Last night I was working (at the HHC public hospital in Brooklyn where I spend a good deal of my time) and I received a phone call from a sister midwife who works with me at the same hospital.  She had just been contacted by a mutual midwife friend who had been contacted by a homebirth midwife who was in the middle of attending a difficult delivery last night and was considering a transfer to a hospital.  While I don’t know all of the details of the birth, I do know that the woman had been fully dilated for several hours already, and had been pushing without much success, and it was getting to the point where the homebirth midwife was beginning to think that a vacuum-assisted delivery might be necessary, hence the need to transfer to a hospital/ MD care.   What the homebirth midwife was most concerned about was the possibility of an MD at a hospital turning her in to the authorities for practicing without an official back-up physician/ written practice agreement.  Nevertheless, any woman in labor coming to any hospital is entitled to immediate emergency care, and cannot be turned away, thanks to EMTALA laws.  The problem is that if the midwife attending her does not have admitting privileges and/or a WPA at the hospital where they transfer to, she has limited authority and cannot necessarily continue to manage the patient.  In other words, the midwife would have to act as a monitrice (midwife at  home, doula in the hospital), which is disappointing and frustrating, to say the least, especially for the woman in labor who was relying on her midwife’s judgment and management.  It pretty much destroys the continuity of care between midwife and client if a transfer to a hospital is required.

And then, of course, there’s the relationship to consider between the midwife and the hospital she’s transferring to.  If the relationship has not been established in advance, the midwife is walking into a situation where she may not know or be familiar with the attending on call, may not have any say or influence in the continued management of the patient, and may actually be judged and excoriated (at the best) and potentially turned into the authorities (at the worst).  The hospital outlook towards women attempting homebirth, and the midwives who attend them, can be outright cruel.  I have heard MDs muttering under their breath before about how “criminal” and “dangerous” it is to give birth at home.  It doesn’t help, of course, that the women who transfer to a hospital are only transferring because something went wrong, or because they need something.  It means that the only type of homebirth that hospital providers see is a failed homebirth, which naturally colors their opinions on the success of the process.  They never see the beautiful, peaceful, uneventful, successful homebirths.  Instead, they can sometimes feel like they are being asked to “clean up the mess” made by homebirth midwives’ mismanagement, and the crazy people who are stupid enough to attempt birth at home.  The attitude of the staff at the hospital and the way they act towards the incoming transfer is crucial.  Either they can be respectful and positive, or judgmental and negative.

So, at the moment, we have plenty of people in New York city attempting homebirth with no back-up hospital to go to.  We have midwives who don’t know where or to whom to bring their patients if they need assistance.  We have couples trying to give birth who face potential castigation at the hospitals they may end up at.

I’m not really sure what happened to the couple last night.  I got a text from my sister midwife whom I work with who told me that the homebirth midwife and her clients would be heading our way, but they never actually showed up.  I was concerned because last night was actually really busy, and we didn’t have any extra beds to accommodate them.  I actually ended up delivering a beautiful 9 lbs. 6 oz baby in triage last night, and the other midwife I was working with had to do a delivery in the recovery room–both of these on stretchers and not actual beds, which is never ideal.  I know for a fact that we would have been kind and welcoming to any incoming homebirthers (we meaning the midwives…I can’t vouch for what the attitude of the doctors and nurses we worked with last night might have been, although I’d like to think that they would be pretty open and respectful, given that so many midwives work at our hospital).  In any case, the couple never showed up.  I can only hope that either they were able to successfully push the baby out at home without needing a vacuum, or else they chose to go to a different hospital than ours.

I can only hope that the homebirth midwives of New York City will be able to find back-up physicians at other hospitals and sign new WPAs/ get new admitting privileges soon, so a situation like this where a homebirth midwife is faced with such a difficult challenge doesn’t occur again any time soon.

And speaking of updates: Choices in Childbirth has just posted a follow-up to their initial action (Action Alert: Part Two), so we can continue to call and harass our legislators about how important this issue is.  Please call or write or sign the Midwifery Modernization Act petition now!  You can read the full text of the proposed Midwifery Modernization Act HERE.

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.

