Largest study to date on home birth

A very exciting new study was released last week in the Netherlands proving once again that 'planning a home birth does not increase the risks of perinatal mortality and severe perinatal morbidity among low-risk women...'.   Because the study included over 500,000 women, the findings will satisfy the argument that home birth safety can't be proven because the prior studies have all been too small.  The entire study can be found at the following link:

http://www.cfpc.ca/local/user/files/{F249B8FE-6B6A-4426-BF21-57FA51A28796}/Home%20Birth%20Netherlands.pdf

There is a lot to be learned from the Dutch maternity system and the American system would likely have to be tweaked to accomodate the difference in American geography and culture.  The Dutch maternity system is completely integrated with the midwives providing primary care  and seamlessly working with doctors who provide the secondary care for higher risk situations.  In America, the home birth care providers are still very much separated from the hospital providers and because of our private/'for profit' medical system the two are direct competitors instead of allied partners.  The UK is already looking at this study as more motivation to continue the NHS' move to offering more home births, let's hope America someday follows suit.

Pondering Fear

I've had a number of conversations both online and in real life recently about why women and our society in general is so afraid of birth, and so convinced that it a horrific and painful experience that requires medication every single time.  (and I'm not trying to say that women should NEVER use medications, they are a fabulous tool in some situations, but they also have risks and repercussions that seem to be largely ignored).

I have been thinking that far too often it feels like by the time women are actually having babies their fears of giving birth are already so entrenched that it is difficult to undo.  As I talked about this to a friend lately I started thinking about a video I had seen recently, it was supposed to be funny, it was just a group of teenagers all facing a screen, the narrator tells us that they are in health class watching a birth video.  The girls are all screaming and covering their eyes, horrified at what they are watching.  I thought it was so sad.  I wondered what kind of video it was and how it portrayed birth and thought about what we watched in our health class.  I realized that often times birth is presented to teenagers as a deterrent to having sex (or at least to encourage them to use birth control) and is made out to be a painful, miserable experience.  I guess the hope is to motivate these girls to avoid pregnancy and the subsequent 'horrors' that come with childbirth.  I think these messages create fears that stick and then when women are ready to become mothers they go to great lengths to try and dissociate themselves from the horrors they expect with giving birth.  Usually just by having an epidural as soon as possible, but sometimes by insisting on a c-section or even avoiding having children altogether.

 

I know I felt this way before I had my first baby.  A man I worked with suggested that a home birth was a wonderful way to go and I told him that "I wasn't crazy, I was having an epidural"!  When I got the hospital and suffered through contractions lying on my back with no support and no clue how to help myself, my belief that birth is intolerably painful was confirmed.  Of course nobody suggested that I walk around, stand up, have a hot pack, any of the things that might have really helped, and I certainly didn't know how much my fear and tension was making it worse.  It took a lot of reading, several years, witnessing some births first hand, and finally the desperation to have a VBAC (and the conviction that I needed to be at home for it to happen) to really get me to accept birthing unmedicated.  Obviously when it turned out to be a completely comfortable experience (thanks self-hypnosis!) I was definitely convinced that birth is totally do-able, but it would have been tough to convince me of that 8 years ago.

 

So why was I so afraid and why are most of the women I know so afraid?  How is the information being presented in health class to high school kids and how can we convince educators to give kids a more balanced view?  (ironically, my own father was a health teacher for years, so I will be having this conversation with him for sure)  How we do we counteract all those crazy dramatic births that they show on TV and in the movies?  How can we 'infiltrate' the colleges and present the idea of birth being normal?

 

How can we get them to see this video:

 http://www.themidwife.net/index_files/Page340.htm 

instead of The Baby Story?

I wish I had the answers, sometimes it feels like it an impossible task to make birth a more 'treasured' experience in this country.  I feel like people put so much effort, time, though and preparation into their weddings, but do none of the above for the births.  How can people spend thousands for their weddings, but get bent out of shape at the idea that they might have to pay to give birth to their children?  They want and expect insurance to pay for all of it and are happy to let their insurance companies dictate which hospital they can go to and which provider they can see?  Would women accept the same situations at their weddings "sorry honey, but I'm paying for this wedding and this where your getting married and this is the person who is doing it".  I can't see a lot of brides being very happy about that situations why are prospective mothers okay with taking whatever is given to them for their births?

