Belly Tales

Sometimes, briefly, you feel like you’re making progress, that midwifery outreach is making a difference, that people are becoming more educated and informed, and then you read an article like this one, over at Time Magazine, and you realize that you exist in a small bubble where your philosophy on birth is far different than the majority of the country, and no matter how much you talk yourself hoarse educating people about the issues, they’re still going to buy into the myths of birth, hook, line and sinker.

Cesarean births are not “safer”. Numerous studies have demonstrated, again and again, that cesarean births carry more risks than vaginal delivery, and these risks multiply with each cesarean birth. Sure, the woman in this article had a “safe” and uncomplicated primary cesarean, but no attention is given to what happens when this same woman comes back for her second or third repeat cesarean—how difficult it is to perform surgery on the same site, to cut through scar tissue, how the risks for abnormal placentation such as placenta previa or placenta acreta increase exponentially with each cesarean, how the risk of hemorrhage increases dramatically. There’s also no discussion about how painful recovery from a cesarean is compared to recovery from a vaginal delivery, and how statistics have shown that this poorly affects bonding and breastfeeding rates in women who’ve given birth by cesarean. (Not to mention the fact that the motivation for elective cesareans for many women is a fear of pain, and in fact, the entire process is often much more painful, for a much longer period of time, post cesarean).

Vaginal delivery can, for example, lead to future incontinence and pelvic damage, while babies born by C-section may suffer from respiratory problems because of not being exposed to certain hormones during the birthing process.

Where is the author, Alice Park, getting this information from? How come there are no articles or references cited? I thought we were well beyond the argument that cesareans prevent pelvic floor damage. While injury to the pelvic floor can and does occur during vaginal delivery, it’s often caused by practices such as episiotomy, vacuum-extraction, forceful pushing and lithotomy position during deliveyr, all of which can be (and are being) minimized during vaginal birth. Routine episiotomy, for example, is now by and large a thing of the past. Furthermore, there is no conclusive evidence which demonstrates that cesarean section prevents pelvic floor damage. To quote from What Every Pregnant Woman Needs to Know About Cesarean Section (2006), published by the Maternity Center Association:

Is vaginal birth in and of itself harmful? It is common to hear that “vaginal birth” causes pelvic floor problems. Of hundreds of studies examined, however, not one attempted to avoid or limit the use of practices that can injure a woman’s pelvic floor to try to determine whetehr vaginal birth itself plays a role. It is wrong to conclude at this time t hat the cause of pelvic floor problems is giving birth through the vagina….

Is “vaginal birth” the culprit in the high levels of incontinence that women experience later in life? Studies that take a longer view find that new problems with urinary incontinence that appear after birth lessen over time. These problems tend to completely disappear by the time of menopause. Older women experience high rates of incontinence, but this appears to be due to other factors. For example, excess weight and smoking play a role.

Does cesarean section prevent incontinence? Routine cesarean section would only prevent continuing symptoms of incontinence in a small portion of birthing women. For most women, it would pose numerous risks without benefit. And it would offer no protection against experience incontinence in later years. As no research has found that vaginal birth itself causes incontinence, there are more sensible ways to prevent these problemss: 1) avoid when possible the use of birth interventions that can injure the pelvice floor, and 2) focus on keeping a healthy weight, avoid smoking and other risk factors.

(Still not convinced? Check out the following studies:

[1] Shorten, A, Donsante, J. & Shorten, B. (2002) Birth position, accoucheur and perineual outcomes: Informing women about choices for vaginal birth. Birth, 29(1), 19-27.

[2] Terry, R, Westcott, J, O’Shea, L., & Kelly, F. (2006). Postpartum outcomes in supine delivery by physicians versus nonsupine delivery by midwives. The Journal of the American Osteopathic Association, 106(4), 199-202.

[3] Soong, B., & Barnes, M. (2005) Maternal position at midwife attended birth and perineuam trauma: Is there an association? Birth, 32(3), 164-169.)

The point being, I can’t believe such a mainstream publication could write such an imbalanced, one-sided and poorly researched article. I think I feel a letter to the editor coming on!