The Summit program covered everything from the overbearing and disempowering birthing machine in this country to our culture’s rampant fear of birth, from the legal restrictions being placed on VBACs, contraception and abortions to the disturbing rise in fetal rights, where mothers with substance abuse problems are prosecuted for “child abuse” on behalf of their unborn fetus, instead of being offered the care and treatment they need….and so much more, more, more. I really wish I could have attended! NAPW even offered several bloggerships to a few of the lucky feminist, birth and reproductive rights bloggers who were able attend. Too bad we didn’t get a longer winter break; school started again on January 9th, alas.

It’s been absolutely fascinating reading the reports and thoughts of many of the bloggers who were able to attend. I’ve linked to a partial list of the blogs on the Summit, so that you can read for yourself. It’s almost as good as being there (although not quite).

Feministing: Semi-live blogging from NAPW Conference

Gymno: Sick Blogging

Gymno: Summit Day 1 (cont.)

Is there no sin in it: NAPW Conference is happening now!

bird in a bottle: More Lynn Paltrow love (and a prelude to Blog for Choice Day)

bird in a bottle: Language and Gender, Part Deux

bird in a bottle: Why I want to be Dorothy Roberts when I grow up

Angry Black Bitch: Thoughts inspired by sessions

Angry Black Bitch: Thoughts inspired by debates, particularly the VBAC v. cesarean delivery debate.

Pandagon: NAPW Summit kicks off

Pandagon: NAPW Summit: end of the 1st Day

Bitch PhD: Join this Organization

Women of Color: The first part of the conference

And even more from brownfemipower here and here and here, and finally: Midwives of Color.
Oh, and this is just too cute not to pass on.

And finally, a word or two from the demi-goddess herself: Lynn Paltrow’s article in the San Francisco Chronicle, On the Anniversary of Roe v. Wade

Obviously, other people feel similarly, and in a landmark case decided in Massachusetts, a court ruled in favor of the plaintiff, Mary Meador, a woman who gave birth via cesarean section and claimed that the risks of VBAC were misrepresented to her and that she was coerced and misled into having a cesarean—so, basically suing for receiving an unecessary cesarean section. (Editor’s note 1/6/07: It has come to my attention that this case is from 1993, so not really landmark these days, although it’s nice to know a precedent like this exists. I wish it had made more of an impact.)

One has only to look at womens’ responses to cesareans that they know are unecessary to see how destructive and devastating this practice can be. How can anyone think that coercion qualifies as informed consent? What amount of pain and anguish can lead to art like this?

In my practice as a nurse, I cannot tell you how many times I’ve seen a cesarean performed for no good reason at all: for provider preference, because he or she wanted to go to sleep, or get to their office hours on time, or because of provider ignorance. Just last night at work, I was with a woman who was moderately preeclamptic with increasing amounts of protein in her urine (an ominous sign). I agreed with the obstetrician’s decision to deliver this baby immediately, but because her baby was breech, she was told that cesarean was her only option, end of story, sign on the dotted line, please. No informed consent, no weighing of the benefits and risks of induction and breech delivery versus cesarean. Forget the fact that this was her fourth baby, and that her first three babies were all uncomplicated vaginal deliveries. Forget the fact that she had a “tested” pelvis that was more than adequate to accomodate her baby (a tiny little peanut that ended up weighing 6 lbs. 8 oz.). Because of lack of provider skill, because of lack of provider education, because breech deliveries are so rarely performed any more, by any one, this woman had a primary cesarean.

Cesarean is increasingly becoming the correct response to any birth that deviates even slightly from “normal”. Cesarean is nine times out of ten (the Meador v. Stahler and Gheridian case aside) the trump card that will stand up to court scrutiny. Doctors are so concerned about not doing a cesaeran that it’s very easy to forget the other angle to it: cesareans are major abdominal surgery, with more risks associated with it than vaginal birth. Imagine what our world would be like if doctors felt more strongly about the possibility of being sued not for failing to do a cesarean, but for performing a cesarean that was unecessary? Imagine how much longer trials of labor would last, how much higher our VBAC rate would be, how much more time women who are being induced would be given to allow their bodies to go into labor. Imagine the increased time and attention that would be spent with true informed consent, and the weighing of options? Imagine how much lower our cesarean section rate would be.

