RH Reality Check Interviews Melissa Cheyney, Midwife


Birth is a big part of Melissa Cheyney’s life – especially right now. As a new mother, having given birth in May of this year to a beautiful girl, as well as a practicing midwife and homebirth advocate, Cheyney has devoted much of her life to bringing new life into this world. In fact, the weekend after we conducted this email interview, Cheyney attended her first birth as a midwife since her daughter’s arrival. But it is her work as a professor of medical anthropology and reproductive biology at Oregon State University that recently caught my eye.

In this capacity, Cheyney and her research partner, doctoral student Courtney Evans, explored the effect of midwife-attended homebirths on elevated rates of prematurity and low birth weight in babies born in a particular county in Oregon between 1998- 2003. And though their research disproved the notion that homebirth yields poorer birth outcomes (in fact, just the opposite was true – all of the homebirths studied resulted in successful health outcomes for the newborns), they did uncover something else in the process. When results of their study hit both the hospital provider and homebirth/midwifery communities, “antagonism was…considerably amplified” between the two; leading Cheyney and Evans to examine the ways in which the hospital/ homebirth provider relationship could be improved.

It is no surprise to Direct Entry Midwives (also known as DEMs) or homebirth advocates that many in the hospital-based birth practitioner community believe homebirth to be unsafe and inferior to in-hospital birth. Both ACOG and the AMA have issued statements proclaiming as much. But Cheyney and Evans discovered a “deep mistrust” between the two communities that led Cheyney to want to do something to ameliorate some of the hostility in the relationship. Cheyney worked with her own back-up physician, obstetrician Dr. Paul Qualtere-Burcher, to create a pioneering protocol guiding the midwife/doctor relationship with the goal of creating optimal experiences for both providers and patients alike. The document, “Proposal for Increased Collaboration between Direct-Entry Midwives (DEMs) and Obstetricans for Homebirth Clients,” is grounded in a series of foundational ideas: homebirth is a viable alternative to a hospital birth particularly when facilitated by a skilled DEM with a physician back-up; research supports the idea that homebirth is a safe option for low risk pregnant women; obstetricians and hospital care represent a “safety net,” as Cheyney and Qualtere-Burcher propose, that can contribute to healthier birth outcomes for both mother and baby if complications arise during a homebirth.

Professor Cheney graciously agreed to answer some of my questions about her groundbreaking protocol, her research into the hostility between both home and hospital-based birth practitioners and why it’s critical to women’s health that these issues are addressed.

Newman: Do you know if there are there similar protocols being developed in other parts of the country between DEMs and physicians (in those states where midwifery is legal!)? If not, would you like to see this replicated?

Cheyney: To my knowledge, this is really the first of its kind, at least one that is being formally implemented and studied. However, in areas where midwifery is legal, these kinds of arrangements exist more informally between individual midwives and physicians that have developed relationships usually over years of working together. I would love to see these protocols replicated and modified to meet the specific needs and goals of the given area. We know that homebirth is safest when it is planned, a trained midwife is present and medical back up is available if needed. It’s really that third criterion that needs streamlining and strengthening in our country.

Newman: Oregon seems to have progressive rules and regulations regarding DEMs – unlicensed midwives are able to practice. Has this been supported by physicians? Has there been resistance, active or otherwise, by OB/GYNs to Oregon’s policy?

Cheyney: Most OB/GYNs in the state of Oregon are unaware of the distinction between unlicensed and licensed midwives. Many refer to us all as “lay midwives” – a term that most DEMs find insulting because it suggests very little or no education. Voluntary licensure is thus, rarely an issue for obstetricians. Place of delivery is much more contentious. Many obstetricians are opposed to homebirth regardless of the practitioner type. However, in my capacity as the state legislative liaison for the Oregon Midwifery Council this year, I did find a few legislators that are concerned about voluntary licensure and they have called for a study session this summer to explore the feasibility of mandatory licensure. I will have a lot to say about that. In addition, a small group of labor and delivery nurses at Oregon Health Sciences University recently addressed the health licensing agency’s board of direct-entry midwifery which I serve on, requesting that the protocols that govern the practice of LDEMs be tightened to exclude breech, twins and VBACs. They are also advocating for mandatory licensure. With these exceptions, I would say that the vast majority of practitioners remain unaware of voluntary licensure status and just oppose homebirth in general.

