This meta-analysis (Maternal and newborn outcomes in planned home birth v. planned hospital birth: a metaanalysis) by Wax et. al. (also known simply as the ‘Wax study”) is not new.  It came out last September in the American Journal of Obstetrics and Gynecology (AJOG), but the reverberations of this controversial study are still being felt in the birthing community today.  As mentioned above, the flaws in this study have been discussed on numerous blogs and in numerous articles, so there’s no need to re-hash the entire argument here. (For further reading on this, though, check out the following links: Science and Sensibility, Our Bodies Our Blog, Science Based Medicine, Nature, ACNM’s response, Midwifery Today’s response).  To sum it all up, though, I quote from Michal et. al., Planned Homebirth v. Hospital Birth: A Meta-analysis Gone Wrong:

The statistical analysis upon which [the Wax meta-analysis'] conclusion was based was deeply flawed, containing many numerical errors, improper inclusion and exclusion of studies, mischaracterization of cited works, and logical impossibilities. In addition, the software tool used for nearly two thirds of the meta-analysis calculations contains serious errors that can dramatically underestimate confidence intervals (CIs), and this resulted in at least 1 spuriously statistically significant result. Despite the publication of statements and commentaries querying the reliability of the findings, this faulty study now forms the evidentiary basis for an American College of Obstetricians and Gynecologists Committee Opinion, meaning that its results are being presented to expectant parents as the state-of-the-art in home birth safety research.

And that’s really the crux of the issue right there: ACOG has based their most recent home birth committee opinion paper on the Wax findings, despite the fact that the Wax study is so controversial, and has been so loudly contested.  ACOG seems to take the Wax study as gospel truth: “Published medical evidence shows [home birth] does carry a two- to three-fold increase in the risk of newborn death compared with planned hospital births.” (i.e. the Wax findings).  But as you can see above, the Wax findings are anything but conclusive. Couple this with the fact that a recent study in the current issue of Obstetrics & Gynecology (ACOG’s very own publication, aka the Green Journal) found that two-thirds of all of ACOG’s practice guidelines have no basis in science, and we have a very serious cause for alarm.  As one of the letters to the Editor at AJOG pointed out in regards to the Wax Study,  this is the dangerous practice of communicating bad science to the public.  To quote liberally from this letter to the Editor:

These practices are unethical, causing harm through unfounded confusion and fear, and misleading policymakers and the public. The Singapore statement on research integrity represents the first international effort to unify policies, guidelines, and codes of conduct for researchers worldwide.⁴   Accordingly, the AJOG publication would fail on 2 counts: (1) poor quality of the study; and (2) author recommendations made beyond what the data support and outside of their professional expertise. Obstetricians are not the leading professional group in home birth and midwifery-led care, and should not reach policy conclusions in isolation. It is essential to use appropriate subject peer reviewers: in this case midwife and epidemiology experts in studies examining midwifery care and birth setting.

Obstetricians have never been the experts on home birth.  In my own personal experience, I cannot think of a single obstetrician who has even seen a home birth.  Nevertheless, as Melissa Cheyney writes in the  Huffington Post (Why Home Births Are Worth Considering), the Wax study is only serving to fan the flames between the obstetrical/ medical community and the home birth community (I purposely refrain from saying the homebirth/ midwifery community, because I feel like midwives can and do and SHOULD straddle the gap between the home birth community and medicine, offering high-touch, low-tech intervention as we do, and advocating for all women, everywhere, regardless of their birth choices or location of birth).  When home birth is seen as more dangerous than hospital birth by obstetrical “experts”, what then happens to the women and families who still choose to have a home birth?  Are they considered crackpots and lunatics endangering the lives of their babies?  What happens if they need to transfer to a hospital?  What happens if they need to transfer to a hospital but the midwife is reluctant to make the transfer based on the stigma and ostracizing treatment she and the family will receive in the hospital setting?  Will the barriers to midwives choosing to attend home births continue to rise so high that ultimately they can no longer provide this service? And if that happens, where does that leave the women who will still choose to have a home birth anyway, without any medical provider available to attend them?

So long as ACOG’s opinion on home birth continues to be based on poor science, we’ll continue to move further and further away from what this country truly needs: an integrated model of care, where women who choose home births and the midwives who serve those women are backed up by obstetricians and the medical model of care, allowing for safe transfers when needed without stigma, judgement or blame.

