Home birth on the rise in the U.S.

When I heard Eugene Declercq speak at the CIMS forum, I jotted down some notes on his data, but it was one of those "scribble it on the back of the conference program because you forgot to bring a notepad" situations, and he talked about so much interesting stuff I didn't have room or time to write it all down. One thing I was intrigued by was his statement that 1% of all births to white women are now happening at home. That seemed high to me, but he co-authored a new article out in the journal Birth, and it has that statistic plus a lot more info.

Some excerpts that were particularly interesting to me:

Large differences occurred in the percentage of home births by maternal race and ethnicity, and these differences widened over time... In 2008, 1.02 percent of births to non-Hispanic white women were home births, representing a 28 percent increase from 2004, when 0.80 percent of births to non-Hispanic white women were home births. In contrast, the percentage of home births declined slightly for non-Hispanic black women from 0.30 percent in 2004 to 0.28 percent in 2008. In 2008, the percentage of home births was 0.20 for Hispanic women and 0.38 for American Indian women, statistically unchanged from the 2004 figures. In 2008, the percentage of home births was 0.27 for Asian or Pacific Islander women, up from 0.24 percent in 2004. Approximately 94 percent of the increase in the overall percentage of home births from 2004 to 2008 was because of the increase for non-Hispanic white women. In 2008, 83 percent of home births were to non-Hispanic white women, compared with 54 percent of hospital births. [emphasis mine]

In 2008, Montana had the highest percentage of home births (2.18%), followed by Vermont (1.96%) and Oregon (1.91%). Three other states (Alaska, Pennsylvania, and Wisconsin) had a percentage of home births of 1.50 percent or above. An additional 10 states had 1.00 to 1.49 percent of home births. In contrast, 18 states had less than 0.50 percent of home births.

Interestingly, the recent increase in home births in the United States began before the release of a series of documentaries and newspaper articles about home birth... Such a development is not without precedent. In the United Kingdom, a government-endorsed movement called Changing Childbirth has been credited with leading to a growth in home births that has continued until the present. However, the home birth rate in the United Kingdom had already been increasing for five consecutive years before Changing Childbirth came into being... Women choosing home birth may be a harbinger, as much as a result, of increased activism related to childbirth...

These make me think about the highly culturally specific nature of the homebirth movement in the U.S. White women (in states with small minority populations) are accessing, promoting, and creating change around homebirth, and I would say I see a culture of normalcy arising around out-of-hospital birth in a certain segment of the population. (Overheard outside a prenatal yoga class: "Well, you don't have to pack a bag since you'll be staying at home, but what are YOU packing to bring to the birth center?") There is clearly a lot of privilege at work here...there are so very very few voices speaking to the non-educated-middle-class-white-woman demographic. I often think some of the Hispanic women I work with in CenteringPregnancy would be interested in having their babies in a setting other than the hospital - out-of-hospital birth with midwives being the standard in many countries they/their families come from - but there is simply no way for them to even know that homebirth is possible in the U.S., much less sort through the complicated process of finding and accessing it, insurance-wise. (And I can't pitch homebirth to them in my role, unfortunately!)

It comes back to my frustration that the people with privilege seek out the nurturing, mother-friendly, midwifery care; and the people who need that care the most, so frequently get a prenatal care through a health department or community health center, every visit with a different provider and then labor and delivery with another set of strangers, usually the general OB service at the hospital. I see basically zero outreach to low-income/minority communities from the birth community, and walking my delicate line between working in the system right now, I am guilty of that too. How do we fix this??

Guest Post: Mollie's path to pregnancy/birth (Part 2: Preparation)

In Part 1, our intrepid heroine learned the secrets of her reproductive cycle and was blown away by a showing of "The Business of Being Born". Check out the next installment on...

Mollie's path to pregnancy/birth: Part 2: Preparation

So now my world had been turned upside down and I was looking for answers. Where did I go? The internet of course!!! I began following the Public Heath Doula’s blog, as well as anyone SHE followed. Soon I had a nice little list of Natural Birthing bloggers: Birth Faith, Our Bodies Our Blog, Science and Sensibility, The Unnecesarean, the Midwife Next Door, Enjoy Birth, and many others. And I read and I read and I read. I couldn’t get enough of it. Sometimes they were a little out there and scary, with a “if you give birth in a hospital you WILL end up with a cesarean”, but most of the time they were informative, and over time I learned about Doulas, episiotomy rates, c-section rates (and the vast discrepancy among hospitals in New York City, which range from 16% to 48%!), and most importantly, the questions to ask your care provider BEFORE you agree to work with them:

Questions to ask
A few more question
And a few more

Around this same time I also attended a talk given by the head of Parent Family Education from St. Luke Roosevelt Hospital. My company often holds mini lectures on topics like getting your kid into private school or how to reduce your stress at work. This one was called “Preparing for Pregnancy and Childbirth”, and thank goodness it had listed as one of the talking points “preconception” (I learned later that the instructor did not know she was expected to talk about preconception, but obliged because there were a few of us non-pregnants who showed up). The talk was basically a quick and dirty intro childbirth ed course, with an emphasis on “This is a really big deal, so after this, you should sign up for a real course.” But the most important thing that came up was this: pick your birth location BEFORE you pick your provider.