Newman: What has your experience as a practicing midwife been like as you’ve developed relationships with physicians? Have you experienced the "deep mistrust?" In other words, were you surprised at your findings that there was antagonism, distrust and conflict between doctors and DEMs?

Cheyney: The vast majority of my personal experiences have been positive, largely because I was fortunate early on to establish a relationship with several local obstetricians through my work as a researcher. For the most part, I feel like I have been treated with respect and as a colleague whenever I have transferred the care of one of my clients. However, about a year and a half ago, I did experience a negative transport that was the result of deep mistrust. I had been caring for a low-risk woman who had a straightforward labor, but experienced a severe complication at birth known as a shoulder dystocia. This is where the head is born, and the shoulders become impacted behind the pubic bone. I responded quickly and was able to extract the baby and perform a successful resuscitation. However, this baby suffered a broken arm, which is the second most common complication from a shoulder dystocia. When we transported to the hospital, the pediatrician in the ER threatened me with child abuse and arrest. His attack on me and subsequently the parents who felt judged during their care made a bad situation even worse. The parents still recount the most difficult part of that day being the interaction with this pediatrician. Later when mom and baby were moved to the postpartum ward, we received nothing but support and compassion from the labor and delivery staff who had recently lost a baby to a shoulder dystocia. Thankfully, this baby made a full recovery and ultimately solidified my relationship with this hospital. My quick action at his birth helped to overturn the misconception that direct-entry midwives are untrained. So while most of my experiences have been extraordinarily positive, my one negative transport experience stands out in my memory and made me well aware of what I might find with this study.

Newman: In your proposal, crafted by you and your back-up physician, you write that "Obstetricians acknowledge that there are twenty-nine studies that now clearly indicate homebirth as a safe and viable option for low-risk women." But with the ACOG and AMA both stating, essentially, that the safest setting for birth is in a hospital, do you find it difficult to "convince" OBs that homebirth is a “safe and viable” option?

Cheyney: In the community where the proposal is now being implemented and studied, half of the practices in the county were represented at the proposal meeting. All of the obstetricians present were willing to concede that homebirth for low-risk women was a viable option. The bone of contention lies with how to define low-risk. As addressed in Cheyney and Everson 2009, midwives tend to have a broader definition of risk that includes psychosocial, emotional and social risk, where physicians are more likely to see risk as simply clinical risk. As a result, a woman may choose a homebirth even when at higher risk for a complication because of a past traumatic experience in the hospital. This can be hard for obstetricians to understand during a transport when they are filled with fear about having to attend a higher risk woman that they do not know well. Dialogue around whether a higher risk woman should still have the right to choose a homebirth tends to be very difficult and heated.

One bad experience may also bias a doctor against all home deliveries.
In addition, in my experience, there is often a divide between theory and practice for obstetricians. In theory, they know that their professional organization opposes homebirth. In practice, they are called in with some regularity to assist in homebirth transports. They are also well aware that homebirth, water birth and births with doulas are on the rise. This means that physicians cannot simply ignore homebirthers and continue to vocalize their mistrust of Direct-entry midwives. We are forced, out of necessity, to interact. As physicians come to know the midwives in their community, a grudging respect has the potential to emerge, making it difficult to remain adamantly opposed in some cases.

Newman: How can providers who are already open and amenable to working with midwives help foster a more supportive culture among colleagues, as you suggest in the proposal?

Cheyney: One of the mechanisms for maintaining distrust between midwives and obstetricians is what my colleagues and I have termed “birth story telephone.” This is very similar to the childhood game of telephone where as the story spreads from one individual to another, it grows in nature and the details change substantially. As home and hospital birth stories are told and retold, and filtered through the lens of the teller, details shift to match the preconceived worldview of the teller. For example, a non-emergent transport for a slow, uncomplicated and non-progressive labor can turn into a mother laboring at home for days with poor heart tones and a uterine infection before the midwife reluctantly brings her in. By the time the story has been passed along, mother and baby who were actually never in danger were saved from a near death experience by the hospital staff.