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.

Sometimes birth is not normal. Sometimes there really are complications and problems which need to be dealt with in a hospital setting. Sometimes a medical approach to birth is exactly what’s needed. Sometimes interventions during birth ARE lifesaving. Yesterday was a perfect example of that. I was helping to take care of a woman who was incredibly high risk and had the odds stacked against her in terms of her chance of having a normal, uncomplicated delivery. She was severely anemic, and had been throughout her pregnancy; and not just the usual anemia of pregnancy—no, this was a woman who had a hemoglobin of 6.5 at one point during her 3rd trimester, and a hematocrit of 19%. (To put that in perspective, bear in mind that normal is a Hemoglobin of 12-13 or greater, and a hematocrit of 32-33% or greater.) She had been seen by Hematology several times during her pregnancy and had had numerous anemia work-ups. It all pointed to iron-deficiency anemia, and she was taking iron replacement therapy, but there’s only so much that this can do. At one point during her pregnancy she had been offered a blood transfusion, which she had refused. When she was admitted, her hemoglobin was 7.8 and her hematocrit was 21%—numbers which didn’t demand an immediate transfusion, but which were very concerning given the fact that she was going to give birth, and giving birth means losing blood, and if you’re severely anemic you don’t really have any blood to lose. Our professor used to say that if a woman is severely anemic, she “can’t tolerate” a hemorrhage…which is what…a polite way of saying that she’ll die?

In addition to the severe anemia, she was also preeclamptic. Her baby had oligohydramnios, probably caused by the preeclampsia (unchecked hypertension and poor placental perfusion can lead to intrauterine growth restriction and oligohydramnios, both of which are not good signs). She had protein in her urine, was hyper-reflexive, and was starting to have toxic symptoms (blurry vision, headaches, visual changes, epigastric pain, edema). She was admitted for an induction of labor immediately on account of the oligohydramnios and preeclampsia. To my way of thinking, this was the right call. With preeclampsia, you don’t want a patient sitting around at home with skyrocketing blood pressure—it can lead to siezures if untreated, and the only cure is birth. Similarly, oligohydramnios indicates chronic, long-term insult to the baby, which sadly means that the womb is no longer the best environment for fetal well-being.

This was her second baby. Her cervix was 3 centimers dilated at the start of the induction, so rather than using a cervical ripening agent like cytotec or cervadil, pitocin was started instead. Because she was preeclamptic, she was also started on Magnesium Sulfate, which prevents preeclamptic seizures by causing systemic smooth muscle relaxation. Mag is an awful drug. It makes you weak and hot and sweaty, and it often complicates inductions because it’s hard to induce contractions when a woman is receiving a medication which is causing all of her muscles to relax. Pitocin and magnesium are always at odds with each other. I think a lot of preeclamptic inductions fail because of the magnesium.

Anyway, maybe it was because of the magnesium, maybe it was because her first labor was also a very long, drawn-out labor, but in any case, her progress was very slow. I admitted her on Friday, and she was still in labor when I came back 12 hours later, on Saturday. She hadn’t made much progress; she was only 4 centimeters dilated when the doctor checked her that morning, and was still 4 centimeters when the doctor checked again 3 hours later. Her bag of water was broken by the doctor, an intrauterine pressure catheter was inserted to measure the actual strength of the contractions, and the pitocin was duly increased. And increased, and increased. It got as high as 28 miliunits/min., which was as high as I’ve seen it in a long time. Her contractions were adequte (because of the IUPC, we were counting montivideo units, and yes, they were adequate), but they were always irregular. When I checked her again 3 hours after the IUPC had been placed, she was only 5 centimeters dilated, and it was a tight 5 (I was worried that I was being too generous, and that the doctor would come behind me and check her again and decide that she was still only 4 centimeters, that she hadn’t made any progress, and that she would therefore need a cesarean for failure to progress).