By and large, the article is pretty fair and objective, but I think the case against the hospital—how dangerous and damaging the overmedicalization of birth can be—and the reasons why a woman might choose NOT to have her baby in a hospital, is missing from this article, or else given very short shrift. There’s still a small hint of “those crazy midwives who deliver babies at home without any medical knowledge at all!” to this article, and it always saddens me when midwives get press like this.

“No one complains until a baby dies or a mom dies,” Professor Tovino said. But once the issue arises, she said, legislatures often become involved as well, with doctors and midwives engaging in a bitter struggle over the proper regulation of midwives, one driven by a mix of motives that are difficult to disentangle.”There has always been a tension between true quality-of-care concerns and anticompetitive concerns,” Professor Tovino said.

Around the nation, there are some 3,000 midwives without formal medical training, according to the Midwives Alliance of North America. About 1,100 of them, including Ms. Williams, have been certified by the North American Registry of Midwives, a private agency whose evaluations are recognized in some 20 states. In Indiana, though, only doctors and nurses may deliver babies.

[...]

Mr. Apsley said his decision to prosecute Ms. Williams was driven solely by the law as it currently stood. “We can all have different opinions about the speed limit or the age of consent or whether drugs should be legalized,” he said. “Those decisions are for the legislature.”

He added that the evidence against Ms. Williams was strong.

According to an affidavit filed by Rick Isgrigg, an investigator with the Shelby County Sheriff’s Department, Ms. Williams conducted a dozen prenatal examinations on Oliver’s mother, Kristi Jo Meredith; monitored the fetal heart rate during labor; made a surgical incision known as an episiotomy when she detected fetal distress; performed frantic CPR on the baby when he emerged; and sutured the incision afterward.

I love the use of the word “frantic” there. When is CPR not frantic? I assure you, it’s frantic in the hospital. I’ve never seen resuscitation done at a homebirth before, but I’m sure the midwife had oxygen and the proper equiptment, was certified in Neonatal Resuscitation, and probably knew what she was doing…albeit frantically. (In theory I know what I’m doing, but I’m still frantic every time a baby comes out blue and I’m the one who needs to begin the bagging).

Where’s the other side to this? Where are the statistics regarding how many babies die every day in hospitals all over this country, or how many doctors are sued for negligence or malpractice? And of course, the excuse given is that more babies die in hospitals because hospitals always manage the dangerous, high-risk births, which is true—hospitals do handle the high risk births, but mistakes are made in hospitals just like they’re made in homes. And then, where are the statistics depicting the number of unecessary invertions performed in hospitals that damage the mother and baby (or both)? The number of unecessary episiotomies cut, the number of baby’s bruised by forceps, scalped by vacuums, the number of women who no longer enjoy sex because their pelvic floor is toast after a pair of forceps made their vagina look like a fire-cracker had gone off inside of it, the number of totally unecessary cesareans, the number of spinal headaches, uteruses ruptured by pitocin, postpartum hemorrhages caused by impatient doctors tugging on the cord or manually removing the placenta?

I could go on and on, but this isn’t really about the safety of homebirth (which many studies have verified, including last year’s large prospective cohort study in the BMJ). This is about choice.

“It is not illegal to have a home birth,” Ms. Welch said, noting that about 1,000 Indiana families had their children at home each year. “But doctors and nurses are choosing not to do home births.”The current law, Ms. Welch said, drives midwives underground. “I don’t want to have a midwife hesitate to take a woman to the hospital because she is afraid she will be arrested,” she said.

If a woman wants to have a homebirth, who is she supposed to turn to? If doctors and CNMs aren’t performing homebirth (for whatever reason), a woman’s choices and options are severely curtailed—either she succombs to the system, and has her baby at a hospital or birthing center with a legal practitioner, or she has a homebirth anyway, though not necessarily with a legal practitioner. Even in states where homebirth is legal, practical barriers are in place which limit the number of practitioners who can offer homebirth as an option. A perfect example of this is what’s going on in the capital region of New York right now: homebirth is legal in New York State, and it’s legal for CNMs/CMs to offer homebirth, so long as they have a signed practice agreement with a collaborating physician. However, doctors in the capital region are refusing to sign collaborative agreements with homebirth midwives, so these board certified, legal CNMs/CMs are forced to work underground, illegally…or else, no longer offer homebirth services to women in the capital region. What kind of choice is that?