However, both Ricki Lake and Abby Epstein admitted that there were several more pieces of the puzzle which they couldn’t delve into due to time constraints in their film, and how they really wished they could.  Now, fast-forward to 2011 and it seems like they’re making good on their promise to continue to explore various aspects of childbirth in America with the upcoming release of a 4 part documentary series which continues where The Business of Being Born left off, entitled (pragmatically): More Business of Being Born.  I, for one, cannot wait to see these films and see the debate continue!!

A few weeks ago, during a prenatal visit, a woman pregnant with twins told me she would love to have a home birth, but did not have the $4,000 cash required upfront to do so. She was afraid of potential interventions in the hospital. After a discussion of her fears as well as potential complications that can abruptly occur in a twin birth, she admitted she would prefer a hospital birth if she could maintain some control over the situation. This is not a woman who cares more about the birth experience than the baby, but she was tempted, and in some ways I can understand her concerns. My cousin’s wife had her twin induction halted at 4 cm because the new obstetrician on call did not do breech extractions for second twins. Her only option became cesarean delivery.

I recently received a phone call from a woman 2 hours away who had planned a home birth for her second baby after having an easy first birth. When the fetus, which was anticipated to be a little smaller, was found to be a breech, the midwife sent the woman to the local obstetricians. They would only deliver the fetus by cesarean delivery. The midwife offered the woman a home breech birth, but admitted she had only delivered one breech (stillbirth) in her career. The woman appropriately questioned the safety of this, and was referred to us. She met the criteria for our vaginal breech protocol, and had an easy vaginal breech birth in our hospital. Unfortunately, this is becoming a rarity. A colleague of mine in another state watched the residents she was supervising emotionally bully a young woman and her mother into a cesarean delivery. The young woman had a rapidly progressing active labor with a normal-sized frank breech fetus. Had the residents been open to the idea, my colleague easily could have taught them how to deliver a vaginal breech.

The running joke in our community is that the only way to get a vaginal birth after cesarean delivery (VBAC) is to have the birth at home. Unfortunately, this is a reality rather than a joke. Our small community hospital, owing to regional liability insurance constraints, stopped allowing VBACs in 2002 after many years of  successfully offering them. This has led many women to risk home birth rather than travel to a tertiary care center to attempt VBAC. I recently counseled a woman against having a cesarean delivery who had a BMI of 52 and who arrived in active labor at over 35 weeks of gestation with two previous successful VBACs. I spent the following months defending that recommendation, despite her considerable operative risks and high likelihood of success.

Recent news and media excitement about the benefits and increased safety of home birth over hospital birth have made the former seem like a very attractive alternative. A growing notion among women in our region, and perhaps across the country, is that hospitals and obstetricians are a more risky option than lay-home midwives for birth. Although my initial reaction is disbelief, perhaps we should look at how we, the  obstetricians, contribute to this trend.

Each of these women deserves an honest discussion about the fetal and maternal risks of each birthing option. However, our lack of experience as obstetricians colored by our fear of liability is narrowing women’s choices, and sometimes motivating them to ignore fetal and maternal safety in an effort not to be coerced into unnecessary interventions. I sense a mounting tension, because many obstetricians do not have the willingness, time, or skills to provide maternal choices.

I believe we are at a crossroad in maternity care in this country, and I am saddened that obstetricians are considered the culprits. Our contracting skill set as obstetric providers, as well as the prevailing risk-adverse culture among physicians and hospitals, have given support to home birth. We can all agree that VBAC, twins, and breech should not be managed at home, yet we frequently demand complete control of the situation and eliminate some appropriate choices in the hospital. I understand that it can be very unnerving to be ultimately responsible for the outcome, as we are, and yet pushed into situations outside of our comfort zones. However, our unwillingness to budge in these situations is causing us to lose the battle regarding what is really important to most obstetricians: safety for mothers and babies.

Certainly, we can be proud of the dramatic decrease in maternal mortality in the last century. But, despite the highest per capita expenditure of health care in the world, infant and maternal mortality rates in the United States are higher than in all of western Europe. We have the third-highest cesarean delivery rate in the world.

According to a recent study, nearly half of all primigravidas attempting vaginal delivery are induced, and half of cesarean deliveries for dystocia are done before 6 cm of dilation, presumably before active labor. It is amazing how many women begging for elective induction change their minds when told it doubles their cesarean  delivery risk.