Conversely, hospital births where a woman feels too many interventions were used can be constructed as abusive or traumatizing to the woman after numerous retellings. These stories effectively maintain the home/hospital divide. Physicians and midwives can work to overturn that divide by refusing to participate in “telephone,” by being committed to accuracy and professionalism; sharing only the stories they have first-hand knowledge of. Midwives and physicians who have positive experiences working with one another also need to speak up regarding those positive interactions.

Newman: What are some of the stereotypes or judgements held by midwives about OBs/physicians?

Cheyney: Let me begin with this caveat, midwives often hold fewer misconceptions about obstetricians because we actually get to see hospital deliveries when we transport. We have first-hand knowledge of the model of care that we often critique. However, very few physicians ever attend a home delivery, and yet feel very comfortable critiquing that option.

That said, because midwives often hear stories of hospital births from clients who are unhappy with the experience and are now seeking an alternative, many maintain an outdated view of hospital deliveries as inhumane and impersonal. The vast majority of women, about 70% in the United States, leave the hospital feeling it was a positive experience. Only about 30% leave with regrets or frustrations about their experience and treatment. We as midwives disproportionately serve that 30%. This can prevent us from seeing the work that obstetricians are doing to humanize and individualize birth in the hospital.

Finally, while obstetricians can envision a world without midwives, midwives cannot envision a world without obstetricians. Thus, midwives have a larger incentive to work towards positive relationships with back-up physicians.

Newman: What if a pregnant woman faced with a VBAC or twins does not want to consult with an OB? Is this protocol suggested or mandated?

Cheyney: It is suggested. Oregon law prevents any clinician from forcing a woman to engage in any intervention or procedure against her will. Midwives can strongly encourage it, and because they have a close relationship with their clients, their suggestion is likely to be followed. Midwives who have agreed to participate in this experimental protocol will have to document in their charts that the physician consult protocol was encouraged.

Newman: What happens now with a transport where the midwife and physician have not previously spoken? Do they get a chance to confer? Is the midwife even allowed in the room or does that depend on the doctor?

Cheyney: Before the protocol, non-emergent transports were highly variable and dependent upon the physician on call for undoctored patient. During emergency transports, there is little time for consultation and that will remain the same with this protocol. However, since the vast majority of transports are non-emergent (more than 95%), there is at least the theoretical potential for midwife and physician to meet in the hall and to discuss the case before entering the room together to propose an agreed upon course of action to the mother. The extent to which this happens in practice varies considerably by facility and by physician. The point of our protocol was to help standardize interactions and to help physicians and midwives to create a culture of interaction and collaboration built on mutual trust and respect. See also our discussion of this in Cheyney and Everson 2009.

Newman: You write in the proposal: “Opportunities are made available for physicians to observe homebirths and for DEMs to observe low-risk hospital deliveries.” This is a fantastic idea and I’m surprised that this doesn’t already happen. Are there any classes or opportunities available in medical school, for those who chose to pursue an OB/GYN track, to learn about midwifery and for midwives in training to observe hospital births?

Cheyney: Currently, there are no opportunities for obstetricians to observe home deliveries during their medical training in the U.S. However, this is an option for physicians in the Netherlands; in fact, it is a requirement for all Dutch obstetricians who wish to attend low-risk deliveries. Obstetricians often have exposure to hospital deliveries with Certified Nurse Midwives, however. Because many Direct-entry midwives have been doulas at some point in their lives and because they accompany women who transfer care due to a complication, there is a general understanding among midwives about what happens in a “low-risk” hospital delivery. Further, most transports are for non-emergent cases with low-risk women, allowing them to see many low-risk deliveries in the hospital. The reverse simply cannot be claimed for physician knowledge of homebirth practice.

Newman: On a personal note, you had a baby recently. As a practicing midwife, a researcher of this issue and a mother, do you have any advice for women who are pregnant or looking to have a baby soon and who plan on working with a DEM, about how best to ensure the most comprehensive care for themselves during childbirth? Should they ask their midwife if she has a back-up physician with whom she has an amiable relationship?

Cheyney: Very few DEMs in the United States have formal relationships with particular back-up physicians. As such, if women asks this question, the answer will very likely be no. It may be more helpful to ask what transports are typically like. Because the vast majority of midwives who go into labor intending to deliver at home do so successfully, I would never advise a woman to make a decision about whether a homebirth is right for her based simply on what a transport may be like. It is most important that the woman’s philosophy of care matches that of her midwives. There is a spectrum of homebirth midwifery, from very hands off to more medicalized. Some will do breech births and twins, some will not. Some have antagonistic feelings toward the medical model; others see the relationship as collaborative. It is important for women to take the time to interview the homebirth providers in their area, and when possible, to choose a midwife with a similar perspective.

