The NY Times on direct-entry midwifery legislation in Illinois

Use of Midwives Rises, Challenging the State to Respond:

Each year, 700 to 1,000 babies are born at home in Illinois, many of them in rural locations, according to the Illinois Department of Vital Health Statistics. Licensed home-birth practitioners work in just 7 of the state’s 102 counties, and most are concentrated in Lake and Cook Counties, leaving the majority of Illinois home births unattended, or attended illegally by someone whose education and licensing are unregulated.

That could change as early as November. After 30 years of trying to get the legislature to license direct-entry midwives, Illinois’s midwifery organizations are guardedly optimistic. In May, the State Senate passed the Home Birth Safety Act. A House vote is pending.

Check out the rest of the article, including their allusion to the fact that not all DEMs want licensure, and a choice quote from the OB/GYN on "natural birth plans". Hey, he's tellin' it like it is!

The Stupak amendment.

[Note: I posted this yesterday, then heard an NPR piece that made me think I hadn't understood the Stupak amendment's restrictions. I was heading out the door, so I didn't have time to revise; I took the post down until I had time to research and make sure I was right. This is something I feel very passionate about and I wanted to make sure I was as accurate as possible. Slightly revised version below.]

I called, on Saturday, but what more could I do? Mostly I just tracked the news and crossed my fingers. The fact that this came out of nowhere (at least for me) and was over with in a day feels so utterly unfair.

In case you are not familiar with the Stupak amendment, it is part of the recently passed House version of the health care reform bill. The amendment restricts the ability of public and private insurance plans, offered in government health exchanges, to provide coverage for abortion.

Read that again: AND PRIVATE. This is where I was unclear yesterday, but it is clarified today by this extremely helpful post from legal experts at Planned Parenthood. I'm quoting it extensively because given what I heard on NPR yesterday, I think there is still some confusion out there about the realistic effects of the Stupak amendment on abortion coverage availability in the exchanges:

The Stupak-Pitts amendment prohibits any coverage of abortion in the public option and prohibits anyone receiving a federal subsidy from purchasing a health insurance plan that includes abortion. It also prohibits private health insurance plans from offering through the exchange a plan that includes abortion coverage to both subsidized and unsubsidized individuals.

Thus, if a plan wants to offer coverage in the exchange to both groups of individuals, it would have to offer two different plans: one with abortion coverage for women without subsidies and one without abortion coverage for women with subsidies. These private insurance plans would need to be identified as either providing or not providing coverage for abortion.

Health insurance plans are highly unlikely to operate in this manner, and it is not even clear that this is feasible under the administration of the exchange and affordability credits. As one alternative, the Stupak amendment purports to allow women to purchase a separate, single-service “abortion rider,” but abortion riders don’t exist. In the five states that only allow abortion coverage through a separate rider, there is no evidence that they are available.

Furthermore, women are unlikely to think ahead to choose a plan that includes abortion coverage, since they do not plan for unplanned pregnancy. In addition, it is not clear that health plans would even be allowed to offer two separate plans under other provisions of the act, such as the anti-discrimination and guaranteed-issue provisions. Those elements of the bill, which are very important to consumers, may make it impossible for plans to provide two separate plans, one that includes abortion and another that does not.

Realistically, the actual effect of the Stupak-Pitts amendment is to ban abortion coverage across the entire exchange, for women with both subsidized and unsubsidized coverage.

(emphasis mine)

Why the Stupak amendment? The argument is, as best I can tell, that those people who can't use all their own money to buy health insurance will be eligible for a government subsidy. This will probably be me at some point very soon (like after I graduate from school in May) so let's take me as an example. I could use the subsidy to buy a health insurance plan that covered abortion. Then I could use that money (along with my OWN!) to buy a private plan. Then, if I needed an abortion and that insurance plan covered it, the government would have somehow, indirectly, kinda sorta had a hand in making it possible for me to get a legal medical procedure.

Did I say legal medical procedure? I also meant abortion. They're the same thing, so sometimes I use them interchangeably.