I’m going to say that last part again.

Pick your birth location BEFORE you pick your provider.

“Um, are you on crack?”, you must be thinking. “That makes no sense.” It sounded strange to me at first too, but the more I learned, the more I realized that the difference between hospitals – even hospitals within a few miles of each other – could drastically change the type of birth I would have. For example: St. Luke’s Roosevelt Hospital has an in-hospital Birthing Center, where many of the standard Labor and Delivery rules do not apply (e.g. there are no restrictions on eating or drinking, and continuous electronic fetal monitoring is not required). Approximately six miles away, Elmhurst Hospital requires every laboring woman to be confined to bed, on her back, with continuous EFM regardless of her risk assessment. The rules of the hospital would DRASTICALLY change not only my overall experience, but the specific ways I could cope with pain (if I’m not allowed out of bed except to go to the bathroom, I’m certainly not going to be allowed to walk the halls or labor on a ball).

“Well, my provider would never force me to stay in bed, and she can just meet me at the good hospital.” She could, if she has privileges there. I happen to love my gynecologist, but because of recent insurance changes, she only has privileges at Jamaica Hospital – not only inconvenient for me, but Jamaica Hospital has a 41% cesarean rate (as of 2008), compared to Roosevelt’s 28% (Read the stats here). You may decide that you want to do a home birth, but I highly doubt your OB/GYN is going to be your provider. Also, if your provider has privileges at multiple hospitals, he may have you meet him at the hospital where his current mom is laboring, not necessarily the one closest to you or the one with the amenities or rules best-suited for your desired labor experience. Now, this point may be moot if you only have one hospital or birthing center in your area, but if you live in a metropolitan area with many choices, it makes sense to get to know the hospitals first, and then ask the hospital or your insurance company for a list of practitioners with privileges at your favorite.

Ok, so I had my reproductive system down, I knew I had some options for hospitals, and I knew more about episiotomies than any child-less person should know. Over the three “preconception” months, we went on three hospital tours – Roosevelt, Lenox Hill, and The Brooklyn Birthing Center. I liked Roosevelt the best, so I asked them to send me a list of practitioners who had privileges in the Birthing Center. I narrowed down the ones covered by my insurance company (oh, side note: I called my insurance company and it was the opposite of helpful – the guy on the phone told me that midwives were illegal in the state of New York so they don’t cover them . . . oh Aetna customer service . . .), and set up consultation appointments. Now, I had no issues going on hospital tours while not yet pregnant, since they didn’t ask (I have heard rumors that some hospitals won’t let you come unless you’re pregnant, hoping to weed out trainee doulas and paparazzi I guess, but in that case, I imagine you can just lie). I got a little bit more push-back from the receptionists at the doctor’s offices (“Wait, you’re not even pregnant?!”) though thankfully, not from the doctors themselves; they knew exactly why I was meeting them so early, and even seemed to appreciate it. One midwife office (the ones I ended up choosing) actually had an orientation night, where they sat for an hour or so and talked about their practice and their birth philosophy, and where anyone could come and ask questions. I ranked my favorites, and now I was ready for baby-making!!!

Should the ACNM become just the ACM?

A long and thought-provoking interview with a CPM/CNM on the American College of Nurse-Midwives' proposal to become the American College of Midwives:

Erin: You have spoken out publicly against the proposed name change of the ACNM. Yet you have worked as both a CPM and CNM, and have previously spoken out for unification of the profession. Why would you be opposed to this move?

Hilary: I would only support this name change if the ACNM concurrently commits the organization to working in partnership with MANA, NARM and MEAC to create one unified midwifery profession in the US. Without this commitment, calling CNMs “midwives” will increase their potential for working in opposition to direct-entry midwives who are striving on the political front to have CPMs included in national health reform initiatives, and of their being at odds with legislative efforts in states where the CPM has not yet been recognized. If the ACNM is going to rename itself the American College of Midwives, is it going to wield this moniker for the betterment of ALL midwives, or is the organization going to promote only its own brand of midwifery? As a corollary, is it going to change the title of all its members to CM – Certified Midwife?

...

Erin: You’ve mentioned a merging of nurse-midwifery with direct-entry midwifery. How would one midwifery credential better serve childbearing women? Wouldn’t it mean less choice for them?

Hilary: It would only mean less choice if we allow the current model of nurse-midwifery to subsume direct entry.