(okay now I realize this analogy is kind of bad because some people don't have fancy weddings and don't spend much money on that either - I am one of those people - but I'm speaking in generalizations here and on average Americans spend $20000 on their weddings.  Shocking to me, I got married in Las Vegas at  $50 chapel, but even people who don't spend anywhere near this much still spend easily a couple of grand out of pocket, but most people FREAK OUT at the idea of spending $2000 out of pocket for their births.  (oh and i'm talking Utah dollars here, double that if you live back East))

I would just really like to see women feeling as empowered about giving birth as they do about planning their weddings.  Brides do tons of research, they pay for a wedding planner to be their expert guides, read all the reviews, visit all the receptions centers, they OWN that wedding.  I want women to OWN their births too.  I want them to know all their options and be as excited about the idea that it is going to be a beautiful and positive day in their life, not just a day that they have to get through.

Apologies for this being a rambling post without much purpose, I'm digging through all these thoughts in my head and spewing them out into this blog hoping that somehow I'll be inspired about where to find answers.

Time reports on VBAC

I have been letting this poor blog get ignored these days as I focus on other things.  Stuff that might have gone up here before is now going up on the Utah Friends of Midwives blog

This article needs to be splashed around the web as much as possible.  Not enough people are aware of the problems facing women wanting a VBAC.  

http://www.time.com/time/magazine/article/0,9171,1880665-2,00.html

In my experience the comment in the article about the doctors leading towards women towards the c-section is true.  When the doctor has so much to gain by doing the surgery - he gets paid more, spends only an hour of his precious time, has less liability - then he isn't in a position to give the women the risks and benefits without being biased.  Not to mention the subtle cues that they give women about their babies seeming big, their pelvises being small or just asking each week if they are ready to schedule yet (when women are big and tired of being pregnant that's a big temptation!).  They have sway and most of them are surgeons first, of course that is going to be their preferred method.

All the more reason for every woman to have a midwife as the primary care provider.  She can keep things normal, screen for the abnormal and collaborate when the expertise of a surgeon is truly necessary.

December Midwifery Rules Committee Meeting

It has been a while since I blogged about the legal issues relating to midwifery in Utah, but it is time for an update.

As you may recall the Utah Medical Association launched another bill last year attempting to restrict the births that Licensed Direct-Entry Midwives could attend.  They claimed that the midwives had asked to do only low-risk births at home, but they were attending births that the doctors considered too high risk to be done at home.  (Don't worry your pretty little head about what the mother considers high risk.)

The bill was incredibly restrictive in its original inception and would have eliminated nearly all home births, but we fought back.  Compromises were struck and most of the restrictions were removed, but the real sticking issues were breech births, twin births and VBACs.  All three are considered 'high risk' by the medical community, breech births are basically an automatic c-section and twins are most of the time too.  VBACs happen in some hospitals where they have the resources to care what they considered a high risk birth.  VBACs are generally not available in hopsitals outside of the Salt Lake valley, those women will have to have a repeat cesarean or travel to Salt Lake. 

The midwives conceeded twins and breech, they are fairly rare anyway and unlicensed midwives will still be able to attend them if the women really are intent on a home birth.

VBAC though just has to stay.  The difficulties that women run into getting a VBAC birth at the hospital, especially a natural, intervention-free birth, are just so great - they need home birth.  I did, for lots of reasons, but a big one was the requirement that women be monitored constantly while they labor.  Depending on the provider you might run into a whole lot more requirements, it isn't uncommon to hear that to doctor requires the woman have an epidural.  Or other times they get to 36 weeks and the doctor tells them that if they'll go ahead and schedule the c-section for their due date because if they haven't gone into labor by then the'll need to have the "elective" repeat cesarean (ERCS).   If a woman truly wants to avoid having another cesarean and wants to improve her chances by staying unmedicated, off the pitocin and upright, she may have no alternative besides home birth.

Fortunately midwives were able to keep the wording in the bill that allows VBA2C, but another consequence was that the Rules for the Licensed Direct-Entry Midwives must be rewritten, this time allowing the UMA to select the doctors who sat on the board (I'm not sure why there aren't any midwives on the Medical Board).  The bill dictates the basic guidelines but the fine details of the rules that midwives must follow in their practice are to be hashed out by the Rules Committee.  The bill does have language give the Rules Committee license to further restrict the VBAC births that LDEM requires but it does not mandate exactly which births.