We have had the Hyde amendment in place since 1977, exempting abortion from Medicaid. Poor women, expendable: check. Apparently health care reform is an opportunity to go even farther: to reach into PRIVATE health insurance, paid for with PRIVATE money, and effectively take abortion coverage out of that, too. This applies not just to individuals, but to businesses; companies that buy plans through the exchange? All their employees' families will lose any abortion coverage they had. All women, expendable: check.

The fact that this amendment comes from the party that has been ranting and railing about "government taking over health care" and using scare tactics like death panels and rationing of care...well, I guess irony has been dead to the Republican party for a long, long time, so we shouldn't be too surprised.

Besides women who need abortions, who else will this hurt? How about women who have miscarriages? Is maternity care next? Keep in mind, this comes from the same party that says health insurance shouldn't cover maternity care, because men don't need it.

This just...disgusts me. Last year I went to a talk by Dr. Nick Gorton and blogged about how he predicted this very outcome - that reproductive health care would be one of the issues to suffer when government stepped into health insurance. At the time, I mused about how we could protect abortion and other political hot button issues in health care reform - but reform seemed so theoretical. I guess I haven't been paying enough attention - but that's going to change. I agree, let's not just be satisfied with keeping Stupak out of the final bill - let's go after Hyde.

If you'd like to take further action now, this is a great place to start: While there's a wall of shame for Dems who voted for Stupak and against reform, there are some bright spots. Those are Democrats who voted AGAINST Stupak and FOR health care reform - despite being in highly vulnerable races next year. Click here to donate to those reps, reward their courage, help keep them in Congress, and send a message to the party: Do NOT allow the Stupak amendment into the final bill.

Links - how important is birth? problems with research, VBAC questions, and more

Enjoy Birth and Stand and Deliver and Talk Birth all meditate on the importance of birth - how it shapes women, how it shaped them - and whether or not it is important in shaping women as mothers. All provoked by this post at Sweet Salty. Excellent food for thought.

No Fat Talk Week - I personally celebrate this 52 weeks a year, and invite you to join!

Winning entries from the National Advocates for Pregnant Women writing contest. How's this for a title: “In the Manner Prescribed By the State”: Potential Challenges to State-Enforced Hospital Limitations on Childbirth Options. I like!

Melissa lists questions to ask a VBAC provider.

Amy at Science & Sensibility asks Do We Need a Cochrane Review to Tell Us That Women Should Move in Labor?. She says, "Somehow, things have gotten turned around, and the normal condition is now the “experiment” and the intervention is the “control”. In addition to being irrational, this is a set-up to perpetuate conventional obstetric care, which imposes unhealthy and unfounded restrictions on women in labor. This is because in “intervention versus control” research, you have to show that the intervention performs significantly better, otherwise the control condition remains standard practice." Read the rest on how this is a bass-ackwards way to go about things. It's alerted my eyes to look for the same issues in breastfeeding research.

Aaaand a new favorite (via, as so often, The Unnecesarean), Arwyn explores the analogy between athletics and childbirth:

"Everyone has heard of and no one doubts the existence of “runner’s high”, so why do we start plugging our ears and rolling our eyes and flapping our tongues when we speak of “birthing high”? ... Even discounting that, or in its absence, there is potential for pride and a sense of accomplishment: something we value so much in athletics, yet scoff at in childbirth, where our effort benefits both us and another. We deny women that pride in accomplishment (for which support of athletics is so vital to girls’ sense of self and women’s equality), that boost in self-esteem and feeling of competency, right when we need it most: at the start of parenting, one of the most demanding journeys a person can undertake."

And that's enough for tonight!

Arizona woman fights VBAC ban

Joy Szabo had a normal vaginal delivery for her first child, then an emergency c-section for her second, followed by a successful VBAC for her third. By the time she was pregnant with her fourth, the hospital in her town had banned VBACs. Yes, the same hospital where she had just had a successful VBAC two years earlier. So she decided to go out and make some noise about it.