A true merger takes the best of both worlds, and in the process gives the participants a greater societal voice. As long as we continue to put our focus on creating hierarchies within the midwifery community, rather than really listening to each other and learning how to work together, we will not be successful in building midwifery as an independent and powerful profession. If we choose instead to have one unified profession, where all midwives are educated to work in all settings, where the goal is to increase the profession until all women throughout the US can have access to a midwife, then we are creating more, not less, choice.

Read the whole thing here.

Guest Post: Mollie's path to pregnancy/birth (Part 1: Preconception)

You may remember that a few weeks ago I posted about my friend Mollie's birth story, in which she had a lovely and exciting (in the good way) delivery in a birth center, attended by a midwife, with the support of her husband and doula. I also promised a guest post by Mollie. So now you know the end of the story, I'm delighted to bring you a three-part series that she's written about how she came to learn about her options for birth, decide what she wanted, and find her care providers and place of birth.

Of note, Mollie and I met a surprisingly large number of years ago (surprising to me at least! I don't feel that old!) living on the same dormitory hall, at a college known for having its students do a lot of independent, self-guided research. As you can see, Mollie learned these lessons very well!

Mollie's path to pregnancy/birth: Part 1: Preconception

The path to becoming a mother is different for everyone, as is the path to getting pregnant. My path was in many ways straightforward – get married, get settled, get pregnant, have baby. I did manage, however, to insert a step in the process which, for anyone who knows me well enough, was absolutely essential: I researched the crap out of it. I left no pregnancy book unread, no birthing blog un-lurked, and no midwife in a 10-mile radius without at least a hit on her website. I needed to know it all, and I needed to know it all before there was even a fetus to worry about.

It all started about 15 months or so before the baby was conceived. I was on The Pill and was interested in a non-hormonal form of birth control. I chatted with some friends and with my GYN, and ultimately picked up “Taking Charge of Your Fertility,” a fantastic how-to guide for the Fertility Awareness Method of both birth control and conception. I devoured this book! I couldn’t believe how much I realized I had never known about my own reproductive system. “Why didn’t they ever teach me this in health class?” I kept yelling! I couldn’t get enough of it. I charted my cycle for over a year before ever attempting to get pregnant, and I learned more about my hormones and my body in that year than in my previous 15 years as a reproductively mature female.

Now it was time to research conception, because who could POSSIBLY do that without adequately researching it!? [har har]. So I picked up a few books (and thank you New York Public Library, for allowing me my fill of research without having to purchase a single book). “Your Pregnancy: a 90-Day Preconception Guide” was pretty informative – a lot about nutrition and vitamins, exercise, and understanding genetic diseases. I went back to “Taking Charge of your Fertility” and reread the conception chapters. I also picked up “What to Expect Before You’re Expecting” . . . oy. If you thought the “When You’re Expecting” book was bad, the “Before You’re Expecting” may just give you an aneurism. Unless you’re not quite sure on the mechanics of sex leading to babies, don’t waste your time with this one.

Alright, so I had conception down. I had negotiated with the husband to start trying in September, so on June 1, 90 days out, I started my preconception routine: I was taking my prenatal vitamins (woo Folic Acid!), charting away, and trying to convince my husband that “no, I promise I won’t go crazy and tell you which days we have to have sex!” I made an appointment with my GYN to get checked out, talk through which medications were still fine to take, and discuss genetic testing.

At the same time I had the “Why didn’t I know this about my body” epiphany, I had the “Why didn’t I know this about childbirth” epiphany. The Public Heath Doula herself invited me on a little movie date one afternoon. “There’s this documentary about childbirth that’s supposed to be great!” she told me. Little did I know I would soon become one of those Natural Childbirth advocates who feel the need to educate the world about epidurals and yell at sitcoms which portray childbirth incorrectly. Because, you see, she took me to see “The Business of Being Born.” I’m not exaggerating when I say it changed my life, or at least my outlook on life. If you haven’t seen it, you need to. If you ignore everything else I write here, if you take away NOTHING . . . just see this film. It’s on Netflix instant-watch, and it’s only an hour or so long. I promise, it’s worth it. And get your partner to watch it too. I’m telling you, my husband was on the fence about this whole non-medicated thing (“If it makes the pain go away, why WOULDN’T you want it!?”) until I sat him down and made him watch this movie. He now excitedly educates his buddies about the side-effects of epidural analgesia and hospital policies on freedom of movement. (He still wasn’t sold on a home-birth, but he eased up on the opinion that I was effing crazy.)

Stay tuned for Part 2... Preparation!

Weekend at the movies: Midwives Diner

What do you get when you go to the Midwives Diner? Well for starters, no IV and as much water as you want!