So far there have not been any real surprises about the changes made to the existing rules.  They were required to change the things necessary to match the new bill and that has been done for a number of issues.  There has been much discussion about everything but nothing terribly offensive or restrictive has made it into the new rules.  On the agenda at yesteday's meeting was the discussion of the VBAC portion of the rules.  The requirements written into the law state the midwives can do vaginal births after 2 sections, but the woman cannot have had a classical, J or T type of incision.  (Basically those are variations to the way that the obstetrician actually cut into the uterus during the caesarean surgery.  Most women get what's called a low transvere incision, which everyone agrees is the most safe type to have had when attempting VBAC.)  The women are also required to get an ultrasound to verify that their placentas are implanted away from the scar.

Dr. Lamb, one of the doctors on the committee, came prepared with a number of proposed changes to the rules.  His first proposal was to require that the midwife must verify the incision type and if she can't, then the woman must be transferred, no exceptions.  There was much debate to this idea because it can sometimes be difficult to get those records and if a woman transfers into midwifery care late in pregnancy they may not show up until after the baby is born.   Even if the woman is sure her surgery was low-transverse, and her external scar is low and there isn't any reason to believe otherwise, she still couldn't have her VBAC at home if she couldn't produce that piece of paper.  

Considering that the hospital is the entity that needs to give you that piece of paper, but they are also going to lose your business if they give it to you.  You think that they aren't going to stall or accidentally lose something?  Sorry, maybe I'm cynical but it is oftentimes quite difficult to get medical records and it doesn't help when they really aren't motivated to want to give them to you!

The midwives refused to add this requirement to the rules, they were willing to require that they try to get the operative report, and have the woman sign another informed consent document that she understood the risk of not knowing what type of scar she had, but they weren't willing to make it a requirement!  The doctor basically said that he wouldn't vote to approve it  the way it was.   The other doctor didn't say, but likely she won't vote to approve the rules either, which is fine unless the nurse-midwife won't vote for them either.  She either approves or the vote is tied.

The discussion  moved onto whether the rules should allow the midwives to attend women who are having a vaginal birth after having two prior caesareans.  The docs adamantly oppose this, and the only doctor who came as a member of the public, a retired doctor, that has come to watch the last couple of meetings had plenty of commentary.  He told us how it is their job to protect the 1-5% of babies that are going to be harmed when there is a bad outcome (hello, what study did that number come from?).  

This is where my blood pressure was really starting to rise.  His implications were very upsetting and his opinions were outdated and completely opposed to everything we believe.  It is offensive to be told that your not qualified to decide where or how to give birth, that only the doctors should make that call.  He also said we should be required to have an IV, that there must be a blood supply on hand, and that after every VBAC that it should be required for the midwife or doctor to reach up inside the woman and verify if the scar is intact.  That is an invasive and barbaric procedure, and there is absolutely no evidence that it is either safe or beneficial.

Later when he got the chance to speak for a few more minutes he shared more of his opinions.  He felt that the rules should dictate who should be allowed to attempt VBAC based on his criteria for who is a good candidate.  He said that women who had prior c-sections for a large baby shouldn't be allowed to try if their second baby is large too (well how exactly do we know that until the baby is born?).  If I understood correctly he was okay with women having a VBAC at home if they had a proven pelvis, in other words if they had given birth before.   That would eliminate the VBAC option for so many women, especially if they had a c-section for their first birth, then the only place available to do the first VBAC is the hospital and we've already talked about how restrictive that can be.

When time ran out it was a stalemate and I guess that is fine.  No votes to allow any rule changes were made, so nothing really changed.  It may draw out the process, but so far no change is a good thing.

It is frustrating to have a system that gives the medical community such an elevated status in society that they are allowed to dictate how everyone else should manage their medical care (or lack thereof).  I'm a fierce libertarian, so I know that my beliefs are pretty radical and I think that a woman wants to give birth in the woods attended by only a shaman then that is her call, just like a person with cancer can choose whether they will have every surgery and drug known to man or no drugs and no treatment at all.  We allow Christian Scientists to do have autonomy over their medical decisions, even when know that it is a high risk thing to do, I'm really not clear on why anybody else shouldn't have the same right.  