We need to draw lines around patient safety, but must they be so rigid? Most midwives know from experience that Friedman’s curve is too strict. A recent study validates that knowledge. I sincerely hope it is taken seriously. Expectant management of ruptured membranes at term has been declared unsafe and of no benefit. The study that settled the question did not account for the number of vaginal examinations women received, and group B strep was not treated, both important variables. Most women do go into labor in 24 to 72 hours. The Cochrane systematic review concludes that, because the differences in outcome are not substantial, women need to be given the appropriate information to make a decision. This very rarely occurs in the hospital setting. The Term Breech Study closed the door on vaginal breech delivery even for the lowest-risk women in most obstetricians’ minds (including the residents I mentioned above). This, despite the opinion of the College that it may be appropriate in carefully selected situations. In any case, vaginal breech delivery is not completely avoidable, and should not be relegated to the history books with vaginal delivery for previa and high forceps.

Our mission has become more difficult in the last 20 years as mothers have become older, heavier, and of lower parity. Many women, admittedly, do have unrealistic expectations. Although I am eternally grateful for the obstetric skills I learned in residency, I have been amazed in my 14 years of practice to see much of the dogma I also absorbed disproven with experience and patience (both my own, my colleagues’, and the midwives I have worked with in the hospital setting). Collaborative practice with midwives is a good start, but in order for obstetricians to be more than providers of cesarean deliveries (a thankless and, in most cases, technically simple procedure) we need to have conversations with our patients that are not one sided and allow for true informed consent. Many of the obstetric disasters we have all seen and which color our  perspective (which David Grimes has called “numerators in search of denominators”) are at least in some part iatrogenic if examined deeply enough. That failed induction for convenience with early artificial rupture of  membranes and chorioamnionitis. The first cesarean delivery done at age 15 after 2 hours of pushing with an epidural that then leads to the fifth cesarean years later, and then accreta and life-threatening hemorrhage, are both typical examples. We need to recognize and own those aspects of obstetric management that are driving our skyrocketing cesarean delivery rate but having no positive effect on maternal or infant morbidity and mortality.

Admitting what is truly evidence based versus what is tradition and culture is a good start. It is essential that we offer real choices to our patients. We need to recover and disseminate the skills that make obstetrics an art and a privilege. Seek out mentors skilled in forceps, vaginal breeches, and breech extractions before it is too late. Then learn to be patient, so that you very rarely need to use them

I find this letter to be very brave and commendable, and while this may sound strange, I am actually really proud of ACOG for publishing it in the first place.  Kudos to Dr. Fineberg for writing this, especially given that she may very well experience a backlash from her colleagues for even suggesting that VBACs, vaginal breech deliveries and vaginal twin deliveries (with breech extraction for the second twin) are things which OBs should be offering their clients, let alone her suggestion that OBs may be partially responsible for driving women with complications to seek homebirth in the first place.

Even more fascinating to me, though, are the commentaries which are going up on The Unnecesarean right now, all written by a collection of different obstetricians who are willing to step forth and give their unvarnished opinion on the true state of things (and huge kudos to them, as well!).  Here are links to their articles:

Lamenting the System, by Dr. Jill Arnold

Lament in Stereo, by Dr. Lauren A. Plante

A Comeback for VBAC?, by Dr. Poppy Daniels

Another Obstetrician’s Lament, by Dr. Gustavo San Roman

An Obstetrician’s Hope, by Dr. David Hayes

The VBAC comments I found particularly compelling, given the sorry state of VBACs in this country right now (see my post below on the new NIH Consensus Guidelines).  The sad truth is, VBACs are no longer being offered as a viable option simply because of politics and a growing culture of fear (aided by our culture of litigation) which states that just because uterine rupture is (occasionally, super rarely) possible, there needs to be 24-hour on-call anesthesia, and an obstetrician on-call ready to brandish a knife at the drop of a hat…and because of this (occasional, super rare) risk, it’s better to not offer VBACs if you don’t have these emergency measures in place.  Nevermind the increasing risks associated with repeat cesareans, the growing rate of cesarean complications, placenta percreta/ acreta etc. etc.  But Dr. Poppy Daniels has addressed this on The Unecessarean more eloquently than I have time to right now, so I’ll let you follow the links.

Besides, I have much more exciting news to share! Stay tuned for a very personal birth story, coming up next!