What I missed

You know you were (are) a Google Reader addict when you get back on after giving it up for Lent, and it's stopped counting new posts after "1000+". If I was going to be really true to my Lenten vow I would have marked them all as read and started afresh. But I did skim some of my faves. So while these links are probably old to everyone else, here are a few that jumped out at me:

Navelgazing Midwife on Touring L&D suites around the country and wondering what they say about what patients want...or are supposed to wait. I commented about how often hospitals seem to advertise "private rooms"... even in pretty dingy public hospitals I have yet to work with a doula client who got anything but a private room, whether L&D or postpartum. Is this just an advertising gimmick?

The Academy of Breastfeeding Medicine on audio galactagogues for mothers of babies in the NICU. I want to hand out little MP3 players to all the pumping NICU moms I see! It made me wonder whether a Hypnobirthing/Hypnobabies type of track targeted especially to NICU moms to listen to before or during milk expression would be helpful.

Alanna at Blood and Milk on how "helpful" postpartum visitors are a lot like "helpful" aid organizations.

Via Motherwear Breastfeeding Blog, a NY Times article on the deadly consequences of cultural beliefs that deprive babies of breastmilk in developing countries.

Breastfeeding and Feminism, Day 2 (...2 weeks later)

My Lent resolution has apparently not yet translated into more posting! A few factors have contributed to that, among them my new full-time job(!) I have gone from per diem at the hospital working 24ish hours a week, to full-time working 36 hours a week (three 12-hour night shifts). Going from working 8-hour shifts to 12-hour shifts is a surprisingly big adjustment (although fortunately not as big an adjustment as beginning to work nights was.) There are drawbacks to my new schedule (less flexibility, losing several evenings, etc.) but the benefits are, well, the benefits! Apart from my grad school assistantships, I haven't had a job with health insurance since I was in AmeriCorps. I am looking forward to having good health insurance, along with retirement benefits. One of my goals in going to grad school was to finally get a "real" job with salary + benefits, and while it didn't happen in exactly the field I expected it to, I couldn't be more pleased (except for the part where I work nights. Hopefully someday I'll work days again!)

Now that I've made my excuses, long-delayed highlights from the second day of the Breastfeeding & Feminism conference:

* Possibly my favorite presentation of the day was Robbie Davis-Floyd's report on the International MotherBaby Childbirth Initiative. Based on the Baby-Friendly initiative, the IMBCI has outlined 10 Steps to optimal motherbaby maternity services, developed with the input of organizations around the world. Steps include treating every woman with respect and dignity, offering continuous labor support, providing evidence-based practices, and providing access to emergency OB care. Three sites have applied and been accepted to become demonstration sites, one each in Austria, Brazil, and Quebec, Canada. You can read more about the (very diverse!) demonstration sites here. She discussed more about the sites and more details of their applications. She also talked about sites that will be added soon, in South Africa, Mozambique, India, and - amazingly - the largest maternity hospital in the Philippines, which does 22,000 births a year (I cannot even imagine). It's inspirational to see institutions from countries with different levels of development and each with their own unique strengths and challenges, working on the aim of improving maternity care. I am so excited to see ow the demonstration projects go.

* Michelle Lauria, an OB-GYN from Dartmouth, gave a great talk on reducing late preterm birth, a project of the Northern New England Perinatal Quality Improvement Network. She also talked about eliminating elective inductions before 39 weeks, and in mothers who do not have a high enough Bishop's score. She said the key is to put power in the hands of the nursing staff with the hospital authorities backing them up; the doctors know if they send someone in for an induction who does not meet the guidelines, the charge nurse will send them right back home. She talked about the next step being setting stricter guidelines on ways that some doctors use to get around the restrictions; she gave the example of mildly elevated blood pressures without proteinuria being called pre-eclampsia and used as a reason to induce early.

She also discussed VBAC at some length. Her take on it was, in her region, it's all about the money - as in, medical malpractice insurance costs. In northern New England, which has a lot of isolated rural communities, she gave an example of a small regional hospital that wants to offer VBACs but would have to pay $120,000 more in malpractice insurance to do so. Given that they anticipate 2 VBACs a year, they would end up paying an extra $60,000 per VBAC. Her proposed solutions are both governmental: either medical malpractice reform of some kind, or for the government to coordinate regional VBAC centers. There would be one hospital in each region designated as the VBAC center, and all the other maternity hospitals would contribute towards the VBAC center's additional malpractice insurance. She considers this unrealistic without government intervention because of the nature of competition between hospitals.

* Beverly Rossman from Rush in Chicago did a very inspiring presentation on breastfeeding peer counselors in the NICU. The NICU breastfeeding peer counselors are truly peers - they are women who have personal breastfeeding experience with very low birthweight (VLBW) babies. She summarized some themes from qualitative interviews from mothers who worked with the peer counselors: instrumental support, emotional support, finding hope, empowerment, community, and emulation. Over and over again the interviewees talked about how much they identified with the peer counselors, how much hope they drew from seeing mothers who had been in their situation, and how important the emotional support was. It left me wanting a breastfeeding peer counselor program in our NICU so badly! (If you'd like to learn more and you have access to the Journal of Human Lactation, you can check out their journal article. Citation: Rossman, Meier, Engstrom, Verheed, Norr & Hill. "They've Walked in My Shoes": Mothers of Very Low Birth Weight Infants and Their Experiences with Breastfeeding Peer Counselors in the Neonatal Intensive Care Unit. JHL. 2011. 27(1):14-24.)


