’re going to need to work at really understanding and respecting that wimmin come in all sorts of configurations for all sorts of reasons.

This “who is civilized” and “who is babaric and uncivilized” binary split that serves the west/the north, giving our cultures a much needed oppressive ego boost needs to GO!

Yowsa. And those are just the highlights. I’d highly reccommend that you go and read the rest of the post, because she writes with so much passion and conviction, and has this incredible way of phrasing things in ways that I would never, ever think of.

Now, how do you respond to a post like that? I didn’t even know where to start. First I had to do a lot more thinking on the subject, which I’ve been doing for the past several days and nights. I wrote an e-mail response to her, which she published in last Sunday’s Reloaded V which started to flesh out some of my thoughts. And now I find myself here again, having done yet another 180 on the subject (my apologies for repeating some parts of my e-mail, but this is pretty much where my thinking is at right now).

I think Dark Daughta is right on a lot of counts. There is indeed an inherent racism/ oppression in a viewpoint which has decided to call one form of ritual cutting “mutilation” while at the same time leting so many other types of cutting fall under the category of “circumcision” or some other word, and therefore under the umbrella of cultural acceptability (male circumcision, labioplasty, clitoral hood piercing, episiotomy etc.). I can see how that is indeed our culture (and by that I mean western culture) taking its own viewpoint on what constitutes a healthy vulva and setting it forth as “right” and “correct” and that anyone else who does anything different to their vulva (especially something brutal or harmful and something we as a culture don’t fully understand) is therefore wrong and backwards and oppressed and brutalized by their own culture…and that this “mutilation” is therefore a form of violence against women. This viewpoint then lays the groundwork for our invasion of their culture; in other words, this viewpoint basically gives us permission to enter their culture and tell them what’s right and wrong, and that they have to stop this cultural practice. And many huge, big name organizations like UNICEF, the World Health Organization, the US Dept. of State, Amnesty International, USAID etc. etc. have all issued policies and statements which call for an end to this practice, and have programs or policies in place which exist to help educate and save these women from their fate.

Calling something “mutilation” implies, by its very nature, that those who are “mutilated” need to be saved. That makes sense, and I see that now, but I had never before thought of it in those terms. So further thinking on this is prompting me to start to refer to this ritual as “circumcision” again rather than “mutilation”. I do appreciate that my view of what constitutes a healthy vulva is certainly not everyone’s view, and who am I (or who are we?) to decide what is or is not the right kind of vulva? Why is labioplasty or clitoral hood piercing okay, while female circumcision is not? And what would happen if circumcision was done well, by medically-trained people using sterile instruments, sharp instruments, making clean, hygienic cuts? So many of the problems inherent in this practice comes from the scarring and infection which is secondary to the cuts themselves. If there was no scarring, if there was no infection, would the damage be less? As Dark Daughta pointed out, female sexuality stems from a lot more than the tiny nub of flesh which is the clitoris. If the clitoris is removed, but in a clean and precise manner, using sharp, sterilized instruments (rather than a rusty tin can or a piece of glass etc.), would women be able to retain a higher level of sexual functioning? I never, ever would have thought that an underground feminist movement to provide clean, hygienic, medically-trained female circumcisions is not that far off from what feminists were doing in the 70s with their underground abortion clinics to provide clean, hygienic, medically-trained abortions, but yeah, I do see the similarity.

I wrote in a comment on my first post that “I undrstand that there are a lot of cultural and personal reasons involved in choosing [male] circumcision, and I don’t feel like it’s my place to say.” So if I can so graciously back out of the debate when it comes to males, why can’t I do the same with females? To say that these girls aren’t educated about the pros and cons of the procedure, that they’re forced into it by their parents and their culture at a young and vulnerable age (usually at puberty), and that they therefore aren’t making informed consent doesn’t hold up, either, because the same can be said of male circumcision. Baby boys are absolutely, positively NOT making an informed decision when it comes to having their penises cut or not. It’s a decision that their parents are making for them for many different reasons, just as it’s a decision that the culture/ parents are making for the girls who are receiving female circumcision. And I ask again: what right do I have to step in to this decision-making process and tell someone that they’re wrong, or that this decision is wrong? I have no right whatsoever.