In New York State, CNMs/ CMs practice legally but CPMs do not.  I personally know of several friends who have had lovely, safe, wonderful births attended by CPMs in this state, but unfortunately these midwives did so illegally, with no back-up and no recourse if something went wrong.  Being charged with practicing medicine without a license is very serious, and especially tragic given that CPMs do have certifications, but are unable to obtain licences in various states depending on state legislation.   How wonderful it would be if CPMs were federally recognized the same way CNMs are (although the bitter politician in me wonders if the ACNM is going to welcome this legislation with open arms).  In any case, check out the MAMA campaign, and let’s keep our fingers crossed!

“[Rep. Mike] Pence [R-Ind.] has acknowledged that health centers use Title X money to perform valuable services that he supports, but he contends that the funds are also being used to support abortions indirectly by covering operating costs and other related expenses for Planned Parenthood and other abortion providers.

“Eliminating Title X funding has never been my goal,” he said on the floor Thursday. “My focus has and will remain on denying taxpayer dollars to Planned Parenthood or any organization that provides or promotes abortion as a means of birth control.”

My argument with this is that once again, abortion and birth control are getting mixed up, and they are two totally different things.  This frustrates me no end.  Family planning and birth control helps to avoid abortions!  If our country is so strongly anti-abortion, this is EXACTLY the type of organization we should be supp orting, not defunding.  I have personally used Planned Parenthood before as a student in order to obtain birth control, and as a midwife I personally send many of my patients to their clinics since 1) they accept medicaid (and all of my patients are medicaid-only recipients) and 2) they have the Mirena IUD and are willing to insert it into medicaid-only patients (my hospital unfortunately only has the copper-T IUD on offer, so patients seeking the Mirena need to go elsewhere; the Mirena, of course, is a form of BIRTH CONTROL).

Planned Parenthood is now currently trying to raise money and defend itself in the Senate against further legislative attacks.  Luckily, I seriously doubt that the Senate will approve the same level of draconian cuts to Title X funding, and even if they do, President Obama has vowed to veto such a bill.  Nevertheless, Planned Parenthood NEEDS YOUR HELP! With the anti-woman climate in Washington right now, it is very naive to sit back on our heels and assume that the Senate will automatically turn this aside.  Write a letter to your Senator, call or speak with your Senator, or sign PP’s Open Letter to Congress.  Or, if you’re in  the NYC area, attend the Planned Parenthood New York’s Rally at Foley Square at 1:00 pm this Sat. 2/26.

“The bill in South Dakota is an invitation to murder abortion providers,” says Vicki Saporta, the president of the National Abortion Federation, the professional association of abortion providers. Since 1993, eight doctors have been assassinated at the hands of anti-abortion extremists, and another 17 have been the victims of murder attempts. Some of the perpetrators of those crimes have tried to use the justifiable homicide defense at their trials. “This is not an abstract bill,” Saporta says. The measure could have major implications if a “misguided extremist invokes this ‘self-defense’ statute to justify the murder of a doctor, nurse or volunteer,” the South Dakota Campaign for Healthy Families warned in a message to supporters last week.

Thankfully, for the moment, due to a national media outcry against H1171, the bill has been momentarily shelved, while Representative Phil Jensen, the bill’s sponsor, decides to either include language to protect abortion providers,or  cancels the bill altogether, since South Dakota law already includes an “unborn child” in the definition of “person”, and Rep. Jensen admits there may not be a need for a separate bill.  The NY Times also has the article here. There is supposed to be a further decision made on whether to go forward with H1171 today, so I will try to update this as the news arrives.

Even if the justifiable homicide aspect is dropped in H1171, there is still another bill pending in the South Dakota legislature which proposes to make getting an abortion in SD even more arduous.  This bill, H1217, would require women to undergo counseling at a Crisis Pregnancy Center (CPC) before being allowed to go forward with an abortion.  As it stands right now, the requirements to get an abortion in SD are already nearly insurmountable.  There is only one clinic in the state which provides abortions, the doctor who does them is flown in from a neighboring state only one day a week, and women are forced to see a sonogram of the fetus and are read from a script emphasizing that the baby is a living, separate entity and that they are connected, before going forward with the procedure.  Adding a visit to a Crisis Pregnancy Center, which are often run by religious/ pro-life organizations, throws up yet another obstacle.  H1217 also proposes adding a mandatory 72 hour wait time between counseling at the CPC and the actual procedure itself.