It was a great conferences with some great conversation! It was hard to choose between the CIMS and the BF & Feminism tracks sometimes because there was so much interesting stuff going on, but I'm glad they combined the conferences for the opportunity to pick and choose from both programs.

Sadly, I won't be able to go to the CLPP Reproductive Justice conference this year. Please, everyone who's going tell me all about it! I am determined to go next year.

Yes, Virginia, crappy OBs really do exist

I read and enjoy several blogs by physicians including OBs. One theme I hear frequently repeated by those doctors is (if I may paraphrase) "the natural birth community (particularly online) paints all OBs as evil/uncaring/c-section happy/in a rush to get to our golf game. I am not like that" - sometimes then there is a chorus of "well YOU are very rare and special" from the commenters - "and my colleagues are not like that. They are wonderful people who care about their patients."

I believe that there are caring, dedicated OBs out there and I believe they are in the majority. Keep in mind that this doesn't mean I believe their caring and dedication play out in ways that are always mother-friendly. I also believe there are OBs who routinely practice in a way that is based on informed consent, patient choice, and respectful communication even when the patient disagrees with them or wants to diverge from their standard practice; I sometimes have difficulty believing they're in the majority, but I don't believe they're rare, special pearls.

However, I do think that the proportion of non-evidence based, aggressive, and/or insensitive OBs is higher than the other OBs realize. They just don't routinely see each other in practice. In a teaching hospital where there are residents, fellows, attendings, etc. all working together this is less true, but once OBs are out in the community in their own practices, they're not following each other around to see what goes on inside the exam room or in L&D. So behavior like this happens to women, is reported by those women or by observers, and is disregarded by OBs as "My colleagues are good people. They're not like that." You can be a nice, caring person and still be like this:

Well, the OB feels this need to check her cervix again. After I just did the same thing less than 2 minutes before. I even said - "hey, I just checked her. She's still only 7-8 cm. But she's hurting bad in that one spot, so anesthesia is coming up to re-dose her."

"You think I can stretch her to 10cm?" he asks.

"No way. Cervix is too thick all the way around." I tell him as I cringe at the thought of manually opening her cervix when she is in such excruciating pain to begin with.

The OB insists on checking her again. And forces her cervix open another 1-2 cm. The woman is screaming at the top of her lungs through all of this. I'm giving the doc the evil eye, and telling him again - "anesthesia is coming up. This woman deserves some better pain relief!"

The OB is telling the woman to push through it.

Fucker.

I look at the woman and mouth "I'm so sorry" to her.

From labor nurse At Your Cervix.

I doubt that this doctor walks around with horns sprouting out of his head, or telling OB colleagues how much he hates his patients. He may even be lovely to some of his patients, or lovely in certain situations. But I think it's OK to admit that not everyone knows what goes on behind closed doors, and that when women tell their stories of inappropriate treatment, we should validate and honor those stories. The kneejerk response should not be "No one I know would do that - we are good people" (and neither should it be "All OBs are EVIIIIIL"). Because clearly, someone IS doing that - and why couldn't it be someone you know?

You buy the hospital ticket, you go for the hospital ride, Part 235624

The Feminist Breeder posted a link today to a friend's blog post about an OB and an L&D nurse discussing c-sections on Facebook. The OB said she was up late waiting for a baby to come out, the L&D nurse recommended "Ahhh just cut her, fuk it!" and when called out for this both the OB and the nurse defended each other, with the nurse loading on some extra distaste for "birth plans".

I actually don't think the OB's original comment was so out of line. I've (obliquely) sighed over a long induction on FB, and I have friends in many jobs (including medical ones) who vent a little bit at the end of a long shift or a tough task. It was really the nurse's response(s) that I thought deserved the ire that's being generated.

And as I was scrolling through all of said ire in the comments, I came across a great comment from Navelgazing Midwife that I wanted to repost here in part. She is responding to many of the people asking why the nurse was hating so much on birth plans.


Doctors and nurses HATE birth plans. Have for years. (There are a minute few who accept them.) The reason the nurse said it sets women up for failure is because the hospital system is not equipped to permit/allow/encourage women to have an autonomous labor and birth. The hospital assembly line moves one way - through as much technology as possible. Asking a nurse to attend to a woman "wandering the halls" (as I've heard said many times before) is unfair because she has other patients to take care of, too. If the patient wants intermittent monitoring, wants to get up periodically, wants to eat and drink in labor, wants to push out of the bed, wants to do without an IV... all of these things cramp the hospital and nurse's (and OB's) style, making their jobs much more difficult... AND, in their eyes, opens them up for some serious liability. *We* can say, "Tough caca. They need to do what we want because we're hiring them and it's my birth," but they can be quite persuasive and manipulative, threatening women in the middle of what should be a glorious experience.