I was really worried about this woman and this baby. I was worried about a severe hemorrhage. She had so many risk factors leading up to it; she was on magnesium, which relaxes the uterus and makes postpartum uterine atony more likely. She had been on pitocin for almost 24 hours, which tires out the uterus and makes postpartum uterine atony more likely. And because she was severely anemic, she couldn’t hemorrhage. She had no blood to loose. I was worried that after another three hours of little or no progress, she would give birth by cesarean, which means that her blood loss would be at least 800 cc. She didn’t have 800 cc to lose.

At least the tracing was always reassuring. I’m sure that if, at any point the tracing had begun to look anything other than beautiful, there would have been an immediate cesarean. Her urine output was always good, her magnesium levels were always on target (never too high or too low), and all of the medications we were giving her seemed to be doing their jobs. The woman seemed to be taking everything in stride, as well. I was amazed by her strength. She never panicked, even when she first found out that she had preeclampsia and would need to be induced. She had an epidural and was comfortable. She slept for several hours at a time, as did the rest of her family (her partner and grandmother, both in their chairs with their mouths open, snoring). She asked a few questions here and there, but for the most part, she seemed to trust that things would be okay. She must have known something that I didn’t. I was worrying plenty for the both of us.

Three hours after my last exam, I was unsure of what to do. I didn’t want to check her again and have to be the one to discover that she was still only 5 centimetrs dilated, and then have to notify the doctor and watch the entire thing get written off as “failure to progress”. On the other hand, we’re supposed to round on the women we’re taking care of every 2 hours, and I was trying very hard to be on top of things; it was already an hour past when I was supposed to check her and write a note. I called my preceptor on the phone and discussed the situation with her. We decided to write a note on her well-being, lab values and fetal status, but defer the exam for another hour, if possible. I hung up the phone and walked to the room, only to discover that the doctor was already there, and had just checked her. She was fully dilated.

I didn’t even have time to marvel over how she’d managed to go from 5 centimeters to fully in 3 hours…not that this is an impossible thing at all (many 2nd time moms do the entire labor in 3 hours or less), but she had been making such slow progress, and her body was battling the magnesium every step of the way. I was so incredibly, pleasantly surprised! I barely had enough time to get my gloves on before the baby’s head was crowning. He wasn’t a very large baby. She pushed him out in 6 minutes, and he began to scream and wave his arms around. Her partner cut the cord. The pediatricians were there on account of the prolonged magnesium exposure in the baby, but everything was fine.

The placenta came out 4 minutes after the baby, and we began to massage her uterus immediately. It wasn’t firm right away, but it firmed up with massage. We ran 40 units of pitocin in 1 liter of IV fluid (we couldn’t give her methergine because her blood pressure was too high, since methergine can cause a stroke if given to hypertensive women) and…please, no heavy bleeding…please, no hemorrhage…please, let it stop….and it did. She lost blood, but a normal amount. She had a small, first degree laceration which we quickly repaired so that it wouldn’t bleed very much.

And that was it. All of those risk factors, all of those hurdles to overcome, and in spite of it all, a normal birth. Even with the doctor in the room. Even with multiple IV lines, and packed units of red blood cells ready and waiting in case she hemorrhaged. Even with an induction that lasted 28+ hours, and heavy medications competing against each other. Even with a midwife that was worried about so many things that could have potentially gone wrong, which didn’t. Even in high risk situations, with all sorts of complications, even with a prenatal course and labor which is anything but normal….normal birth can and does still occur.