I know the answer my critics will give, because of the baby.  They feel entitled to intervene because they need to protect the baby from what they believe is a bad choice their mother might make.  Who are they to decide which choice is right or wrong?  How can we ever really know beforehand what will be the best course of action....  Have an ERCS and give birth to a baby with breathing problems who later develops asthma and suffers from severe, even life-threatening allergies or have an ERCS and zero problems, there isn't really any way to know for sure which it will be.  Even for the mighty Obstetrician, he just can't know, so why isn't it my call to decide how I will handle my birth.  As Michelle says, "My Body, My Baby"

Birth Choices: Panel Discussion at The Leonardo

Last night I attended a discussion at The Leonardo, a museum in Salt Lake City.  This event was part of a series The Leonardo is doing about "Choices".  The museum is currently hosting the Body Worlds exhibit and has chosen body related subjects for the discussion series in conjunction.  Last night the subject was choices and birth, here is the museum's flyer:

http://www.utahsciencecenter.org/documents/Birth.pdf

Joe Andrade  PhD, a history professor, was supposed to talk about the history of birth (or something?), but he wandered off subject quite a bit.  He did mention that Brigham Young had sent women to medical school in Philadelphia so that they could care for the health of the pioneer mothers, and I had never heard about that before.

Richard M Hebertson is a retired Ob/Gyn, a former head of Obstetrics at LDS hospital.  He talked about the birth of his first child and how he was isolated in the waiting room and not given any information.  His wife had pushed for four hours to give birth to that first child, but she didn't remember the birth because she had been given nitrous oxide gas.  He went on to talk about how he had practiced during a glorious age of obstetrics *cough* when they had learned so many things.  He was particularly impressed with regional anesthesia, which he saw as a big advancement over the 'twilight sleep' drugs used when he began his practice.  Dr. Hebertson talked about letting the fathers back into the room for birth and how he had trained in natural childbirth, which I took to be some training with the Bradley Method.  He was also impressed with the introduction of electronic fetal monitoring, which made the ladies I was sitting with roll their eyes back into their heads!

The next panelist was a currently practicing Perinatologist at the University of Utah, Kirtly Parker Jones, MD.  She really impressed us when she first began to talk about choices, because she seemed to be embracing home birth and really supporting women's options.  We got less impressed as the discussion progressed.

Mary Rizzuto was the next panelist to speak and her angle was that by receiving both a heart transplant and a kidney transplant that she had been reborn.   Nobody was quite seeing how organ donation really fit into the choices facing women giving birth, but her story was interesting nonetheless.  She knew her part of the panel was a little disjointed and kept her comments brief.

The final panelist was a woman named Linze Floyd who had given birth this spring at home.  She talked about how she had researched her birthing options and come to the conclusion that a home birth was the best option for her.  They showed a slideshow from her birth while she talked, with some really beautiful pictures.  The second picture showed her in a birth pool, and I thought I know who her midwife is, I've seen that tub before!

The moderator of the discussion showed a graphic map of the world that reflected the birth rates around the world, and a second map that showed how the world's maternal deaths are largely taking place in Asia and Africa.  There was a good question about how US maternal death rates compared to Europe and Dr. Jones felt that was because America had what she called "3rd World Counties" where poverty and lack of access to care raised the maternal death rate.  This is true, but she wasn't going to accept that our over-use of technology was any part of that.

One of the doulas I was with, Michelle made some good points about how the medical community sometimes acts as though you have plenty of choices, but when the choice you make isn't what they had in mind, you are attacked.  She made sure to mention the American Medical Association's plans to outlaw homebirth. 

The discussion turned to risk and Dr. Jones tried to make a point about the choice women usually make when their pregnant, and that is to take all the risks on themselves in order to protect their babies.  I started to take issue with some of the things she was saying, because the implication is that women who want to have vaginal births are being selfish somehow by not submitting to surgery.  The doctor is right that women pretty much will do everything in their power to give the best to their babies, and for some of us that means going to great lengths to AVOID surgery, because we know that a surgical birth carries risks for baby too.

Linze made some good points talking about the restrictions she'd encountered when she investigated a hospital birth, and how she was required to have a heplock in place and would have to submit to electronic fetal monitoring.  Dr. Hebertson seemed to fall back on the old excuse that it is really difficult to get changes made and how hard he had to work to get the Certified Nurse Midwives permission to practice at LDS Hospital.  I think it's admirable that he worked for that choice to be created for women, but it doesn't really explain why it should be so hard give women the autonomy to give birth as they really desired without hospital politics getting in the way.