I use the phrase, "You buy the hospital ticket, you go for the hospital ride" because if you want a homebirth in the hospital, you will be sorely disappointed (the "set-up for failure" the nurse speaks of). If you want a homebirth, have a homebirth. Otherwise, acknowledge the limitations, choreograph what you can and don't be surprised if your birth doesn't turn out like you envisioned.

The same can be said about doulas; hospitals, nurses and doctors generally despise them. They get in the way of the care provider's directions, they "make" women question the status quo and rock the boat of misogyny and anonymity in the hospital's birthing assembly line. Some dislike doulas so much, they refuse to work with a client who has one -and some hospitals have banned them altogether.

If a woman feels like she's going into battle in the hospital, I would *highly* encourage her to seek out other options (new doc, new hospital, etc.) if at all possible. I do understand that not everyone has that luxury, but many do. I hope they exercise their power of economics to hire someone who respects them.


I will add the caveat that I don't think that hospitals, nurses, and doctors "generally" despise doulas, birth plans, etc. because I have now worked at multiple hospitals and I would say that generally I have been well-received as a doula - the haters have been the exception, not the rule - and I haven't seen much open disdain for birth plans although I could imagine it's taking place behind the scenes.

But apart from that I will say a big YES YES YES to the rest of this. I know I've posted about it before but I just had to do it again, because I've heard a little too much lately about people's basic dignity being disrespected in the hospital and/or by care providers. Some of these people can change and do, some can and don't, some are stuck with their "hospital ticket" and the ride that it entails.

In short: it's hard to fight the tide of people, like the nurse in the post, who put quotes around the words "birth plans", coming at you in the hospital who are used to getting things done their way, who have gotten things done their way with the 15 other women they've worked with this week, and at all of the 2,500 other births they've worked at in their career. If you think you can buck the tide, ask yourself, who has more practice getting births done their way, you or them? And then prepare yourself thoroughly for resistance, because at best you won't need it and more likely, you will.

(My goodness, all my posts lately have been not very positive, have they? I blame the deadline for my master's paper putting me in a negative frame of mind.)

Health care reform and looking down the road to the next reform

Am I excited about health care reform? Yes, although after all the back-and-forth and ups and downs, it ended by feeling a bit anticlimactic - stumbling across the finish line in a daze, just glad to have gotten here. Remember when Obama said he wanted it done by last August?

I am hugely frustrated, as many other people are, by ridiculous restrictions on abortion coverage. I'm also seriously disappointed by the lack of coverage for immigrants (and not just undocumented immigrants - there's a 5-year waiting period even for documented immigrants to get on Medicaid). And I just want to tell a little story.

The CenteringPregnancy group I'm co-facilitating right now is Spanish-speaking, so obviously most of the women are fairly recent immigrants from Latin America. The way Medicaid works, at least in this state, is that when you show up for your first prenatal visit you get two months of "presumptive eligibility". That means that Medicaid will let you get two months of care, and after that you have to prove that you're Medicaid eligible to continue to be covered. So the clinic tries to get as much done as possible before the two months is over. After that, you're paying out of pocket until you go into labor, at which time emergency Medicaid kicks in to cover the birth and a short period thereafter.

At last month's Centering visit, one of the participants got a call - during the visit - that her husband had been arrested and was about to be deported. At this month's visit, we found out that he was deported and that she was struggling to support her family. She was worried about having enough money for food for her other children. At the end of the group, she began to cry. And on top of this, she has to deal with the expenses for this pregnancy. She has an ultrasound scheduled but will have to decide whether to try to scrape together the money for it, or skip it altogether.

Worse, if she or any of the other women outside of their Medicaid eligibility need to be admitted to the hospital for some reason, like blood pressure monitoring, they'll end up with the bill from that too, and those bills are just insane. This is the reason we're getting health care reform, and yet we are making it impossible for a significant segment of the population to access.

Acting like undocumented immigrants are somehow leeches on taxpayer funds is a falsehood. Undocumented immigrants DO pay taxes. Many pay income taxes, and nearly all have payroll taxes taken out. And all of them pay sales taxes. They put a staggering amount of money into Social Security that they can currently never hope to see returned to them. Is all of this so terrible that they won't even be allowed to purchase insurance, again using their OWN money, on the insurance exchanges? God forbid they ever be able to receive Medicaid coverage for medical necessities.