Now, before someone comes along and rips into me, let me just make this very very clear: I am not advocating female circumcision, nor am I advocating male circumcision. I am not condoning either practice, nor am I saying that they’re both fine and acceptable, and that they should continue unhindered. All I am saying is that it’s not my place to judge these practices, and it’s not my place to make these decisions. Since I’m not a member of a culture that practices female circumcision, the rich cultural context with which this practice resides is lost on me. The shame or humiliation someone of that culture might feel by not being circumcized and therefore not being a full participant of their culture is something I’m never going to be able to empathize with. And I am questioning whether it is right for our culture (Western culture) to go on huge “Stop Violence Against Women” campaigns in cultures which are not ours, in contexts which we don’t fully understand (and probably can never fully understand).

I do think that these practices need to stop. But I don’t think that the impetus for changing this is going to come from us (from the West), and I don’t think it should. If it’s going to change, it needs to come from within; from women and advocates who are of these cultures, who understand the context, who can see the patriarchy at work in such acts, and who want to rise up against it. And when they do, we as Westerners can and should support them with all of the resources our rich, privileged cultures afford us.

I guess the only sticking point I still have at this point is the following: if you’re a member of a culture, and if it’s all you know, and if you’re never exposed to anything else, you will never have the objectivity necessary to ever question or rise up against these practices that you have seen and been a part of since birth? And maybe that is where an organization can step in and offer education to members of these cultures; ideally, the education should come from members of the culture themselves. I think the folks over at RAINBO are on the right track, and if we as Westerners want to support the education of women (and therefore indirectly the hope that eventually these practices might stop), we can do this by supporting organizations like this.

As far as being a practitioner, the take-home lesson here is once again very simple, and very difficult to fully learn: LISTEN TO WOMEN, and DON’T JUDGE. How is it that I can see this so clearly on issues like abortion, where I absolutely, 100% feel that it is not my place to say, and that since I’m not carrying her baby or walking in her shoes, I have no right to judge at all….and yet issues like female circumcision still bring about huge, heaping amounts of judgement? As a white woman from a privileged background, I’ve been trying for awhile to own my privilege, and see the way that this affects my point of view on everything. This is a difficult, never-ending task, and while I feel that I’ve managed to own this on several more obvious issues, this is an issue I hadn’t even picked up on. I guess the ultimate, life-long goal for every evolving human soul is to continue to move towards a state of less and less judgement. To become as close to non-judgemental as you can possibly be. I say possibly, and “close to” because I think being non-judgemental is an impossible goal. Our psyche, our sense of self, our identities, our culture, our experiences and background and upbringing, everything we use to know ourselves as who we are–all of this is based on judgements which we have formed through living, judgements which we have consciously or unconsciously absorbed, and I think it’s impossible to seperate yourself from them. I am not using this as an excuse. Moving towards a more non-judgemental state requires very close and painful examination of those life experiences and background and upbringing and culture. It requires seeing the ways that your life experiences and culture has potentially prejudiced you, seeing the ways you are privileged, seeing the ways that power affects your identity–power you have, or don’t have, or have in some areas but not others. It requires seeing where you come from, seeing the way that this has formed your world view, and then seeing the way that this outlook affects how you see others. That’s a huge part of becoming less judgemental.

The LISTEN TO WOMEN and DON’T JUDGE take-home message means that all future encounters with women who have been circumcized will involve calling it circumcision, following her cues, and letting her talk or not talk about it, as she desires.

Anyway, those are my thoughts on this subject at this moment in time. Granted, I will continue to think, and I’m sure my thoughts will continue to evolve. I’d be really interested to hear what others think about this as well. It is a very sticky subject, and it’s not about to get any more clear any time soon.