If a state does nothing but put up barriers to homebirth so that it’s virtually impossible to have a homebirth legally, and then continues to punish women and midwives for choosing to have a hombirth illegally (because that’s the only way to have a homebirth in that state), women are caught in a no-win situation. While the midwife is the one being prosecuted here, it’s really homebirth itself that’s indirectly under attack.

This reminds me of the prosecution of another midwife in Pennsylvania, Judith Wilson, a CPM with over 20 years of experience who is being charged with Involuntary Manslaughter, Endangering the Welfare of a Minor and Unauthorized Practice of Midwifery after the death of Isaac Daley, a footling breech baby she delivered in 2002. When it became clear to Judith that the baby was in the footling breech position, she explained the risks to the parents, John and Healther Daley, and recommended that they transfer to the hospital immediately. However, John and Heather, weighing all of their options, made an informed decision and chose to stay at home, willing to bear whatever consequences occurred. This is called CHOICE. Now Judith is being prosecuted by the state, even though John and Heather Daley do not blame Judy, continue to support her, and refuse to press charges. More information on this case can be found at The Mommy Blawg.

When the state steps in to prosecute a midwife for continuing to help and support a couple who has made the informed decision to give birth at home, despite the known risks, what is really under attack here? And what else was Judy supposed to do in the situation above, after explaining to the family about the footling breech, and recommending that they go to the hospital? If the family refuses, what more can she do? Abandon John and Heather Daley in the middle of their birth, in order to legally save her own skin? As Barron H. Lerner pointed out in his essay in the NY Times yesterday (Saying No Is a Patient’s Choice, However Risky), the choice to turn down medical options or interventions is always a choice.

Women choosing to give birth at home are taking a big risk, said Dr. Kevin R. Burke, president of the Indiana State Medical Association.

Well, that’s your opinion, Mr. Burke. But they should still be allowed to take that risk, if they so choose. Just like people should be allowed to have an abortion, if they so choose, or refuse a life-saving blood transfusion, or choose to die at home, forgoing all of the drips and transplants and procedures that could prolong their life for another 10 months. For some reason, though, birth, and homebirth in particular, triggers gut reactions in people which have absolutely no basis in reality. Personally, I think it has everything to do with what Robbie Davis-Floyd discusses in her book Birth As An American Rite of Passage: birth, as one of the major rites of passage in our society, is something that needs to be controlled by our society so that it upholds our cultural beliefs and values (i.e. the trancendence and dominance of technology). Choosing to give birth beyond the bounds of these controls necessitates the need for even tighter controls, hence the prosecution, and the barriers in place which restrict homebirth, and all of the hew and cry which arises whenever a story like this comes out. Call it a fantastical theory, if you like, but it rings true ot me.

Coercive C-Sections
Don’t get forced into having a surgery you don’t need
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By Lisa Collier Cool

Amber Marlowe anticipated an easy delivery when she went into labor on January 14, 2004. But after a routine ultrasound, doctors at Wilkes-Barre General Hospital, in Pennsylvania, decided that the baby — at what looked like 13 pounds — was too big to deliver vaginally and told her that she needed to have a cesarean. The mom-to-be, however, wasn’t convinced: After all, she’d given birth to her six previous kids the natural way, including other large babies. And monitoring showed that the fetus was in no apparent distress.

After she said no to surgery, doctors spent hours trying to change her mind. When that didn’t work, the hospital went to court, seeking an order to become her unborn baby’s legal guardian. A judge ruled that the doctors could perform a “medically necessary” c-section against the mom’s will, if she returned to that hospital. Meanwhile, she and her husband checked out against the doctors’ advice and went to another hospital, where she later gave birth vaginally to a healthy 11-pound girl. “When I found out about the court order, I couldn’t believe the hospital would do something like that. It was scary and very shocking,” says Marlowe. “All this just because I didn’t want a c-section.”

She and her husband, John, turned to the National Advocates for Pregnant Women (NAPW), in New York City, for help in contesting the judge’s ruling — the first of its kind in Pennsylvania. The couple is also considering legal action against the hospital. “It’s not about us,” says John Marlowe. “What’s going to happen to the next lady who goes there? We want everyone to know what’s going on. What they did was wrong, and our goal is to put a stop to it so that other women don’t end up with c-sections they don’t need.”