Today I caught my 50th baby! She was born at 4:18 pm to a young woman from Puerto Rico who was absolutely thrilled and excited about her first pregnancy. She was an induction for postdates (per hospital policy, all women are induced if they’re still pregnant at 41 weeks); she’d actually had an incidence of preterm labor earlier in her pregnancy, but now, instead of the baby coming too soon, we had the opposite problem—a baby that didn’t want to leave. Because she was an induction, she was on pitocin, and because she was on pitocin, she pretty much had to stay in bed (again with the hospital protocols…). She was so strong and so tough, though, laboring in bed for the entire afternoon and refusing an epidural the entire time, through every single pitocin-induced, booming, more-intense-than-natural-labor contraction. The only thing she took for pain was a dose of stadol when she was around 5 cm dilated. I think her birth team made a big difference for her. Her mother and the father of the baby were at the bedside with her all afternoon, fanning her and bringing juice and ice water, putting cold packs on her head when she was hot, massaging her legs and arms. I couldn’t get over the father, in particular. He was such a young man (19 years old!), but his maturity was well beyond his years. He knew just when to be attentive, and just when to be quiet and not pester her with questions or ministrations or conversation (during transition, she didn’t want anyone to touch her). When she was pushing, he was so excited by the tiny glimpses of head we were seeing with each push; he couldn’t wait to meet his baby. He kept encouraging her to keep pushing, she could do it, soon she’d have their baby etc. etc. (I barely had to say a word of encouragement, he was doing such a good job of it all on his own). We pulled the mirror out after the first hour of pushing, and this really made a difference for her. Once she could see her progress in the mirror each push was better and better. The baby crowned in right occiput anterior, and she was able to breathe the baby out in between the contractions in such a way that she didn’t even tear her perineum (she did have a small laceration inside the vagina which required 5 stitches, but the actual perineum itself was intact). When the head restituted, the shoulders came out almost transverse rather than vertically. It was almost as if the baby were spinning inside her very roomy pelvis. The little girl (7 lbs, 2 oz.) started crying almost right away, and her beautiful family all burst into tears (especially the young father), which then made me tear up as well (seeing a family cry always gets to me, every time). The father cut the cord. Afterwards, the baby latched onto the breast like a pro and had a very tasty meal of colustrum while I did the small repair. There was no other midwife in the room with me (my preceptor was out at the nurse’s station, within shouting range, but minding her own business). The saying goes that somewhere around 100 babies, you start to get a clue as a new midwife. I guess that means that I have roughly half a clue, right now, but today, for the first time, I felt like…yes, I really am I midwife.

Rachel commented, in response to my Worry-wart = New Midwife post: “I was interested to see in your description how “medical” the treatment of the L&D patients seems to be, despite having a midwife on hand. Any thoughts on that?”

Of course I have thoughts on that!

First of all, this is hospital midwifery and hospital birth. Unfortunatley, you almost have to think of it as a different species of midwifery all together. Because this is occuring inside a hospital, and there are hospital regulations to follow, there are protocols in place which limit the amount of freedom a midwife has to manage her clients in a more traditional “midwifery” manner, and there is a constant push-and-pull of politics and power at play. Who ultimately gets to make the calls? Is it the women themselves, who are educated and empowered enough to demand the kind of birth experience they want? Is it the midwives, fighting and advocating for these women? Is it the doctors, whom the midwives collaborate with? Is it the nurses, who often choose to ignore the breastfeeding-friendly initiative that’s been established in our hospital, and try to bring the baby to the nursery as quickly as possible after the birth in order to limit the amount of work they have to do right after the birth?

Ultimately, it’s a combination of all of those things which impact the overall birth experience. This is a midwifery service located in a very busy urban hospital in a very poor, underserved section of Brooklyn. Our clients are women from all over the world. Many of them are recent, first-generation immigrants, and presumably many of them are here illegally (we never ask). Many of them don’t speak English—they speak Spanish, Urdu, Polish, Hindi, Arabic, French, French Creole and Patois, predominantly. On the whole, many of these pregancies are unplanned. Home situations vary incredibly. Sometimes the father of the baby is supportive, sometimes they’re married, certainly sometimes it’s a planned and wanted pregnancy, but sometimes the woman and her partner are no longer on speaking terms, sometimes there’s a court order against him, sometimes the aunts and mothers and grandmothers of these women will be raising the baby while the woman goes back to finish high school. Planning for the pregnancy and birth is often done under very difficult circumstances. By and large, these women are not showing up to labor and delivery with doulas and birth balls and birth plans, having read all the latest childbirth books and having bought the latest, most ergonomic birth sling. They’re not online, with internet access, reading blogs like ours or doing research about their birth choices. But most importantly, these women are not choosing midwifery care. They’re coming to our hospital clinic because they can get prenatal care for free with us if they don’t have health insurance and they qualify for medicaid and WIC and PCAP. They’re being taken care of by midwives because their pregnancies are predominantly low-risk and healthy, and because the hospital finds midwifery care to be cost-effective and economical, but are these women seeking us out, or looking for the midwifery experience? Not really. And are these women really after a natural childbirth experience? Again, for the most part, not really.