So, I’m back in the blogosphere again, and realizing that I’ve been missing a lot of important news by taking a vacation for a few months. Here’s a quick overview of some of the stories I’ve found most pressing (and/or impressive) lately, even though some of these stories are old news by blog standards, and many other people have already done a much better job at covering them than I have.

First, Verizon Wireless, the cellphone megagiant, has gotten itself into a heap of trouble by initially refusing to allow NARAL Pro-Choice America to host a text messaging service on its network. Verizon initially claimedthat company policy allows it to refuse “highly controversial” and potentially “unsavory” messages from being distributed on its network. NARAL quickly shot back with an action alert and Verizon was flooded with thousands of e-mails and text messages from angry subscribers, and several anti-censorship groups also joined the fray. Quickly realizing it had made a huge mistake (especially when it discovered that other cellphone networks like Sprint and AT&T had approved the NARAL text messaging service without a whiff of protest), Verizon reversed its position, allowing the NARAL text service to go forward, and issued a statement in the press, but NARAL is still hounding Verizon to put its new public policy in writing. Interstingly, since the issue dealt with text messaging and shortcodes, the story was picked up not only by pro-choice and anti-censorship news carriers and blogs, but by sites like Ars Technica and Slashdot.

Sticking to the technology theme, the website Facebook recently started banning pictures of women breastfeeding from user accounts, and in some instances has banned specific users altogether (for example, Karen Speed from Australia, who has chronicled the entire event on her blog, One Small Step for Breastfeeding). Facebook banned certain pictures on account of their “obscene content” and asserted its right to remove pictures as a violation of its terms of use policy, but as the Sydney Morning Herald points out, it’s not exactly clear what constitues an “exposed breast”, which is the specific violation, and Facebook hasn’t provided any further. clarification. Right. So, breastfeeding is obscene, and women aren’t allowed to post their own pictures of themselves breastfeeding on their own facebook accounts. If this bothers you as much as it bothered me, go join the new facebook group entitled Hey, Facebook, breastfeeding is not obscene!

In other news, a 43 year old Russian woman has recently given birth to a 17 lb. baby, her 12th baby to date. Wow!!

Finally, this is a quick reminder to local folks that the 5th annual Miles for Midwives will be occurring this weekend, Oct. 6th, at Prospect Park. The 5K run/walk helps to raise awareness for midwifery, as well as raise money for the ACNM local NYC chapter, and Friends of the Birth Center. My beloved boy and I will both be there, of course, running and sweating in the sunshine. Race time is 10:00 am, rain or shine. If you’re interested in joining the race, you can register at Active.com.

Finally, the long-awaited SUNY Downstate Gala will be occurring this coming weekend, celebrating 75 years of continuous midwifery education. SUNY Downstate is actually the oldest and longest running midwifery program in the country, and is commerorating the event by a day-long educational symposium featuring speakers such as well-known author Barbara Katz Rothman and keynote speaker Joyce Thompson, CNM, followed by a dinner-dance. Sounds amazing! Go Downstate!

My post last week on the UK’s new birth agenda Maternity Matters prompted a UK midwife, Anna Skye, to write the following response on her blog Tales of Midwifery—the Truth. Rather a much-needed reality check, I suppose, to someone (yours truly) whose knowledge of the matter was based only on what she was reading in the media and on government websites. Somewhat deflating, as well, but at least it’s comforting on some level to know that midwives in the UK face just as many challenges as midwives here in the US, and that the true commonality between us may very well be our committment to continue to fight against overwhelming odds and overwhelming systems. When you decide to become a midwife, I think you are committing yourself to a life of pouring your energy and passion and heart and soul and blood and sweat and tears into a cause and a goal that requires enormous work and enormous sacrifice, but does, indeed, make change….just very, very, very slowly. But then, I am still a student, and not yet burnt-out or jaded. Perhaps you should ask me again in another 20 years; hopefully I’ll still be here, still fighting.