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To schedule an interview with Amie Newman please contact Communications Director Rachel Perrone at rachel@rhrealitycheck.org.

  • http://www.unnecesarean.com invalid-0

    I have been loving all of the midwifery articles lately. This interview is fantastic. Thank you!

    Congrats to Melissa on her recent birth.

  • amie-newman

    Please do feel free to send me releases and news so that we can keep up with it all! amie@rhrealitycheck.org

    Thanks!

    Amie

    Amie Newman

    Managing Editor, RH Reality Check

  • http://www.skepticalob.com invalid-0

    “Obstetricians acknowledge that there are twenty-nine studies that now clearly indicate homebirth as a safe and viable option for low-risk women.”

    Actually, there are ZERO studies that show homebirth with a direct entry midwife to be as safe as hospital birth. All the existing scientific studies as well as state and national data show that homebirth with a direct entry midwife has almost triple the neonatal death rate of hospital birth for comparable risk women.

    Even the studies that claim to show that homebirth is as safe as hospital birth actually show the opposite.

    If Ms. Cheyney would provide a list of those 29 studies I’d be happy to explain how they demonstrate that homebirth increases the risk of neonatal death.

    The US government is now collecting statistics on homebirth and the statistics from 2003-2005 show that the most dangerous form of planned birth in the US is planned homebirth with a direct entry midwife.

    Homebirth kills babies, and the only people who appear to be unaware of this fact are homebirth advocates.

  • invalid-0

    Oregon is in no way representative of the legal, regulatory or collaborative environments that affect home birth midwifery care in other states. Unlike Oregon, most states that license midwives who deliver babies at home require them to qualify as a Certified Professional Midwife, an educational and credentialing process that confirms expertise in the safe provision of out-of-hospital maternity care to women in freestanding birth centers and in private homes.

    Physicians in states that require midwives who deliver babies in out-of-hospital settings to meet national standards as a Certified Professional Midwife are, in fact, working harmoniously with their midwife peers. And who could blame a physician in Oregon–where not only is there no definition of what a so-called “direct-entry midwife” is, but where anyone can declare themselves to be one and avoid requirements to prove that they are qualified to safely deliver babies at home–for refusing to work with midwives?

    As much as the state of Oregon may be a progressive leader on other issues, when it comes to setting examples for other states to follow on out-of-hospital maternity care, it is most definitely the example NOT to be followed.

  • crowepps

    This is a pretty strong statement and I would sure like to know your sources.  I googled around and discovered a number of different studies that suggested home birth was safer for uncomplicated pregnancies if the attendent had been properly trained.  Perhaps the solution is not making everyone deliver in the hospital (with their high infection rates) but instead making sure the midwives have better training and stricter certification.

     

    There was a note in one place that study accuracy is compromised because birth certificates are often inclear as to whether it was a planned or unplanned home birth, and that there is a huge difference in infant mortality between ‘unplanned home birth’ and ‘planned home birth with a trained attendent’ – 50 to 1.  Perhaps ‘unplanned home birth’ could also be described as late-term miscarriage or premature birth, both of which are ominous for the continued health of the infant?

     

    My daughter had her last baby in a ‘birthing center’ with a ‘certified nurse midwife’ and was very pleased with the experience.  The midwife had her screened by ultrasound several times during the pregnancy by the physician who delivered her first baby to see if there were any problems likely, which seems like a sensible precaution.  Certainly the physician didn’t discourage delivering at the birth center.

  • snowflake

    I do not understand this site’s seeming passion about midwifery at home.

    One of the boons of living in an industrialized nation is being able to give birth with a specialist or even a team of them at your side looking out for the health of mother and baby.

    There are women in third world countries who would give anything to give birth with a doctor present. Maternal complications and infantile hypoxia and subsequent brain damage can occur IN MINUTES (I should know!)

    If you baby needs resuscitation do you want it done in an ambulance by an EMT or by a doctor in the hospital?