Women generally see one midwife for their prenatal care, but unfortunately, labor and delivery is covered in shifts. It’s a 24-hour service, so there are always two midwives on L&D at any given time of the day or night, but it may not necessarily be the midwife who took care of you during your prenatal care. Which means that when you come to the hospital to give birth, the midwife you know and are familiar with may be there to deliver your baby, but there’s also a good chance that she won’t be. It’s not ideal, by a long shot, but this is the difference between private practice midwifery, which is often a luxury item reserved for those who can afford it, and hospital midwifery, which serves underserved populations with excellent care, but isn’t set up in such a way that the midwives are on-call for their clients.

So, in a hospital setting, where does the midwifery care come in? We don’t have a birthing center, and there really isn’t a birthing center vibe to the place. However, I think the midwifery aspect comes into play in many areas which aren’t immediately obvious because they’re subtle, but I do think it makes a big difference overall. For one thing, the number of women getting epidurals on this floor seems to be much less to me than in other hospitals where I’ve worked as a nurse (and these were all private hospitals predominantly served by private doctors). I chalk the decreased epidural rate up to the increased labor support the women get from the midwives and the nurses. The c-section rate is also much lower in our hospital than it is in many other hospitals in the city (22% last year, v. 30-35% in other hospitals in NYC, and certainly much lower than the national average), and our VBAC rate is much higher than in many other hospitals in the city, as well as higher than the national average (I think this comes from the fact that there is one dedicated VBAC counselor who counsels all the women, and the midwives really work hard to find the op report and talk to women about the benefits/risks of VBAC). Women are allowed to eat clear liquids (juice/jello etc.) during labor, which is a big improvement over many other hospitals where women STILL aren’t allowed to eat anything (and which is still occurring on a regular basis at other hospitals). Women can get out of bed if they’re not on pitocin (again, something which doesn’t occur that often in other hospitals). We push in side-lying or sitting positions, we push with squat bars, we let women push on the toilet or standing (hanging) in a suspended squat.

More than any of this is, though, is the midwifery philosophy which is held by the midwives, and which is always at work in the hospital. I’ve been working here for only about 4 weeks, but a lot of that time has been spent advocating for natural childbirth and breastfeeding and trying to find a way to limit the number of interventions performed in labor and delivery. As the midwife, it’s a constant struggle. Sometimes it means jumping through hoops, or presenting patients to the doctors in a such a way which highlights the positive (she’s making change, just slowly…but no, I don’t think she needs pitocin or a cesarean or etc. etc.) and downplaying the negatives. It doesn’t mean changing the facts, it just means fighting and doing everything you can to let a normal birth unfold, even in a hospital. It’s a crazy balancing act, balancing so many different needs and agendas and pressures and desires. I think this philosophy can be seen in the amount of patience which the midwives display, the effort put into offering a humane, hands-on touch, and the deeply held belief that BIRTH IS NORMAL, that women CAN do it, that all women deserve respect and informed choice, that they deserve explanations, that no one is going to just walk in and rupture their membranes without talking to them about it first and making sure it’s okay. To me, the midwifery philosophy, at its very core, means LISTEN to WOMEN, DON’T JUDGE, and return the power of labor and birth back to the WOMAN, where it belongs. We don’t deliver babies, we catch babies; it’s the woman who does all the hard work. It’s the woman who delivers her baby. It’s her body, it’s her baby, and it’s her birth. Women in this hospital are powerless in so many ways, and are often so used to giving up there power. They don’t always ask questions because they don’t realize that they have a right to ask questions—that they can ask questions. The midwifery philosophy at work in a hospital helps to correct this imbalance and inequality, even if only a little bit. So much of midwifery care is education, and education is power.