Like we didn’t see this coming: as predicted, the newly revamped the Supreme Court is doing its best to steadily chip away at women’s rights without actually having to lift a finger against Roe v. Wade, and in the process is opening the door for State legislatures to enact even more restrictive abortion legislation on a state by state basis. Today, the Supreme Court upheld President Bush’s ban on “partial-birth” abortion, setting a dangerous precedent which, until now, has always been avoided due to the fact that exceptions for the mother’s health are not present in this legislation. Feministing has a great post up on Justice Ruth Ginsberg’s dissent to the decision, as well as the fall-out in the media, including each presidential candidate’s response to this news. Of course, SCOTUS blog and Women’s Health News also have comprehensive posts on the subject. While I occassionally disagree whole-heartedly with ACOG on other matters, this is actually a situation where I applaud their stance on this subject: “partial-birth” abortion is a purposefully inflammatory media term, not a medical term, and the “partial-birth” abortion (i.e. non-intact dilation & evacuation) is rarely used in favor of the safer, more common practice of intact D&E, which is what is medically recommended by ACOG. Rulings which refuse to have exceptions for the woman’s health is placing current “morality” (which is transient, and can obviously change from one administration to the next) over the rights of an individual, which are constitutionally defined and supposedly untouchable. You can read the rest of ACOG’s amicus brief here. I’ll let others expound on what this means for the future of our country (I have a case-study due tomorrow which I must work on now), but this is indeed, a very sad new day.

So, I didn’t think I’d be doing much blogging over my holiday, but as luck would have it, there’s a big debate about birth occurring in England right now—so big it’s been splashed across the pages of many of the newspapers I’ve been reading, and absolutely impossible to ignore. UK Health Secretary, Patricia Hewitt, recently released a new document entitled Maternity Matters which outlines the UK’s proposed new agenda to provide consistent, individualized midwifery care and increased birth choices within the NHS by the year 2009. Looking through the document and the changes it proposes, I can only cheer; Maternity Matters is aiming to provide improved safety, accessibility and continuity of care to all women in the UK, including a choice gaurantee:

“By the end of 2009, women will be able to have:

- choice of how to access maternity care - women will be able to go directly to a midwife or via a doctor.

- choice of type of antenatal care - women will be able to choose between midwifery care or care led by both doctors and midwives

- choice of place of birth - depending on their medical history and circumstances, women and their partners will be able to choose between home births, or giving birth in a midwifery unit or with midwives and doctors in hospital

- choice of place of postnatal care - women will be able to chose how and where to access postnatal care.”

If these changes are adopted, homebirth in the UK will become a viable option again for many women with uncomplicated pregnancies who meet certain low-risk criteria. From a London Times article on the subject:

At the moment just 2% of deliveries in England take place at home but midwives believe this could increase to a third of all births.“The proportion of overall deliveries at home remains static at 2% and we believe that, given a genuine, properly-supported choice many women would choose a home birth,” said Lewis.

“Part of this strategy is to ensure that a home birth becomes a serious and realistic option. …“We know that, if we look at the evidence from other countries, where women have the confidence and support to make this a safe option, there is evidence of a significant increase in women choosing home births.”…

In Holland a third of all women give birth at home. In Wales, where 3% of deliveries are home births, the Welsh assembly has set a target of 10% by the end of this year. In Scotland 1% of births are at home while the figure for Northern Ireland is 0.4%. Devon is the English county with the highest number of women giving birth at home, with a rate of 5%.

Belinda Phipps, chief executive of the National Childbirth Trust, said: “If Holland can manage 30% of all births taking place at home then Britain can do the same.

Of course, this will require a careful assessment of the resources available, as well as a large increase in the number of midwives in the UK (right now, the Royal College of Midwives estimates that the UK is several thousand midwives short of what will be needed to implement these target goals), but listening to a BBC radio interview with Health Secretary Patricia Hewitt, I was encourged to hear how carefully customized the approach will be, examining the needs of each primary care trust, and assessing what resouces are needed to make these proposed changes reality by 2009. If these changes are implemented as proposed, I think the results will be absolutely outstanding.