    In one of the scenarios stated in the article, complications develop during delivery, the infant must be recessitated, the infants arm is broken during delivery (ah–OUCH!!!)and the infant must be ambulanced to the hospital. The midwife feels she should have credit for saving the infant’s life–maybe so. And maybe the same complications would have happened regardless.

    But how can the article write off the doctor’s anger, who now has this case dumped on him by the midwife–he has no ability to affect the prenatal care–too late for that. But now he must pick up the case and the complications while the midwife goes on to the next case! I understand his anger at the situation. The child may owe it’s life to the midwife, but what else does it owe to the midwife? How long was it’s oxygen cut off? Do we think all the doctor’s anger is chauvinism?

    Another thought– A young first-time mother has no history of previous pregnancies to use to determine whether they are going to be “low-risk” or not. Why risk it?

  • invalid-0

    FYI, in regards to your first interview comment, the Midwives Association of Washington State does have a formal document which aims to create a smooth transition between midwives and hospital staff when transferring from a homebirth. It can be found on their website: http://www.washingtonmidwives.org/guidelines.shtml

    Go Midwives!!

  • http://www.unnecesarean.com invalid-0

    Snowflake wrote: “But how can the article write off the doctor’s anger, who now has this case dumped on him by the midwife–he has no ability to affect the prenatal care–too late for that.”

    Any chance you would like to explain how prenatal care could have prevented shoulder dystocia? Please elaborate.

  • http://www.unnecesarean.com invalid-0

    Snowflake, if you are willing to blame the Melissa Cheyney for the baby’s broken arm and, presumably, the parents for negligence, then you must be similarly angered by the incident that had just occured in the same hospital in the care of a doctor:

    “Later when mom and baby were moved to the postpartum ward, we received nothing but support and compassion from the labor and delivery staff who had recently lost a baby to a shoulder dystocia.

    The difference is that the hospital baby died.

    “Why risk it?”

    I would ask the same thing about hospitals. There are many hospitals with 50 percent cesarean rates. With the VBAC-unfriendly climate, a primary cesarean usually means another cesarean and increased maternal morbidity and complications with each successive cesarean. If you knew that, as a low risk woman, you were going to be goaded into an unnecessary surgery that will affect your future reproductive health, would you risk it?

    Defensive medicine is really aggressive to women’s bodies. It defends doctor and hospital interests, NOT women and babies.

    By the way, it’s pretty messed up to blame any care provider for shoulder dystocia related complications if protocol was followed.

  • http://www.skepticalob.com invalid-0

    That’s an easy question to answer.

    First, there may have been signs that this was a particularly large baby and possible at risk for shoulder dystocia. In that case, it would have been anticipated and preparation made to deliver the baby with all emergency personnel and equipment available, allowing for a calmer delivery and possibly avoiding the factured bone.

    Second, a protracted labor may have indicated that the baby was very large compared to the mother’s pelvis and a C-section recommended. The shoulder dystocia and injury to the baby would have been entirely avoided.

    The key point is that obstetrics is preventive medicine. Identifying potential serious problems BEFORE they occur and take steps to PREVENT those problems is preferable to trying frantically to treat the problem when it happens.

    Ms. Cheyney’s patient was lucky. She was able to deliver that baby without too much difficulty (probably because the broken bone created more room). However, if the bone had not broken so readily or if the baby had required expert resuscitation with intubation, the baby would have died. The fact that this had a happy ending is entirely a matter of luck, not skill.

  • http://www.unnecesarean.com invalid-0

    “The fact that this had a happy ending is entirely a matter of luck, not skill.”

    So you must feel that the baby that died in the hospital was quite unlucky, since his doctor was very skilled?

    “The shoulder dystocia and injury to the baby would have been entirely avoided.”

    Like it was avoided in the hospital? That baby died.

    “First, there may have been signs that this was a particularly large baby and possible at risk for shoulder dystocia.”

    How? I encourage you to read ACOG’s Guidelines on Fetal Macrosomia before you reply.

    A question for you, Dr. T… how can a patient tell defensive medicine from preventative medicine? If one of your patients had asked you that when you were practicing, how would you have answered?

  • http://www.unnecesarean.com invalid-0

    …prevent shoulder dystocia. You did not answer that, except for noting that there MAY have been signs and the baby was POSSIBLY at risk for shoulder dystocia.