And the thing that really gets me about all this is the fact that all of these pregnant, uninsured undocumented women? Their babies will be born American citizens. Medicaid will willingly, automatically cover those babies and any health problems they have (perhaps as a result of inadequate prenatal care?), for the rest of their lives. But we won't take care of their mothers, even during their pregnancies.

Obama says immigration reform is coming next; it can't come soon enough after this health care bill.

U.S. midwives in Senegal

Via a blog by DC-based midwifery students about their trip to work with a maternity clinic in Senegal. Fascinating stories and pictures, and a window on to the realities of accessing medical care in developing countries:

We discuss options for getting this baby out now. Recommendation—immediate transfer.

But as I was to learn, the decision to transfer involves three levels of decisions:

* The medical recommendation that a transfer is the only available solution in this situation;
* The family’s agreement on this recommendation—which involves getting a complicated set of approvals from various family members and money with which to pay for the transfer; and
* Access to transfer—collecting money to pay for the ambulance and the ability to get the ambulance here from Ziguinchor

Check out all the entries - a multi-layered look at traditional birthing practices, medical management, and cultural and social factors, from practitioners striving to come with an open mind:

We are not arrogant or neo-colonialist enough to carry ourselves as if we are here to bring our view of midwifery to Africa. We are here to bring our skills and information and assistance to our Sista-midwives and to help the women who are birthing. We teach and learn from each other.

Xkcd for the maternity care win!

This says so many things on so many levels about modern maternity care, I can't even begin to list them. In fact, there are so many that I'm pretty sure Randall Munroe couldn't have actually meant them all.

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!

Sen. Stabenow to Sen. Kyl: Oh SNAP!

United States Senator John Kyl (R. - Ariz) said in health care reform hearings: "I don't need maternity care", so health care reform should not require insurance companies to provide it.

Senator Debbie Stabenow (D. - Mich) fires back: "I think your mom probably did."



(Via Feministing.)

Sen. Kyl then snorts "Yeah, about 60 years ago." Perhaps someone should also show him the evidence that prenatal (AND preconception) health of the mother have impacts on the health of her baby, decades into the future. Or is that just an "I got mine" statement?

If we pass health care reform that does not mandate maternity coverage, we're not getting true health care reform.

Jennifer Block on who's winning the home birth debate

New article from Jennifer Block on Who's Winning the Home Birth Debate. It's a step beyond the usual "Hey, home birth might be safe" or "Some people say home birth is safe" articles and into "If research has shown that home birth is safe, why is there still so much opposition?" She writes:

if the only research that will satisfy those with authority and power is research that is unfeasible, the controversy will never be resolved. There could be 20 more large, observational studies that come to the same conclusion as those that already exist, but they still wouldn't be randomized controlled trials. The home birth advocates would continue to say "The research proves it's safe!" and the American medical establishment would continue to say "The research isn't good enough!"

And, as she points out, evidence of homebirth dangers will continue to be produced via anecdote and rounds of "birth telephone".

If anything, I could have done with this article being a lot longer. I liked that she acknowledged the presence of the (in)famous Dr. Amy and Dr. Amy's "debate" site, and I'd like to see her really dig into the statistical discussion, the evidence base, and the depth and breadth of the barriers to translating evidence into practice. Perhaps you'd like to write another book, Jennifer Block?

In the meantime, props to Babble. At a wedding a few weeks ago, I ran into someone I know who works there and I told her I really liked Jennifer Block's response to Hanna Rosin, which they ran. Next time I see her I'll have to add my thanks for this. I hope they keep up the Jennifer Block connection, or at least keep running articles in this vein.

Saving women's lives in Afghanistan

Afghanistan has one of the highest maternal mortality ratios in the world (only Sierra Leone's is worse). In a culture where women grow up without proper nutrition, are married off and begin childbearing too young, are denied education and basic human rights - things start bad and then just get worse.

Pashtoon Azfar is working to change that; she's the president of the Afghan Midwives Association and she's been pushing education in not only technical skills but interpersonal skills. This is crucial as women who aren't accustomed to using medical personnel for births aren't going to trust someone who's, well, not nice.

“Does she greet the mother properly?” she asked. “Offer her a chair? A drink of water? Introduce herself? Let the mother ask questions? They are trained. They have to do it.”

Such simple steps that so many maternity care providers could use! It's not just about technical skills - it's also about trust. Read more here.

"These midwives, they are champions. Oh, I love them. They are my heart."

"From Worst to First" - Getting hospitals to change their ways

There's an inspirational campaign going on in New Jersey called "From Worst to First". With New Jersey at a 39.4% cesarean rate, they are publicly naming and shaming hospitals with high cesarean (and episiotomy) rates. Once there are women out front of a hospital with brightly colored signs saying "Bad Maternity Care Harms Women", most hospital administrations seem eager to at least meet with them.

The Worst to First website is here - if you scroll down to "Status of New Jersey Hospitals Addressed by NJMCWTF2010" you can click on individual hospitals and see photos of each protest and a short report of what happened.