Coercive medicine
Increasingly in the United States, pregnant women are encountering legal or more subtle pressures to have c-sections. Currently, more than a million expectant women have the operation annually, as America’s rate of surgical deliveries has hit an all-time high. In 2003, cesareans accounted for nearly 28 percent of births in this country, compared with just 5 percent in 1970. Many factors contributed to this rise — increasing numbers of repeat c-sections, doctors’ fears of malpractice lawsuits, and women waiting longer to have kids (which is related to higher rates of complications), to name a few. But while the procedure is usually quite safe and can be potentially lifesaving for mother and baby, it also poses a number of potential risks, including severe bleeding, infection, injury to the fetus, blood clots, and even the mother’s death in extremely rare cases.

Yet hospitals in at least a dozen states have obtained court orders to compel unwilling women to undergo this major abdominal surgery. And while Marlowe was able to escape the scalpel, other patients were operated on — despite their verbal or even physical resistance. In a tragic 1984 case, staff at a Chicago hospital forcibly tied a pregnant Nigerian woman who had declined a c-section to her hospital bed with leather wrist and ankle restraints. The woman objected to the surgery because she planned to return to Nigeria where the operation wasn’t readily available, and she rightfully worried about health risks, including a ruptured uterus, if she became pregnant again and had another child vaginally back home. As she screamed for help and frantically tried to free herself, doctors, with a judge’s permission, wheeled her off to the O.R. to perform the procedure.

Defying doctors’ advice can even lead to criminal prosecution, as Melissa Rowland discovered last year. While pregnant with twins, the 28-year-old Utah mom initially declined a recommended c-section, even though doctors warned that without it her babies might die due to low levels of amniotic fluid and other problems. Several days later, on January 13, 2004, she changed her mind and had the operation. Her daughter, Hannah, survived after treatment with oxygen and antibiotics, but a twin boy was stillborn. Contending that the initial refusal caused his death, prosecutors charged Rowland with first-degree murder. After spending three months in jail, she accepted a deal in which the murder charge was dismissed in return for her guilty plea to two counts of child endangerment (unrelated to her c-section refusal). She’s now free, and serving 18 months of probation.

“This case is a tragedy compounded by a shocking abuse of legal authority,” contends Lynn Paltrow, executive director of NAPW and a lawyer specializing in reproductive issues. “It shouldn’t be a crime for pregnant women to disagree with doctors and make their own medical decisions. Nor should they be punished for a bad outcome when there’s always some risk to giving birth, regardless of whether it’s vaginal or by c-section.”

And you can’t be legally compelled to undergo any other medical procedure for the benefit of another person. “You don’t have to donate your kidney, your bone marrow, or your blood, even if someone else might die without it,” explains Howard Minkoff, M.D., chair of obstetrics and gynecology at Maimonides Medical Center, in Brooklyn, New York, and coauthor (with Paltrow) on an analysis of the Rowland case published in the December 2004 issue of Obstetrics and Gynecology. You also can’t be prosecuted for murder if you refuse. “So why should c-sections be any different?” the doctor adds. “That’s saying pregnant women have fewer rights than anyone else, including a fetus.”

A subtle pressure
Of course, only a minute fraction of the c-sections performed in this country are court ordered. Far more women undergo the procedure at the recommendation of their doctor. The most common reason a woman is encouraged to have a c-section is if she previously delivered a child this way. These “repeat c-sections” have become so common that they now account for nearly 410,000 births annually in the United States, about 10 percent of births each year.

And it doesn’t seem that this number will be getting any lower, as an increasing number of hospitals that formerly permitted women to try for vaginal birth after cesarean (VBAC) now prohibit the practice, making a return trip to the O.R. mandatory for moms-to-be with a previous surgical delivery. Because it’s getting harder and harder to find medical centers that allow VBAC, the rate has plunged by nearly two-thirds, from 27.5 percent in 1995 to 10.6 percent in 2003.