    Also, one half of all cases of shoulder dystocia occur at birth weights of less than 4,000 g. The only accurate measure of fetal weight is post-birth weight.

    Having everyone standing around the patient with suspected macrosomic fetus allows “for a calmer delivery?” Calmer for whom, Amy?

    “The shoulder dystocia and injury to the baby would have been entirely avoided.”

    You should teach seminars to your peers, the rest of whom agree that shoulder dystocia is unpredictable. I suspect you’re being farcical to bait for a response. If that’s so, it worked. ;) I chomped the bait.

  • snowflake

    As a person living well with Cerebral Palsy, I nonetheless hate to see people poo-poo the likelihood of birth complications and their effects.

     

    You said what I couldn’t!

  • crowepps

    I’m sure you already know this, but cerebral palsy isn’t necessarily caused by brain damage during childbirth but can also be caused by developmental brain malformation, lack of oxygen before or after birth, intraventricular hemorrhage, toxic injuries, metabolic disorders, infection or post-birth head injury.

  • invalid-0

    “The shoulder dystocia and injury to the baby would have been entirely avoided.”

    You are lying through your keyboard. All of the women who experienced shoulder dystocia during their labors at a hospital who had no risk factors for shoulder dystocia must be laughing at your claim that, had Cheyney’s client been in the hospital, her “shoulder dystocia and injury to the baby would have been entirely avoided.”

    See, if you read the post, you would see that at the same hospital a baby had just died in the hospital from shoulder dystocia complications.

    Why didn’t they prevent it there? We don’t know for sure, because we don’t have enough information, just like we don’t have enough information to make silly, silly statements like “the shoulder dystocia and injury to the baby would have been entirely avoided.”

    “The fact that this is a happy ending…” The fact? So you were there and you know this to be a fact?

    What a joke. Wonder why women sue obstetricians? It’s because of the lies about the safety of hospital birth, such as SHOULDER DYSTOCIA WOULD HAVE BEEN AVOIDED ENTIRELY IN A HOSPITAL as this MD claims. So imagine a family’s shock when they their baby dies in a hospital after hearing silly lies like this.

    I know this is slipping away from the topic of the original post, Amie, but I just had to point out the extreme goofiness and lies. Snowflake, Amy didn’t articulate anything that you didn’t. You shared your honest feelings. She lied. In fact, she basically just denied that your birth injury would have happened in a hospital.

  • http://www.skepticalob.com invalid-0

    As I said, shoulder dystocia and the broken bone are entirely avoidable by C-section.

    It’s well known that C-section, even purely elective C-section, saves babies’ lives.

    In the article Neonatal Morbidity and Mortality After Elective Cesarean Delivery by Signore and Klebanoff in the June 2008 special issue of Clinics in Perinatology, the authors founds that C-section dramatically reduces the risk of stillbirth, neonatal death, shoulder dystocia and intracranial hemorrhage. In fact, if 1 million women underwent C-section at 39 weeks instead of waiting for onset of labor and attempting vaginal delivery, 692 more babies would be saved, 517 cases of intracranial hemorrhage and 377 brachial plexus injuries would be prevented.

    • http://www.unnecesarean.com invalid-0

      I actually feel disappointed that Amy didn’t come back to answer any of my questions.

      It’s getting pretty off-topic, so I can always be found by e-mail. unnecesarean (at) gmail.

    • invalid-0

      Why do babies experience shoulder dystocia complications while under obstetric care? It should be prevented based on Amy’s argument. The elective cesarean study is irrelevant in this case unless the implication is that all women should have an elective cesarean. Ironically, Erb’s Palsy still occurs in babies delivered by cesarean. Erb’s Palsy is also one of the rare consequences of shoulder dystocia. We can deliver a baby by cesarean to avoid Erb’s Palsy because we fear shoulder dystocia risk signs and still deliver a baby with… Erb’s Palsy.

      Jill—Unnecesarean asked how prenatal care could prevent shoulder dystocia. Amy jumped in with how she feels that obstetric care can prevent shoulder dystocia.

      A few of the problems with Amy’s comment:

      What would the signs have been that would have indicated that this may be a big baby? How reliable are these signs as predictive measures of fetal weight? Answer: Not reliable.