Her local newspaper wrote an article about her situation. The Unnecesarean posted excerpts from her story and contact info for the hospital, prompting a Twitter response from the hospital's PR person (read all the way down the entry). Now the ICAN blog has Joy's story in her own words. Here's a bit from her second meeting with the hospital CEO:

...I asked why they are doing labor and delivery if they cannot offer a timely cesarean. She defended the hospital, saying that they can do emergency cesaereans, but did not want to accept the risk of VBAC. I asked what the hospital policy is if I show up and just refuse to consent to a cesarean. She said they would seek a court order. She repeated to me that Page Hospital does not have the facilities nessasary to handle an emergency.

(My translation: "Can Page Hospital handle an emergency c-section?" "Yes! No! Depends on who's asking! Go away or I'll get a court order!")

The newspaper article features a photo of the kick-ass message she's painted on her minivan, equating her hospital's threat to get a court order for a cesarean with rape. Because of the VBAC ban not only in her hometown, but on multiple hospitals closer to where she lives, as of now Joy Szabo has decided to try to find an OB/hospital in Phoenix - a 5 hour drive from her home - that will work with her VBAC.

The ICAN blog has links for "mom-sized" activism (or really, any busy-person-sized). Tell Page Hospital and the Banner hospital system that forcing a mom with 3 children to travel hundreds of miles just to give birth as her body intended, and threatening her with a court order for unwanted surgery...well, that's just Not Cool. And yes, that last part does sound a lot like rape.

A subway car full of nursing moms

A New York State Senator and a subway car full of nursing moms took the A train recently in support of breastfeeding and the right to nurse in public:

State Senator Liz Krueger (D-Manhattan) joined the New York City Breastfeeding Promotion Leadership Committee (NYCBPLC) today for their annual Breastfeeding Subway Caravan. The Subway Caravan began in 2004 as a means to highlight the importance of breastfeeding and reinforce a women's right to breastfeed wherever they have a right to be. The focus of this year's Caravan is the passage of Senator Krueger's Breastfeeding Bill of Rights (S1674-D). The legislation codifies mothers' rights to breastfeed into a single, concise document and bans commercial interests from influencing new mothers' choice of breastfeeding.

I wish the last part referred to a ban on formula gift bags in hospitals, but it's just a right to refuse the gift bags - maybe to prevent women from being pressured to "just take it in case you need it". Read more on the Senator's website here.

Update your links

On my short list of blogs you should be reading (besides mine) is Jill's The Unnecesarean. She recently had a sad case of domain-stealing, so update your links from Unnecesarean.com to TheUnnecesarean.com (or add it now if you haven't yet).

Just recently she has had in-depth information and discussion on how refusing an unnecessary c-section led to loss of custody, the outcome of charges against a doctor for being abusive towards a woman in labor, and noted the new Cochrane Review stating that use of antibiotics for GBS in labor is not supported by evidence. See? You don't want to miss this! And I can't link to all of it (just a lot).

IKEA misses the memo - breastfeeding in public is legal

A mother at the Ikea in Red Hook, Brooklyn was asked to move to the bathroom to finish breastfeeding her daughter. The comments on the blog post are pretty standard, including a former breastfeeding mom who puts down this woman's "poor planning" in not having pumped a bottle of milk in advance. Whoops! The mother who was asked to move must have forgotten that babies are born to be breastfed only in private. Perhaps the commenter was also forgetful, as she forgot - as the Ikea security guards seem to have - that women have a right to breastfeed in New York State anywhere they are legally allowed to be. As several more astute commenters pointed out, the security guards had no more right to escort her to the bathroom for openly breastfeeding than they did to escort someone to the bathroom for being say, openly black.

Here's the bottom line for me, and what a lot of the commenters don't seem to get: you don't have to like certain things. You don't have to like breastfeeding in public, or gay people holding hands, or someone wearing skimpy clothes. But these things are legal. If you choose, you can be a jerk about those things you don't like. The law doesn't and can't prohibit dirty looks or rude words; only common decency does. But companies and their employees are subject to the law, and by law cannot force a breastfeeding woman to move just because they don't like public breastfeeding. The end. What happened in Ikea shouldn't have happened and shouldn't happen again.