I say “if”, however, because while I was in England, I was amazed by the amount of negative press I kept seeing on this proposal. If the media’s very loud, very uninformed voice is able to sway public opinion on this matter, I fear these changes will never become reality. Nevermind the BBC interview above, where the interviewer began bullying and interrupting Patricia Hewitt before she could even finish explaining what the proposal was all about—other authors have written even more poorly researched and grossly stereotyped articles. For example, Alice Miles’ London Times article Natural birth! Hello? This is the 21st Century:

Yet we must do more than chuckle, for Maternity Matters is no joke. It is the next stage in a midwife-led campaign to limit the choice available to women giving birth. …A “normal” birth . . . birth without medical intervention: why? Why should we? This is an extraordinary conspiracy against women, a sort of quasi-religious belief in the virtue of pain, which Ms Hewitt is bafflingly encouraging. …We are not expected to have our hips fixed naturally. We are not even expected to endure a mild headache without a paracetamol. Yet somehow the deeply painful and, for some, traumatic experience of giving birth is forced upon woman after woman in the name of some Earth Mother concept. …These midwives trained to help women give birth are for some reason trained only to help them give birth naturally. They are the chief conspirators against us. Please, let us have fewer of them, not more, Ms Hewitt.

Good gods! She’s on a mission, that’s for sure. And while I do feel that on some level this article is motivated by a deep-seated fear of pain, there are several things which must be addressed here. First of all, no one here is proposing to FORCE a woman to have a natural childbirth. Nor do I think it’s the normal modus opperandi of midwives to ignore a woman in pain, or to ignore her desire for pain relief; yes, midwives are trained to help women give birth naturally—we are specialists in normal birth—but I can’t imagine any situation where pain medication would be refused, if that’s what a woman wants. It seems to me that what this proposal is doing is trying to offer more choice, not less. Birth with epidural anesthesia is already widely available and the norm for many women in the UK; for those women who feel very strongly about pain relief, they have the option of planning for a birth in the hospital, with their epidural waiting for them on arrival. They have always had this option, and no one is going to take that away. But for those women who would prefer to have their child at home, and who often encounter resistence of difficulty in pursuing this option, the UK’s new proposal is simply intending to make this choice more readily available to them as well.

While Miles seems to be painting homebirth as a backwards, Luddite option, something akin to squatting behind a bush, and a choice only made by ludicrous, fringe elements of society—earth mothers and hippies—in actuality, research has shown that a planned homebirth for a low risk woman, with emergency transport arrangements made in advance and trained care providers (that would be those natural-birth obsessed midwives, Ms. Miles) attending, is just as safe as hospital birth. Period. In painting homebirth as a choice made by the fringe, she’s mocking and alienating all of the women who make that choice, and who probably wouldn’t consider themselves earth mothers or hippies at all. And who in their right mind would compare childbirth to having your hip fixed? In one case, something is seriously wrong, and needs immediate repair; in the other case, usually nothing is seriously wrong, your body is going about a perfectly healthy, normal process that it has, in fact, been painstakingly designed to do (from an evolutionary perspective), and which often works best when medical intervention is avoided.

Maybe a “predictable, pain-free [cesarean] birth…with a sugeon I had met and trusted, accompanied by lots and lots of drugs” is what Miles would advocate, but the entire point of this is informed consent. Advocating for planned cesareans across the board is just as obsessed and single-minded as painting all women who choose homebirth or pain-free birth as freaks. Nevermind the fact that solid research has shown that cesarean birth is nearly four times as risky as vaginal birth; what about the postpartum pain? A cesarean is major abdominal surgery, with a very slow, very painful recovery period afterwards. If you’re trying to avoid pain, it seems like having a cesarean is a very poor way of going about it.

Birth is always a surprise, and doesn’t always go the way you expect it to (sort of like parenting); those who plan homebirths sometimes end up having to go to the hospital. Those who plan natural childbirth sometimes find that they need pain medication. Those who plan to get an epidural the second they walk through the hospital door sometimes end up having their babies in the car on the way to the hospital, or arrive fully dilated and pushing, and deliver before they can even ask for pain relief. Things don’t always go as planned: that’s part of the beauty of birth. But scheduling a cesaraean before you even know if your birth will medically require one is signing up for major abdominal surgery, point blank, with all of the risks inherent in that, and not even giving your body the chance to try to deliver normally (i.e. vaginally).