      What is Amy’s evidence that delivering a suspected macrosomic baby “with all emergency personnel and equipment available” may prevent bone fracture? Or result in a “calmer” delivery? She will not produce any evidence because this is woo fabricated by medicalized birth advocates.

      Amy’s comments are based on the biased assumption that no one besides a doctor would understand risks for shoulder dystocia, know how to screen out women or understand the consequences of a protracted labor. This bias is typical of medicalized birth advocates, who rely on appeals to authority and common practice to garner the respect and compliance (and $$) of patients, whom they like to refer to as “laypeople.” This type of advocacy is rooted in a long history of training physicians to perform misogynistic practices that control womens’ bodies and place the perceived needs of the fetus above those of the pregnant woman. Non-physician medicalized birth advocates share this dogmatic belief system and have bought into the idea that they need a doctor to control and assume responsibility for their bodies.

      Assume incompetence and you will see a broken collarbone and a transfer to the hospital as a result of provider incompetence. There were two babies mentioned in that paragraph. The baby with the broken collarbone is alive. The one that experienced shoulder dystocia in the hospital is not alive. By Amy’s logic, we must assume provider incompetence caused that baby to die.

  • invalid-0

    Thanks for your discussion of midwifery and homebirth, and blessings on your new little one.

    This sentence gave me pause: “Dialogue around whether a higher risk woman should still have the right to choose a homebirth tends to be very difficult and heated.” Of course she should, and she does- the question is whether she should maintain the right to hire a qualified attendant willing to serve her.

    Word choices matter as we advocate for childbirth choices. Informed consent demonstrates respect for women’s autonomy, and requires that providers and lawmakers honor a woman’s decisions about risk. Doctors and midwives are obligated to communicate the best medical information about risks and benefits of all possible options WITHOUT COERCION OR DISCRIMINATION, and the woman then decides which risks she’s willing to accept for herself and be responsible for for her baby. She is a woman with a higher-risk pregnancy, not a higher-risk woman. Putting women first might mean a subtle change in language but could bring about a dramatic change in how our country delivers maternity care.

  • snowflake

    Sorry about the initial double post–some times the interface doesn’t show me that it accepted my post.

  • snowflake

    To quote Sara B.: "Amy’s comments are based on the biased assumption that no one besides a
    doctor would understand risks for shoulder dystocia, know how to screen
    out women or understand the consequences of a protracted labor. This
    bias is typical of medicalized birth advocates, who rely on appeals to
    authority and common practice to garner the respect and compliance (and
    $$) of patients, whom they like to refer to as “laypeople.” This type
    of advocacy is rooted in a long history of training physicians to
    perform misogynistic practices that control womens’ bodies and place
    the perceived needs of the fetus above those of the pregnant woman.
    Non-physician medicalized birth advocates share this dogmatic belief
    system and have bought into the idea that they need a doctor to control
    and assume responsibility for their bodies. "

     

    OK, let’s complete ignore Dr. Amy’s female gender in a traditionally male profession, her greater education, her internship and her residency.  Let’s also ignore that she is the person midwives usually turn to when a birth is not going as "planned." (Snowflake’s comment: It is a risk to think you can plan a birth.)

     

    Let’s instead call her "biased", "misogynistic", and "dogmatic" and assume she knows nothing about her field of specialization.   

     

    Sigh…This is feminisim? 

  • http://www.skepticalob.com invalid-0

    “Why do babies experience shoulder dystocia complications while under obstetric care? It should be prevented based on Amy’s argument.”

    No, that’s not my argument. It certainly might have been prevented by better obstetric care, but shoulder dystocia cannot always be anticipated before delivery. That’s the critical point.

    Homebirth midwives like to pretend that they can prevent serious complications or manage them if they occur, but they’re just kidding themselves. It was simply a matter of luck that the baby did not require an expert resuscitation with intubation after the delivery. Had the baby needed that, he or she simply would have died.

    The midwife had no idea this was going to happen, and no experience to properly handle the situation had it been even more serious (broken bone plus severe oxygen deprivation). That’s why I said that the baby’s survival in this case was due to luck, not skill.

    The bottom line is that many life threatening complications cannot be managed at home, and they happen regardless of whether or not the midwife thinks they are likely to happen. In the absence of immediate access to appropriate treatment, babies die. That’s why all the existing scientific evidence, as well as national and international data, show that homebirth nearly triples the rate of neonatal death.