I find the whole thing particularly ironic since Ikea is Swedish and Sweden is an international model for its very high breastfeeding rates. I find it hard to imagine a mother in a Swedish Ikea being escorted to the bathroom for feeding her baby. They would have to escort something like 80% of them. I assume that's why their p.r. person gets it when she says: "This incident is being looked into as this totally goes against our culture and focus on family." Maybe the Swedes forgot that their American employees would need some extra training? (Interestingly, the thread where the original Ikea story was posted has another asked-to-stop-nursing-in-public story at a New York H&M, also a Swedish chain.)

(It's also not a great store location for this to happen in, given that scaring up a crowd of Brooklyn moms for a nurse-in would be as easy as walking around the playground.)

In any case, it sounds like both sides are responding actively to what happened, which is good. I'm curious to see what more (if any) news comes of this...

(Thanks to my friend and classmate Adriane for passing this along!)

New breech guidelines from Canada

The Society of Obstetricians and Gynecologists of Canada has come out with new guidelines for breech birth, saying that the automatic c-section is not an evidence-based practice and that all breeches should be evaluated and offered vaginal delivery if appropriate. New guidelines are here. I was curious to read through the guidelines, but as I read them I thought “What doctor is going to be willing to go through this checklist when they could just schedule another c-section and be done with it?” That’s why I liked an article that accompanies the published guidelines, by Dr. Andrew Kotaska, called titled, “Breech Birth Can Be Safe, But Is It Worth the Effort?”: (all the emphasis is mine)

Whether term vaginal breech birth is safe is no longer a question. The PREMODA study has clearly shown that with careful selection and management by average maternity units, breech birth can be safe. …

In the PREMODA study, the overall vaginal birth rate was only 23%. Is it important to mount the significant effort required to offer women breech birth if only one quarter will thereby avoid Caesarean section? … In North America, over 100 000 women have pregnancies that remain breech at term annually. With a success rate similar to that of the PREMODA study, some 25 000 could safely avoid Caesarean section.

…[T]he current practice of “not offering” women a trial of labour while providing ready access to Caesarean section is coercive, especially given the equivalency of long-term neonatal outcome. Now, with a more comprehensive understanding of the components required to make short-term outcomes of vaginal breech birth equivalent as well, it would be unethical not to provide this information to women. Although it may be difficult in some settings to offer vaginal breech birth routinely, its availability elsewhere should be disclosed and assistance offered to obtain it if requested. To offer only Caesarean section is ethically and legally difficult to justify if a reasonable alternative is available.

This is really the crux of it, and the guidelines even state that women who refuse a c-section recommendation must still be given care (why does this even need to be said?) Why is it OK to providers to offer one option and not the other? What if no c-sections were offered and all women were required to deliver breech vaginally, regardless of the risks – would anyone be ethically down with that?

I think the next big step is to change the attitude that offering women one choice (to be accurate, no choice at all) is acceptable. After some new evidence came out about Term Breech Trial and other breech trials in 2006, ACOG did a weak “we guess maybe you could try vaginal breech if you REALLY REALLY want to” policy change, and I think everyone would agree it didn’t change much here. The Canadian guidelines, on the other hand, are actual guidelines with specific recommendations on how to safely offer and assist breech deliveries, along with a recommendation to train more providers in breech skills. But without strong advocacy the status quo seems likely to persist there as it does here. Will there be loud enough voices in Canada demanding that those guidelines be applied?

Nurse practitioner removes IUD without consent

In the oh no she DIDN'T! category, a nurse practitioner (and the community health center she works for) is being sued because she removed a patient's IUD without her consent, lectured her about how IUDs were like abortion, and refused to insert a new one. According to the plaintiff, the NP said "Everyone in the office always laughs and tells me I pull these out on purpose because I am against them, but it’s not true, they accidentally come out when I tug.” So funny! You know, everyone always laughs and tells me I eat so many cookies on purpose because I like them, but it's not true, they just accidentally fall into my mouth. Read the original complaint here.