Ask doctors what’s behind the ban, and you’ll hear the same answer: fear of lawsuits. Trying for a VBAC carries with it a 1 percent risk of uterine rupture. This dangerous complication is an emergency that requires surgical repair — or, in some cases, a hysterectomy — to stop potentially life-threatening blood loss. “Medical liability is a huge problem for obstetricians, because people are losing their practices over malpractice claims,” reports medical ethicist Anne Lyerly, M.D., assistant professor of obstetrics and gynecology at Duke University in Durham, North Carolina. “So it’s understandable that a lot of us practice defensive medicine by avoiding risky deliveries that might have adverse outcomes.” A 2004 American College of Obstetricians and Gynecologists (ACOG) survey bears this out, since 15 percent of its members say they’ve stopped doing VBACs to protect themselves from malpractice claims, and another 14 percent no longer deliver babies at all for the same reason.

In 1999, ACOG responded to concerns about VBAC risks with new practice guidelines, saying that the delivery should only be provided at hospitals equipped to do an immediate c-section if anything went wrong, instead of within 30 minutes’ notice, as was previously required.

That’s fine for big medical centers that have anesthesiologists and surgeons on duty 24/7, like the one where Dr. Minkoff delivers babies, but not for smaller hospitals. “Often, they can’t afford to have doctors standing by in case a woman who arrives in early labor needs surgery later on, so in many parts of the country, especially rural areas, pregnant patients can’t find anywhere to have a VBAC,” he explains.

An ethical debate
How far should ob-gyns go to save an unborn baby they consider at risk? Some of the very doctors you’d most expect to advocate for pregnant women actually support forced c-sections, a 2003 University of Chicago study found. When the researchers surveyed directors of 42 maternal-fetal medicine programs around the country, 14 percent reported that their hospital had used court orders to compel unwilling women to have O.R. deliveries. What’s more, 21 percent of these specialists in the care of pregnant patients consider coerced c-sections “ethically justified” to spare a fetus possible harm — even over the woman’s physical resistance, as long as her struggles weren’t strenuous enough to endanger her or the baby.

ACOG adamantly disagrees. In 2004, its ethics committee ruled that it’s never right for health care providers to subject pregnant women to physical force, even with a court order authorizing a c-section or other procedure. The committee also said that seeking such orders against a patient’s wishes is “rarely if ever acceptable.” The American Medical Association, another prominent doctors’ group, has a similar policy.

So what should happen if a doctor is convinced that a vaginal birth would be disastrous? “Personally, I’m willing to counsel women very strongly in that situation — and bring in another physician to offer a second opinion about the risks of not having a c-section,” says Dr. Lyerly. “I also tell patients that it’s a very safe operation — and I should know, since I’ve had three c-sections myself.”

However, doctors’ opinions can also be tragically wrong. Years ago, a Washington, D.C., hospital got a court order to perform a c-section on Angela Carder, who was gravely ill with cancer. Since the mom was in such poor health, the hospital’s doctors believed that delivering the 26-week fetus immediately would give it a better chance of survival than waiting for a natural delivery. The result? Carder and her baby both died soon after the operation. Later, in a landmark 1990 ruling, an appeals court overturned the order, finding that Carder had a right to make medical decisions for herself and her unborn child. Her family also received an undisclosed financial settlement from the hospital.

“I hope that doctors and judges are humbled by this terrible mistake that never should have happened,” says Dr. Lyerly. “We can make dire predictions and think patients are too irrational to weigh the risks for themselves, but we’re not infallible. And since doctors and moms can both be wrong, and if they can’t agree on the best way to give birth, ultimately it has to be the woman’s choice.”

When surgery is being considered, experts say pregnant women need to feel confident that their wishes will prevail, whether they consent to an elective or emergency c-section or decline one they deem medically unnecessary, as Amber Marlowe did. In 25 years of delivering babies, Dr. Minkoff has learned to respect his patients’ decisions about how they want to give birth — even if he doesn’t always agree. “It’s my duty to fully explain why I think a c-section should be seriously considered and the risks of not following my advice,” he says. “But in the end, the strongest advocate for the safety and health of an unborn child is the baby’s mother. And that’s the way it should be, because she has the most at stake.”

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Lisa Collier Cool is an award-winning health journalist and mother of three from Pelham, NY.