I learned about this campaign through e-mails via a doula listserv. The e-mail reports were longer and more detailed than the reports on the website, and I thought I'd share an excerpt of one here:

We met with the Administrative staff of Saint Clare's Hospital in Denville
on June 8th, 2009 for a meeting to discuss the first steps towards our "Worst to First" Campaign.

In attendance was the Administrative Director of Nursing, the Maternal Child
Education Coordinator, the Communications Manager, the Executive Vice President of the Hospital, the Patient Care Manager, the Maternal Child Heath Coordinator, the Vice President of Public Affairs, the Labor and Delivery Staff Nurse and Doula, Quality Manager of Maternity, and the Director of Clinical Quality. Stacey Gregg Action VP for NOW-NJ, Anne Mitchell Stacey Gregg's Summer College Intern/Activist, & Morris County NOW Secretary Doreen Manno.

For the first hour and a half of the meeting, Stacey and the administration went back and forth about the condition and quality of patient care and how it was reflected negatively in the statistics that we're trying to break with our campaign.

Unfortunately before this point, the hospital staff present was unwilling to admit their statistics. They were trying to question the validity of the state's statistics of the ten hospitals that already really have episiotomy rates below 5%.

It wasn't until Stacey made the analogy between the unnecessary cutting of woman during birth and how if a woman was a rape victim, you would not be discussing the reasons why a rapist does what they do. You would only be concerned with coming up with solutions and ways to protect her. She gave the examples of a rapist claiming any justifications "didn't have enough time, it takes to long the other way"," that's the way I was trained to do it", "the women want it or they ask for it", and "they don't mind it this way", the way a doctor might defend his high rate of episiotomies. She stated that she did not want to discuss how they got here it just had to stop, and she took one of the signs that we had bought with us into the room that stated "STOP Violence Against Women" and stated that Women are being harmed. ...

"There are ten hospitals with low episiotomy rates that are doing things differently; obviously they're not doing the same things that are going on around here." Stacey said. ... Discussion was held about how to get the doctors to best respond and change the way they practice. From there, we began to formulate an action plan to reduce episiotomy rates at Saint Clare's.

Wow.

On the doula listserv I get these e-mails through, doulas are saying "We need to do this in OUR state!" Is it too much to hope this goes nationwide? I'll head up my state's chapter!

Don't count on your epidural

I used to work with a great midwife who gave a presentation of research on women's satisfaction with pain relief in labor. She said "If women are expecting pain relief and don't get it, they are not satisfied. If they are expecting unmedicated labor and end up with medications, they are not satisfied."

I thought of that when I read Reality Rounds' great post on expecting an epidural...and not getting one.

This is something I wish more women understood. Just because you expect to get pain relief in labor, you may not get it. You may never get it: you may have a fast labor, or show up too late, or have to wait too long for the anesthesiologist and by the time he shows up the baby is crowning. (If he ever shows up.) You also might have to wait for hours. When you get one, your epidural may not work, or only work partially. (My least favorite kinds of epidurals.) And most women do seem to feel a baby emerging from the vagina, regardless of the epidural.

I agree with RR: every woman should take a class that teaches them non-medical forms of pain relief. If your expectations for pain relief are met and you never needed those techniques - great. But if you need them, they could come in pretty handy. Above all, of course, keep your expectations flexible - then it's harder to be disappointed.

Links - breast reduction, questioning your OB, and midwives as health care reform

I have multiple posts in the pipeline but my work is making it tough...sitting in front of the computer for 9 hours a day at work makes me want to do anything but, once I get home! And I'm leaving tonight to fly cross-country for a wedding. Which will be awesome, but will not leave me any more time for posts. So in the meantime I leave you with some starred posts from my Google Reader:

What one woman heard when she started asking her OB the tough questions (she has decided to switch - sounds like a good choice.)

FABULOUS post on why "you can't get there from here" - that is, you can't get from a medically managed first stage to a physiologic second stage very easily. You can't get from a Pitocin induction to an unmedicated labor very easily. And when everyone starts with interventions, of course any other way seems impossible.

Important things to know about breast reduction surgery and breastfeeding. I am not a big fan of breast reduction surgery, partly because I know what a difference the right bras can make, and also because I believe it's another way in which our society medically legitimizes the "abnormalization" of ALL women (small breasted, large breasted, etc.) I also don't think there's good information out there about its effects on breastfeeding.

Interview with a homebirth midwife who is doing research on, and developing a protocol for, interactions between OBs and DEMs. Super interesting perspective on the OB/DEM relationship. She talks about "birth story telephone" and why both professions hold skewed version of each other.

Radical Doula writes on the connection between health care reform and midwifery care in the American Prospect. Awesome!

My flight leaves in about 4 hours...have a fun weekend!