But seriously, think about this: if this is an accurate quote, the NP has done this enough times to be "always" teased about it in the office. How many other women did this happen to before she hit on one who was angry and organized enough to sue her? Why was this a cause for humor and not for concern? Like I said about the abusive OB who was being sued, for every woman who sues there are many more who experienced the same thing and did not or could not speak up.

When doctors take it out on patients

Via Feministing comes the story of a woman who is suing the OB who cared for her in labor over abusing her verbally and refusing pain medication, saying "Pain is the best teacher". I believe that when he saw her, he could have legitimately considered her too far progressed for any pain meds (every doctor seems to have a very different rule of thumb about how late is too late), but you don't have to be a jerk about it. More troubling is the allegations that he deliberately gave her a vaginal exam in the middle of a contraction (already painful and during a contraction even more so), stitched her up with a too-large needle, and had her start pushing when she was not fully dilated, telling her to "Shut up and push". And of course there's the "you'll hemorrhage and die" card.

These incidents are not as rare as we would like to think. I've seen very disrespectful treatment myself and heard far, far worse stories from other doulas. There are doulas who refuse to practice in hospitals anymore because they can't stand to see treatment like this. In the doula listserve I'm on, doulas often write in with these stories asking for advice - what can we do to change this treatment? How can we encourage patients to complain, without having them dwell on the negative aspects of their birth experience? It's the rare family who will actually bring suit.

My own personal and unscientifically formed perspective is that this treatment seems to be more common when it's not the patient's regular care provider (in the suit above, her OB was out of town) or is someone in the practice the patient hasn't seen very often. I wonder what all the reasons are that this could be...

Informed Choice: The Gold Standard

After I wrote my last post, where I discussed the rights of women to make decisions about their medical care and have those decisions honored, I got a link to a statement from a Canadian OB/GYN who is responding to statements from the American Medical Association (AMA) and American College of Obstetricians and Gynecologists (ACOG).

A bit of background: Ricki Lake, the TV talk show host, gave birth to her second child at home and decided that she wanted to make a documentary about our country's maternity care system and the alternatives available. The result was The Business of Being Born, which was released theatrically and on DVD in the past year. I have met more than one pregnant woman who decided to switch from hospital care to a home birth after seeing this movie. It's been screened all over the country and in hospitals, and it's gotten a decent amount of media attention.

This, apparently, requires action from our country's medical authorities. Both ACOG and the AMA released statements opposing home birth. ACOG's called for births to take place only in the hospital or birthing centers, and the AMA's supported that resolution. ACOG calls home birth "fashionable" and "trendy" (as someone noted, this is probably a big surprise to the Amish, who aren't generally called "trendy" yet have chosen home birth for generations). Why? It might have something to do with the fact that this movie is actually influencing women's choices, and that means less business for the OB/GYNs (although with home birth at less than 1% of the total births in this country, it's going to take a lot of screenings for that to truly tip the balance).

There are plenty of doctors who are not on board, however. Dr. Andrew Kotaska, noted Canadian researcher and Clinical Director of Obstetrics and Gynecology at Stanton Territorial Hospital, issued the following response. I wanted to repost it not just because it shows that there is opposition within the profession, but because of his statements about patient choice:

I would invite ACOG to join the rest of us in the 21st century. Modern ethics does not equivocate: maternal autonomy takes precedence over medical recommendations based on beneficience, whether such recommendations are founded on sound scienctific evidence or the pre-historic musings of dinosaurs. In the modern age, the locus of control has, appropriately, shifted to the patient/client in all areas of medicine, it seems, except obstetrics. We do not force patients to have life-saving operations, to receive blood transfusions, or to undergo chemotherapy against their will, even to avoid potential risks a hundred fold higher than any associated with home birth. In obstetrics, however, we routinely coerce women into intervention against their will by not "offering" VBAC, vaginal breech birth, or homebirth. Informed choice is the gold standard in decision making, and it trumps even the largest, cleanest, RCT. [my emphasis]