I’ve recently had a birth which really illustrate these points, and which I’ll write about below, but in any case, I do think the difference is palpable. Yes, it’s hospital birth. Yes, there are lots of monitors and beeping machines, there are hospital protocols which must be followed, women get epidurals (but only if they want them), we use pitocin, there aren’t tubs, and unfortunately no one has time to rub lavendar oil into anyone’s back (simply because this is an incredibly BUSY hospital, and you rarely have time to pee, let alone massage someone during labor), but I think we still provide excellent midwifery care to our clients. Even if it wasn’t necessarily the kind of care they were looking for in the first place, I think that many women find that they really enjoy midwifery care, because we as midwives are trying so hard to give them choices, to help them take control of their bodies and their births, to be able to say no to treatments or procedures they don’t want, and of course, treating them with dignity and respect (again, things which aren’t always in large supply in hospital settings).

Case in point: last week I was taking care of a woman who was laboring with a baby that was Occiput Posterior, meaning that the baby was face up instead of face down, and that therefore the back of the baby’s head (the hardest part of the baby) was up against the woman’s back. OP happens quite frequently during birth, and can make labor a lot longer and more difficult, because it’s not the optimal fetal position for a quick and easy birth. And indeed, this woman was making progress, just SLOW progress. She was 6 cm dilated at 8:00 am when we first came on our shift, then she was 8 cm at 10:30 am (when I broke her water because she was asking for something to speed the process up). She was 9 cm at noon, had progressed to anterior lip at 2:00 pm and was finally fully dilated at 4:00 pm. I was getting really nervous because she was gong so slowly and I was conscious of the hospital pressure which always exists, and which goes something like this: as soon as you’re admitted to the hospital, you better be moving towards birth, and moving at a pretty regular, pretty rapid pace. It was my preceptor that day (a big, loud-mouthed woman who’s been a midwife for 10+ years, possesses loads of confidence-born-of-experience—which I don’t yet possess—and is not afraid to tell the truth, whatever that may be) who was the calm rock of this birth. She’s the one who told me to quit checking our patient, to just sit tight and watch her labor unfold and trust that everything is going the way it should. So that’s what we did.

Because our patient didn’t have an epidural and she didn’t have pitocin going (she just had two fabulous midwives, sitting in her room with her because it was a quiet day), we got her out of the bed and let her sit on the toilet for awhile, let her walk a little bit, but eventually she wanted to get back into the bed, so we helped her back into bed and then helped her roll side to side every 20 minutes or so. Position change is a key to managing OP birth, as I’ve been learning; just keep changing position, and eventually the baby will slowly rotate and work its way into an anterior position (that’s the hope, anyway). Luckily, the tracing was beautiful—we couldn’t have asked for a nicer tracing, with these huge, reassuring accelerations into the 170s with almost every contraction—so we weren’t under a time crunch to get the baby out quickly. Everything was going smoothly, just slowly.

Then, once she’d been pushing for about an hour, one of the doctors stormed in (having just finished a c-section) and threw a little hissy fit, right in front of the patient: why is this woman STILL pregnant?!? Why haven’t you started pit? What are you guys doing in here? Start pit! This is ridiculous. Etc. etc. Nevermind the fact that he hadn’t been paying attention to her all day; she was a midwifery patient, and we had been managing her, but now that it was 5:00 pm and he was signing off to the oncoming doctor he suddenly wanted her to have been delivered ages ago (I guess it looks bad to the oncoming doctor that he’s had a patient all day who still hasn’t delivered yet? Again, this is part of the hospital pressure mentality which says “as soon as you’re admitted to the hospital, you better be moving towards birth, and moving at a pretty regular, pretty rapid pace”). This doctor kept saying: she was 6 cm at 8:00 am, what are you guys DOING in here?? She should have had her baby already!! etc. etc.