Cotton-Pickin’ Days makes another good point in response to Miles:

Guess what, honey? All those drugs and a pain-free birth is just momentary denial. Childbirth and parenting are meant to be painful. It’s what makes you appreciate your children so much more. What’s worth doing in life takes effort and if you think that it’s possible to glide through childbirth, you’re sadly mistaken. Even if a c-section appears to be the tidiest way to go about giving life to children, it isn’t. And it’s wrong to tell women who’re considering their options that your way is the best.

And meanwhile, over at the Guardian, another of Britain’s largest newspapers, Catherine Bennett was also hard at work slamming Maternity Matters in her column: While women in the developing world are dying in childbirth, why are we fetishising doing it at home? While I think the root of this article is lodged firmly in the time-honored tradition of grousing about NHS expenditures, and the decision to prioritize, and therefore spend more resources on birth and on women’s satisfaction with their births, the article nevertheless comes off as poorly researched and highly patronizing.

Bennett begins by focusing on how dangerous birth is, stating that the “consequences [of birth] for at least 529,000 women a year are fatal”. While she acknowledges the inequalities in these statistics, where the risks are obviously higher in undeveloped countries versus developed countries, the underlying message is that despite these advances in developed countries, birth is still a dangerous and risky business, and the women and organizations which support homebirth and the idea that birth is not a medical condition are clearly deluding themsevles, recklessly and arrogantly putting their own lives and the lives of their children at stake. “Such is the hostility to medicine among some natural-birth enthusiasts that doctors are presented as a greater risk to a mother’s health than childbirth”. Which then, of course, leads her to the crux of her argument: how selfish and willfully negligent it is to demand or want a satisfying birth experience, and why should the NHS be spending its limited resources on womens’ satisfaction?

‘Sometimes, even the most fanatical home-birthers have to accept that natural isn’t synonymous with safe. “Our own birth story was as far from perfect as we could have envisaged” posts a mother whose home birth was replaced by a caesarean, following a diagnosis of pre-eclampsia. “My overhwlming feelings in the 48 hours after the birth were of failure.” The baby, you gather, was completely fine.’

Ah, yes. The baby was fine. That classic, soul-destroying argument of “you have a healthy baby, why are you complaining?”, as if a healthy baby, and a healthy outcome, is the only imporant criteria by which satisfaction can be measured. How many times have I heard this used against women? How many times have I seen this argument whipped out to quiet, or perhaps comfort, a woman’s sense of disatisfaction or failure or guilt regarding her birth? You have a healthy baby, shut up and be grateful.

Which is not in any way to deminish how important the health of the baby and mother are, of course. There are certainly times in birth when things don’t go as planned, and a diagnosis of pre-eclampsia is certainly something which must be taken very seriously, but trying to silence a woman’s grief by focusing only on the baby implies that her grief is selfish and egotistical. She becomes caught in this strange paradox where her own feelings are unacknowledged and unaccpetable, and why does she feel so sad and upset when everything turned out just fine? Our society’s constant focus on the baby, the baby, the baby as the only measure of a successful birth is one of the chief contributing factors to our society’s high rates of postpartum depression and birth-related post traumatic stress disorder. So long as we continue to use the health of the baby as the only criteria of a successful birth, we will continue to see advances in “fetal-rights” which place the importance of the baby over the rights of the mother. One has only to look at the fetal rights movement in our own country to see the terrifying implications of this, where pregnant women are losing their constitutional rights and blaming and prosecuting pregnant women in the name of their fetus is becoming de rigeur.