There was a lot of information that got fired around the room, and in the end I'm not sure if any progress was made on any fronts.  The doulas I was with all left still feeling frustrated. We can talk all day about how many wonderful choices women have, but we know full well that a woman who wants to have a vaginal birth after a cesarean is going to find out that her choices are actually very limited indeed.  And we know that when we go into the hospital the women will hear "well we need you to do X  because it is hospital policy" and "you can't do Y because the hospital doesn't allow it" and that when it comes right down to it women don't have much choice at all about some of the things that will happen to them.

This just keeps coming up.

I know I harp on this all the time, but I came across another article about hospital-acquired infections... I think this is one of the best arguments for home birth for normal, healthy women (especially if they don't like hospitals)

http://www.msnbc.msn.com/id/9818616/

In case you didn't catch this information from the sidebar...

— Infections contracted in hospitals are the fourth largest killer in the United States, causing as many deaths as AIDS, breast cancer and auto accidents combined.
— One out of every 20 hospital patients gets an infection. That's 2 million Americans a year, and an estimated 103,000 of them die.
— The single most important way to reduce hospital infection, according to the federal Centers for Disease Control and Prevention, is for doctors and other health care workers to clean their

hands in between treating patients.

1 out of 20 patients! Holy moly!

At The Farm, a commune in Tennessee and home of modern midwifery pioneer Ina May Gaskin, they have tracked their statistics for births managed by their midwifery service for more than 30 years. For the low-risk women that they cared for from 1970-2000 95% completed their births at home (or someone else's home) and only 1.3% were transported in an emergency situation (that doesn't mean that they weren't fine in the end, but that something did go wrong that they required hospital care quickly). That is 1 in 100 women, roughly, who had an problem that the midwives couldn't handle and was potentially life threatening. 1 in 20 vs 1 in 100 -which risk do you prefer? Women should be entitled to make that choice based on their own instincts and situations, there isn't a really obvious right answer.

The AMA disagrees with me, they think that they are entitled to make the choice for you by outlawing home birth.

Broken down system

This information came across my radar today...

Medical expenditures associated with an uncomplicated pregnancy and hospital birth averaged about $7,600 in 2004, according to a new report released by HHS‘ Agency for Healthcare Research and Quality, CQ HealthBeat reports (CQ HealthBeat,10/19). For the report, the agency gathered data from 2001 to 2004 from three panels of the Household Component of the Medical ExpendituresSurvey. [...]
http://www.all-healthtalk.com/average-medical-costs-for-prenatal-care-childbirth-in-us-about-7600.html


I am amazed. $7600 for an uncomplicated birth, imagine a complicated one! It just boggles my mind that it can cost that much and yet the women in the hospital are still hooked to a machine and left alone for most of their stay. You'd think that with that kind of financial outlay that the hospital could afford to at least get enough nurses on staff to have only 1-2 patients per nurse.

Of course that isn't where the money goes... Big chunk to malpractice insurance, big chunk to bureaucracy, and then of course you have to pay the CEOs of the HMOs and insurance companies. How expensive is that? Take a look:

Here is a list I recently obtained of insurance executives salaries:
1. Oxford Health Plans, Norman C. Payson, former chairman and CEO, $76million.
2. WellPoint, Leonard D. Schaeffer, chairman and CEO, $21.8 million.
3. Coventry, Allen F. Wise, president and CEO, $21.7 million.
4. UnitedHealth, R. Channing Wheeler, CEO, Uniprise, $9.6 million.
5. Aetna, John W. Rowe, MD, chairman and CEO, $8.9 million

And unexercised stock options:
1. UnitedHealth, William W. McGuire, MD, chairman and CEO, $530 million
2. WellPoint, Leonard D. Schaeffer, chairman and CEO, $93.1 million
3. Oxford Health Plans, Norman C. Payson, former chairman and CEO, $25.6million
4. Aetna, John W. Rowe, MD, chairman and CEO, $24.1 million
5. Health Net, Jay M. Gellert, president and CEO, $23.5 million.

The nurses make a living wage, but certainly aren't getting wealthy. The doctors constantly battle to keep their heads above water with their outrageous malpractice costs and having to stand on their heads for every dollar from the insurance companies. The government is not setting a good example either, they reimburse doctors a pitiful $500 for a Medicaid delivery. No wonder it is so difficult for poor people to get care when no doctor can afford to attend them and stay in business.

Our health care dollars are so poorly managed, not nearly enough of it pays for actual medical care! The anarchist in me says it is time to destroy the system and start from scratch. I just hope congress and the next administration can find a way to work for the needs of the people instead of the needs of their campaign donors.