And to be honest, I was absolutely, 100% cowed and terrified. As a new midwife, in my near-constant state of terror, I have very little confidence in myself or my management skills, and unfortunately this translates to a whole lot of fear right now; fear of birth, fear of doing something wrong, fear of making a really big mistake etc. etc. If it had been me alone in that room, I probably would have burst into tears. I had already been wondering to myself if we should have started pitocin. But no, thankfully my preceptor was in the room with me, and she very calmly, tranquilly and firmly told the doctor to chill his pants. She basically said: we’ll start pit if you absolutely insist (he is the doctor, after all), but she’s having an OP baby, she’s making progress, and things are fine and NORMAL in here, so please leave and let us do our thing. And what do you know…he left! And then we started pit (and actually, for what it’s worth, the incoming doctor got into an argument with the outgoing doctor at the board, stating that our patient probably didn’t really need the pitocin. If her contractions were enough to get her to fully dilated, albeit slowly, then they were probably enough to get the baby delivered.) But anyway, we started pit, and she pushed and pushed and pushed. And here, I think if she’d had an epidural, she wouldn’t have been able to push that baby out, but thank goodness she didn’t have an epidural so she could really feel the urge to push with each contraction, and eventually the baby did a long-arc rotation and was born from right occiput anterior at 5:39 pm, screaming his head off, and voila!….a totally normal labor and birth.

Would that birth have been different if she hadn’t had midwives taking care of her? Yes, I think so. Maybe she would have had an epidural, and been unable to push her baby out. Maybe a different provider would not have accepted her slow progress, and started pitocin on her a lot sooner. Maybe someone else would have considered her lack of progress as “failure to progress” and she would have been taken to the back for a cesarean. Maybe if no one had gotten her out of bed, or sat with her in the bathroom while she pushed on the toilet (something the midwives have to do, because the nurses won’t take responsibility for the patient if she’s off the monitor, so unless the midwife is in the bathroom with her or walking with her, they don’t let her out of bed), maybe if she hadn’t been walking and changing position so much, maybe that baby wouldn’t have rotated. Who knows. The point I’m trying to make is that midwifery care, admittedly in a somewhat altered and modified form, is alive and well in a hospital setting. Unfortunately, there are just more rules to conform to, more egos and personalities to manage, more pressure and time-crunch, and there isn’t that lovely, private-practice one-on-one kind of care which is one of the hallmarks of midwifery care in other settings. Is there still a lot of things which can be changed? Yes, of course. Is there still a lot of things which are far less than ideal in our set-up? Undoubtedly. But I think the midwives are giving excellent care to our patients, in the best way we can, and I think it really does make a difference.

So, you’re probably wondering how it’s going. I’m in the middle of my third week as a new midwife, and it’s going…okay…so far, I guess. I wish I could sound more confident and enthusiastic about it at the moment, but I’m having a hard time feeling very confident or enthusiastic these days. Which is not to say that I am not absolutely *thrilled* to be finally working as a midwife, or delivering babies, or taking care of so many beautiful pregnant women (I am!!!), it’s just that my general state lately has been one of extreme nervousness and tension and uncertainty. Which is, according to many of my loving and supportive preceptors, something that is expected, and something that is normal for a lot of new grads, but even so…it’s not a very pleasant place to be living in at the moment. Even if I did expect that it would feel like this.

I think the nerves and tension is all coming from the sudden onslaught of responsibility. I feel unbelievably responsible, for everything, at the moment. Heavy with repsonsibility. I’m taking my patients home with me, worrying about them at night. And I’m so scared, with all of this new responsibility, that somehow I will totally, terribly mess something up. Which I’m sure I will, given that I’m new, and bound to make mistakes, and that some of the best learning you ever do is from your mistakes. It’s just…I can’t make huge mistakes. I really can’t. These are people’s lives and bodies and pregnancies and babies on the line, so…no mistakes, right? Except that how can you learn a new job, as a new grad, and not make mistakes? Do you see where the tension headaches and the knots in the middle of my back come from?