Comparing birth in undeveloped countries to birth in a developed country is a fruitless endeavor, and I still don’t understand why Bennett decided to even mention this in her article in the first place. Unfortunately, women in undeveloped countries are often grossly malnourished, receive little or no prenatal care, have limited access to skilled birth attendents, are often remote from emergency medical care, and practices such as female genital mutilation and epidemic disease, such as HIV, are often rampant, all of which make birth a much riskier undertaking. A low-risk birth in London is a world away from a low-risk birth in sub-Saharan Africa; the two are not comparable, and quoting WHO statistics on world maternal mortality has very little bearing on the fact that a homebirth for a healthy, low-risk woman receiving prenatal care from the NHS, with swift and immediate transport to medical facilities as necessary, can be just as safe as giving birth in a hospital, and is, and should be, a viable option for women in England. As for the argument regarding precious NHS resources, a homebirth is always going to be less expensive than a cesarean, and avoidance of a hospital-stay, which uses hospital staff and resources, will probably prove to be highly cost-effective.

In the end, all I can say is this: best of luck to you, England! Whether Maternity Matters is a success or not (and I certainly hope it will be!), you get huge props just for proposing such changes in the first place. The very idea of individualized, universal midwifery care, with increased choices and rights for birthing women, including homebirth as a real and viable option for low risk-women, is something that the US is years, if not centuries, away from embracing.

So, I’ve been a bit incommunicado thanks to the intensity of my clinical schedule, and the fact that last week was our first exam, and I was busy spending every spare minute studying for it (I’m very pleased to report that I did well on my exam, despite my deepest concerns regarding my sincere lack of study-time). In the meantime, lots of news has been breaking out all over the place, and I’ve been letting it slide. But no longer! Here’s what’s new in the world of women’s health and midwifery news:

First, Merck has recently stated that they’re going to stop lobbying for state legislatures to adopt universal HPV vaccine requirements, in part because of all of the sudden bad press and objections to their lobbying efforts and their fear that continued lobbying would undermine use of the vaccine. Meanwhile, questions continue to arise regarding Merck’s financial invovlement with Texas Governor Rick Perry’s campaign. The CDC has also recently emphasized that no additional warning labels will be placed on Gardasil and that so far, all of the side effects reported with use of the vaccine (mostly inflammation reactions at the injection site and fainting) are low risk.

Since we’re on the subject of vaccines, it appears that research is now targeting Chlamydia for a new vaccine.

A post by Miriam Zoila Perez, the latest NAPW guest blogger, is up on Feministing regarding Radical Doulas.

The Mommy Blawg has a great break-down of all of the latest midwifery legislation being proposed in various states, particularly legislation working to legalize that status of direct-entry midwives (CPMs).

And finally, via Women’s Health News, Tenessee Representative Stacey Campfield has recently proposed legislation requiring a death certificate for each terminated pregnancy in the state of TN, while simultaneously not requiring death certificates for each spontaneous abortion (miscarriage) that occurs in the state of TN. In most states, death certificates aren’t issued until the baby reaches certain gestational age and/or weight requirements, such as 20 weeks, or 500 gms. Since most elected terminations occur during the first trimester, and most spontaneous miscarriages also occur during the first trimester, does it not seem a bit hypocritical to issue death certificates for one and not the other? Naturally, the Tennessee Guerilla Women have plenty to say on the subject. And while Campfield continues to look foolish by trying to deflect attention away from the nitty-gritty details of his bill, NARAL Pro-Choice America has joined the fray by setting up an online form for the women of Tennessee to contact their state representatives.

Amanda from Pandagon and Jessica from Feministing, both of whom were lucky enough to attend the National Advocates for Pregnant Women Summit a few weeks ago, decided to continue to explore many of the issues and topics covered at the summit through weekly guest bloggers hosted on Feministing. The first two are up already:

Jill Morrison on Laws that Punish Pregnant Women and Priscilla Huang on Killing the Immigrant Body.

Both are fascinating and highly recommended reads. Can’t wait to see who the new guest blogger will be.

Texas governer Rick Perry has recently signed an Executive Order requiring all girls between the ages of 11 and 12 to be vaccinated with Gardasil, Merck’s new HPV vaccine, which is currently the only vaccine on the market that treats HPV (other HPV vaccines from other companies are in the pipeline and soon to be approved by the FDA). In response to this, Texas legislators have recently proposed a new bill to remove Gardasil from the vaccination list required by TX law for entry into public school.