Science supports homebirth as a reasonably safe option. Even if it didn't, it still would be a woman's choice. ACOG and the AMA are, by nature, conservative organizations; and they are entitled to their opinion about the safety of birth at home. As scientific evidence supporting its safety mounts, however, (to which BC's prospective data is a compelling addition) they will be forced to accede or get left behind. The concerning part of this proposed AMA resolution is the "model legislation."

If ACOG and the AMA are passive-aggressively trying to coerce women into having hospital births by trying to legally prevent the option of homebirth, then their actions are a frontal assault on women's autonomy and patient-centered care. Hopefully the public and lawmakers realize the primacy of informed choice enough to justify Deborah Simone's words: "We don't need to be angry or even react to these overtly hostile actions from the medical community. We just need to keep doing what we do best; the proof is always in the pudding." It is sad to see the obstetrical community still trying to earn itself a wooden club as well as the wooden spoon; if the resolution passes, it is sad to see the politico-medical community helping them.

Andrew Kotaska
Yellowknife

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Next post answers Seth's second question: Why is there a gap between the evidence base and medical practice? Part of the answer lies in a conversation I had with my parents (both doctors) just a couple of days ago. Stay tuned!

Why Birth is Fundamental Pro-Choice Issue

As my first real post, I'm going to re-post an entry from my personal blog. I wrote this a couple of months ago, and writing it was one of the moments where I thought "Man, I should have a blog about just this stuff." I really want people to understand how all of these issues - reproductive rights, reproductive health, birth, abortion, childcare subsidies, health insurance, public health initiatives - aren't just connected. They are the same thing.

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I could go on about this for hours, possibly days, but there is so much in the birth world right now that seems to be such a neat parallel to the fight for abortion rights - until you realize it isn't a parallel, it's the same thing. That's the reason I go to such amazing birth workshops at the Reproductive Rights conference every year: reproductive rights go all the way from birth control to birth. Right now, to me, there is almost no area in which we see the state exerting more control over women's bodies. This story isn't common, but I venture to say it's only because more woman don't challenge the system. Try to refuse an intervention at the hospital based on not just your own understanding of best practices, but on solid evidence from excellent research, and watch how fast they come at you with dire warnings that you are PUTTING YOUR BABY AT RISK. Even as small a thing as refusing continuous fetal monitoring - proven over and over again to do nothing to reduce risk to the baby, but plenty to increase risk of cesarean - means snippy, angry nurses, endless badgering, and the prevailing attitude that you think you're better somehow, but you're NOT, and why can't you be like all the OTHER nice, compliant women who strap on the belts and lie in bed - THEY love their babies, why don't you? I've never witnessed legal threats, but I think it's easy for this attitude to cross the line from emotional (and physical) manipulation to stronger forms of pressure.

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And in going back to that post to get the text, I saw that my friend Seth posted some questions for me a couple days later that I never saw. Sorry, Seth! On the other hand, they're really excellent questions and now I'm going to use the answers as my next post. He asked:

My instinct is that things can't be as simple as you and the author of the linked page seem to think, but I am very poorly educated on these issues, so let me just ask some questions:

1. If the obstetrician truly believed there was a serious risk to not performing a C-section, did he do the wrong thing? Did the hospital director? Did the judge? Did the sheriff?

2. If there is indeed a serious disconnect between the opinions of doctors on these issues and the consensus of the scientific community, how did it arise? How can it be fixed?

3. To what degree, if any, should the best outcome for the unborn child be taken into account if it is contrary to the wishes of the mother? (Whether the two actually are in conflict is not the issue for this question.)

All this really starts getting to the heart of how these issues are linked, and I am eager to start the discussion! That post will probably come in a couple days, as I have about 10 hours of driving to do in the next 24.