I’m still on orientation at the moment. I have three full months for orientation, which means that my orientation will finish sometime around Jan. 10th. Ostensibly, I can ask for more time, if I feel like I need it, but I do recognize that there is a strong hope that by three months in I will be able to work like a fully functioning midwife, someone who can be an asset to the practice. And I hope the same as well, although at the moment, I’m a bit terrified of being on my own, and I certainly don’t feel ready for that. Have I mentioned lately how NUTS this practice is? How busy and crazy and overwhelming and exhausting it is? Which is fabulous, on the one hand, and is certainly one of the reasons I picked this job (after a year of this, just think of all of the amazing experience I’ll have)…but, on the other hand, is incredibly overwhelming, exhausting, crazy etc.

The sheer pace of the place is enough to knock you out: in the clinic, on average, the midwives are seeing about 25 patients a day, often more like 28-30. IN ONE DAY? Good lord, how do you even have time to say hi to that many women, let alone ask them all about their health and bodies and pregnancies, or deal with all of the many problems and questions they have? Just to give you an example: one of the women I was taking care of last week had had a positive chlamydia test two months ago, had been treated, had then slept with her partner again (who had not yet been treated), had contracted chlamydia again, and had then been treated again. She had also had a positive PPD test (for tuberculosis), an abnormal pap result, and a prior cesarean, in the Dominican Republic, and was desiring a vaginal delivery this time around. So on my visit with her, we were talking about safer sex and what that involved, abstinence until her partner could be treated, a referal for her partner to the male STI clinic, the need for a chest x-ray (to follow-up on the positive PPD test), the need for a colposcopy during her pregnancy (to follow-up on the abnormal pap smear), and the importance of getting the operative report from the hospital where she had had her cesarean in the Dominican Republic, so that she could be counselled for a VBAC and receive a trial of labor with this pregnancy (in order to have a trial of labor at this hospital, women need written proof of the fact that they had a low-transverse uterine incision during their cesarean, and are therefore at lower risk for uterine rupture). And then we went ahead and did all of the normal pregnancy visit things: is the baby moving? How’s your diet? Looks like you’re gaining a good amount of weight. Vital signs stable? Urine dip negative? Measure the uterus, palpate the baby, listen to the fetal heart, review warning signs and danger signs. Are you still taking the prental vitamins and iron? Any questions? And then, after all of that, we did a chlamydia test one more time to make sure that she’d been adequately treated. The entire visit took me about an hour. And rightly so. But technically, she was a revisit, and was supposed to only take about 15 minutes. On average, I’ve been seeing about 9-10 women a day, on a good day for me. I just can’t go any faster than that without missing something or forgetting something or not picking up on something…in essence, making a mistake.

And labor and delivery…wow. Where do I even start? I’m going fine so far, I’ve delivered three beautiful babies so far, but that’s only because I’ve been sheltered by my preceptors so far, and am not truly doing the entire job yet. They’ve been giving me one or two patients to manage so far, or else they plunk me down in the middle of triage to sort out all of the incoming women, and that’s fine. But that’s about as much as I can do right now. And meanwhile, beyond the doors of triage, there are all of the women who are in labor, who I can’t really keep track of at all. Room 5 is 6 centimeters dilated, room 7 is 8 centimeters dilated, room 8 needs another dose of cytotec, room 10 needs another note written on her at 2:00 pm, and room 5 and 7 need a note written at 2:30, and room 10 will need a note as soon as the cytotec is placed, which will happen just as soon as one of the midwives gets a chance…I have no idea how to keep track of the floor. I have tunnel vision. Keeping tabs on one or two patients is about as much as I can handle, and that is plenty to keep me busy. More than plenty. Admitting a patient, and getting through all of the paperwork, takes me a solid hour or so. I’m being very thorough…I’m proud of my notes, but I’m slow.

And the thing is, it’s okay to be slow right now. No one is yelling at me to be faster….yet. But I know…I dread…that soon enough, too soon, I will be off orientation, and then I’ll be in trouble. And granted, I’m sure that my ability to handle all of this will increase tremendously in the next three months, and worrying about running the floor at this point is fruitless and stupid, because no one is asking me to run the floor yet. So why even worry about it at this point? And yet, I can’t stop myself from thinking about it. I find myself worrying about everything right now.

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!

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.

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.