Governor Perry’s Executive Order has kicked up a lot of dust. While many people initially opposed universal HPV vaccination under the premise that it would encourage promiscuity in teenagers and women, concerns about the safety of the vaccine, as well as its long-term effects, have also been raised. From a legal standpoint, many people feel that requiring HPV vaccination for entry into school is an enfringement on their rights, particularly since the public health need for this vaccine is not as pressing, given that HPV is not an airborne or contact communicable disease that can be transmitted at school, but is actually an STD requiring genital to genital contact, and the rates of cervical cancer in this country are actually very low (annual pap smear screening for cervical cancer is one of our greatest public health success stories!). Questions have also been raised about the motivation behind this vaccine, given that Merck was a contributor to Perry’s campaign fund, and Merck alone stands to profit from routine vaccination of all girls in Texas, which the New York Times is estimating will cost at least 60 million.

Rachel over at Women’s Health News has posted three very thoughtful posts about this new law which encapsulate much of the current debate. The comments from her readers in particular are very telling:

1) On the Texas HPV Vaccine Law, 2) Backlash against Texas HPV Vaccine law continues, and 3) HPV Vaccine Concerns

For my own part, I would like to address some of the misinformation about the HPV vaccine that is floating around right now. From a reader on Rachel’s site who was arguing against universal vaccination: “…2) There are 15 types of HPV. The vaccine, created by Merck, which has received so much media attention, protects against 2 types of HPV. These two types are implicated in causing 70% of the cervical cancers that develop. 30% are caused by the 13 other types of HPV which this vaccine is no protection against.”

There are actually over 100 genotypes of HPV which have been discovered to date, of which approximately 30 strains are found in the genital mucosa. Of those 30 strains, 15 have been shown to be associated with cervical cancer, in particular types 16, 18, 31, 33 and 35. These types are considered the “high risk” strains and are usually subclinical/ non-detectable. Approximately 70% of cervical cancers result from infection with HPV genotypes 16 and 18. In contrast, HPV types 6 and 11 are considered “low risk”, and are responsible for 90% of all cases of genital warts (i.e. highly clinically detectable). HPV is spread through direct genital to genital contact, and can be transmitted even when using a condom, since a condom does not cover the entire genitalia.

Gardasil is a quadrivalent human papilomavirus L1 virus-like particle vaccine which offers protection against HPV genotypes 6, 11, 16 and 18. In other words, the two strains that are most often responsible for cervical cancer, and the two strains that are most often responsible for genital warts.

However, as many readers have pointed out, Gardasil only offers protection for 2 of the 15 genotypes associated with cervical cancer and only 2 of the genotypes that cause genital warts, and the research is not conclusive on how long Gardasil is able to offer protection, or whether booster vaccines will be needed at a later date. It is also important to note that all of the research on this topic has been funded and carried out by Merck. Most importantly, the pap smear has been a highly effective screening tool for cervical cancer since the 1960s, responsible for early detection and treatment of cervical dysplasia, and the number one reason why cervical cancer rates are so low in this country (although still disproprotionate: cervical cancer rates are highest for low income and uninsured women). Worldwide, cervical cancer is the second largest cause of female cancer mortality, with an estimated 493,00 new cases each year and 274,000 annual deaths. In other words, even if you do choose to be vaccinated with Gardasil, annual pap smears are still crucial.

It will be interesting to see how this plays out, both in the media and in the legislature. It will be interesting to see if other states follow Texas’ lead. The HPV vaccine is an extraordinary breakthrough, the first vaccine ever created that actually targets cancer, but as with any new vaccine or drug touted as a new miracle, I think a little caution in the beginning is well founded, since new research is still incoming and the long-term effects are unknown.

Source: ACOG (Sept., 2006) ACOG Committee Opinion #344: Human Papillomavirus Vaccination. Obstetrics & Gynecology, 108 (3), Part 1: 699-705.