The 2006 CDC Waxman report has already noted that CPC’s are notorious for providing false and misleading information, and that the majority of counselors are pro-life activists, not trained healthcare professionals.  RH Reality Check has a great article on this.  Mother Jone’s also wrote extensively about the Waxman report and the false information provided by Crisis Pregnancy Centers.  Here are a few other links to blogs discussing H1217:

Our Bodies Our Blog

The Curvature

Blog For Choice

While our focus is caught up on the Federal level and the House’s swift and drastic attack on women’s reproductive rights (more on this to come), it’s easy to lose sight of the smaller state battles which can do a lot to set precedent and undermine Federal laws in the first place. If you’re looking to directly support the women of South Dakota, here is a good place to start: South Dakota Campaign for Healthy Families.

Related links:

The Daily Kos: an account from an abortion clinic escort

Belly Tales: post from 2008 on the eve of the 2nd SD referendum vote (which didn’t pass)

Most forms of FGC are decidedly harmful, and pediatricians should decline to perform them, even in the absence of any legal constraints. However, the ritual nick suggested by some pediatricians is not physically harmful and is much less extensive than routine newborn male genital cutting. There is reason to believe that offering such a compromise may build trust between hospitals and immigrant communities, save some girls from undergoing disfiguring and life-threatening procedures in their native countries, and play a role in the eventual eradication of FGC. It might be more effective if federal and state laws enabled pediatricians to reach out to families by offering a ritual nick as a possible compromise to avoid greater harm.

This is a really slippery slope, though.  On the one hand, you want to be able to keep a dialog open with members of these cultures, and you want to be able to offer them alternatives to the actual practice of cutting, which is often done by non-medically trained practitioners in unsterile environments, and can be dangerous and deadly, besides the actual sexual and future child-bearing limitations that these practices entail.  On the other hand, it seems a hard thing to condone, and I’m not sure how positive change could be affected through this practice, coming as it does from an outsider/ western institution like the AAP.  The New York Times ran an article on this after the AAP’s announcement, and they did a good job up summing up both sides of the story, but in particular the response to this announcement by advocacy groups like Intact America:

“There are countries in the world that allow wife beating, slavery and child abuse, but we don’t allow people to practice those customs in this country. We don’t let people have slavery a little bit because they’re going to do it anyway, or beat their wives a little bit because they’re going to do it anyway.”–Georganne Chapin, executive director of Intact America.

And she is right about that.  Is allowing American physicians to perform a “ritual prick” the same thing as condoning the practice?  And even if a ritual prick is less damaging to a little girl than male circumcision is to a little boy, what it’s standing in place of is still a debilitating and often times misogynistic practice that in many cultures  is designed to limit a woman’s sexual enjoyment (and therefore her promiscuity), enhance male sexual pleasure, and preserve her status/ virginity/ honor/ marriageability and group identity, and has with it a host of medical conditions

Female Genital Cutting is a difficult subject to broach, even at the best of times.  This something I have struggled with for years.   My first initial response to seeing it was one of shock and outrage at the brutality of it, and ended with me declaring that it is and always will be mutilation, and that I must speak out against it whenever and wherever I saw it.  Further thought on the subject has made me come to realize that as an outsider to these cultures, I can’t approach a woman by telling her that she’s been mutilated as the starting point for any future conversations–that will immediately close her off to me and only serves to project my own cultural bias over her own.  The important thing to remember is that to women brought up in cultures which practice FGC, it is no more strange to them than piercing bellybuttons or lips or eyebrows is to us, even if the implications, the actual act itself and the repercussions of it can be much more damaging to them than a bellybutton piercing.  When viewed within their culture, it’s a mark of belonging and identity, a way of fitting in, a symbol of their womanhood, a manifestation of their virtue and honor, and on its most basic level, the way that they think vaginas are supposed to look–beautiful, even, to their eyes.  When a woman who has been cut sees a picture of an uncut vagina for the first time in her life, the reaction is usually one of shock and horror at how ugly and deformed it is, lacking the symmetry and neatness of infibulation. As members of the western/ dominant/ imperial culture, we are not in a prime position to be doing the actual hard work of change.  Our position of privilege and dominance allows us to advocate for change, but the actual change itself needs to come from within, from programs like Tostan’s, which spends 30 months teaching and empowering community leaders and members of the community, giving them the tools they need to choose to stop FGC for themselves.  Compared to that kind of impetus, the AAP advocating for a western doctor to perform a “ritual nick” seems like trying to put out a fire with a squirt-gun.

But then, on the flip side, I do hear the AAP’s argument for trying to limit the prevalence and severity of FGC by offering a cleaner, safer, less invasive option, and it does seem like they have some research to back this up (but very limited research…and it seems there is also a fair amount of research arguing against adopting this practice. To quote again from their policy: “In some countries in which FGC is common, some progress toward eradication or amelioration has been made by substituting ritual “nicks” for more severe forms.² In contrast, there is also evidence that medicalizing FGC can prolong the custom among middle-class families (eg, in Egypt).³⁵ Many anti-FGC activists in the West, including women from African countries, strongly oppose any compromise that would legitimize even the most minimal procedure.⁴ There is also some evidence (eg, in Scandinavia) that a criminalization of the practice, with the attendant risk of losing custody of one’s children, is one of the factors that led to abandonment of this tradition among Somali immigrants.³⁶“)  My question is: does the AAP really think that women and families from cultures which practice FGC would be approaching their pediatricians about this in the first place?  And in the AAP’s defense, they are by no means recommending this routinely, only offering the option of a ritual nick as a potential last ditch effort when other attempts at education and dissuasion have failed.   The actual recommendations at the end of the policy are as follows:

The American Academy of Pediatrics:

1. Opposes all forms of FGC that pose risks of physical or psychological harm.
2. Encourages its members to become informed about FGC and its complications and to be able to recognize physical signs of FGC.
3. Recommends that its members actively seek to dissuade families from carrying out harmful forms of FGC.
4. Recommends that its members provide patients and their parents with compassionate education about the physical harms and psychological risks of FGC while remaining sensitive to the cultural and religious reasons that motivate parents to seek this procedure for their daughters.

I don’t anticipate any actual change to legislation any time soon which would non-criminalize acts of FGC, despite what the AAP may suggest.  In fact, it seems like ths US is cracking down on FGC even more at this time, especially in the form of the new proposed legislation (The Girls Protection Act H.R. 5137) which would criminalize not only acts of FGC in the US, but also sending women and girls abroad to have the procedure done (which  is already law in most of the countries of Europe).  It will be interesting to see how this plays out in the months to come.  Any other thoughts on this?

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.

Attempts to draft an 11th hour Written Practice Agreement between homebirth midwives and the Health and Hospitals Corporation (HHC for short–basically, the City’s public hospitals, which includes the hospital where I currently work) sadly fell through, although the latest update from Choices in Childbirth did add that HHC is still considering options.  Nevertheless, at the moment the crisis is unresolved, and this leaves women planning homebirth with no back-up options at this time.

What can we do about it?  First things first: SIGN THE PETITION in support of the Midwifery Modernization Act, which seeks to amend the Midwifery Practice Act in New York State so that having a written practice agreement in place with a collaborating physician is no longer required.  After that, you can continue to flood the Department of Health and Board of Education by making the following calls:

While Facebook maintains that breastfeeding photos are okay, it does have a no-nipple no-areola policy, and will remove photos that other users indicate as obscene, which is apparently what happened with the breastfeeding photos that were originally removed.  I still don’t understand how photos of teenagers clad in lingerie are acceptable while photos of breastfeeding babies are not.  While some people argue that this is for the protection of the women and babies from predators, I really think what it does is send the message that public breastfeeding is not acceptable.  It seems like any use of the breast for anything other than sexual gratification is what’s considered obscene.  In our sex-drenched culture, sexy women in lingerie won’t even make us bat an eyelash, but a baby taking sustenance from a breast….that’s obscene.  How can breastfeeding not be considered “family-friendly”?  It’s the very essence of family friendly — it’s feeding and nourishing said family.  And for the folks who wonder why people would want to even take a photo of a nursing baby in the first place…just look at all the photos taken of babies with bottles in their mouths.  It’s cute, and as a parent, I can only imagine that there’s something very satisfying and fulfilling about watching your baby eat.  Babies are born to breastfeed, and it’s not obscene.  Anyway, kudos to the lactivists of California for making their real world presence felt outside the Facebook headquarters this holiday season.

And with that, I’m off for the rest of the year.  See you next year!