Where’s The Birth Plan?


Obama
"won’t rest" until he’s cut health care costs and improved quality?

Over here,
Mr. President, says Jennie Joseph, a certified professional midwife who runs a
birth center in Winter Garden, Florida. Midwives like Joseph provide
what you could call "less-is-more care."

Compared to healthy women who get
standard obstetric care and deliver on high-tech labor and delivery wards,
women with low-risk pregnancies who get care with a midwife and deliver in
birth centers or even in their own homes, benefit from a five-fold decrease in
the chance of a cesarean delivery, more success with breastfeeding, and less
likelihood that their baby will be born too early or end up in intensive care. And all of this for
a fraction of the cost of the status quo. 

A new economic
analysis
forecasts savings of $9.1
billion per year if 10 percent of women planned to deliver out of hospital with
midwives.   (Right now, just one percent do). If America is serious about reform, midwifery advocates are
saying, "Hey, how about us?"

Childbirth, in fact, costs the United States more in hospital charges than any
other health condition — $86 billion in 2006, almost half paid for by
taxpayers. This high price tag — twice as high as what most European countries
spend — buys us one of the most medicalized maternity care systems in the
industrialized world. Yet we have among the worst outcomes: high rates of
preterm birth, infant mortality, and maternal mortality, with huge disparities
by race.

In Orange County, Florida, where Jennie Joseph practices, one in five
African-American babies were born premature in 2007. In response to these
disparities, Joseph also runs a prenatal clinic that turns away no one and
coordinates care with the local hospital. Among the women who got prenatal care
"The JJ Way"  in 2007, less than 1 in 20 gave birth preterm, and there were zero disparities. "It’s not rocket science," Joseph told
me. "It’s really just about practitioners being willing to have conversations
with women." Joseph is perhaps being coy, but whatever she’s doing, we should
be studying it very closely.

Midwives
like Joseph aren’t nurses or doctors. They don’t offer epidurals, schedule
labor inductions, or perform surgery. What they do is provide primary care for
normal pregnancy and physiological childbirth, and they only intervene or
transfer to the next level of care when needed. The model works. In a study of 5,000 healthy women who
planned home births with certified professional midwives in North America, 96 percent
gave birth vaginally with hardly any intervention, and their babies were born
just as safely as similarly low-risk women who plan hospital births. The
results track with other studies of planned, midwife-attended, out-of-hospital
birth.

Standard
obstetric care, on the other hand, routinely induces and speeds up labor,
immobilizes women and has them push in disadvantageous positions, cuts
episiotomies, employs vacuum extractors, and in nearly 1 out of 3 births,
delivers surgically via cesarean section. This routine use of intervention is
not based on medical necessity, and there’s actually a vast body of
evidence now showing that much of what we do
in American labor and delivery wards is unnecessary, ineffective, and
potentially harmful. Midwives like Joseph, it turns out, are providing
evidence-based care…at bargain prices.

"The obstetric model of care right now does not empower
anybody," says Joseph. "We’re not getting high quality of care that enables us
to have healthy outcomes. We’ve got the worst outcomes. Where do we think they
come from? They come from a system that doesn’t work."

Back in April I attended a symposium in Washington, DC, sponsored by the think
tank Childbirth Connection, called
"Transforming Maternity Care: A High Value Proposition." An impressive array of
stakeholders participated: seasoned physicians, midwives, nurses, hospital
administrators, health system executives, insurance officers, public health
officials, and NIH researchers met in workgroups for more than a year to evaluate
the current system and hammer out recommendations. There was remarkable
consensus that the system isn’t working, that there are "perverse incentives"
for the overuse of medical intervention at the expense of maternal and infant
health.

A
physician and chair of the United States Preventive Services Task Force
reported:

"There’s a shortage of providers whose training focuses on wellness,"
and even suggested that "we should support the education of providers,
facilities, and insurance on the evidence that supports the safety of home
deliveries for the appropriate low-risk women within the context of an
integrated system of care."

A VP from WellPoint, one of the largest health
insurers, said flatly: "You get what you pay for. What we are paying for now is
high intervention, high cost, high procedural care." An executive from
Geisinger Health System made a startling admission:

"There are many healthcare
organizations across the country [that] have become, unfortunately, dependent upon
NICU [Neonatal Intensive Care Unit] volumes to fund many of their other
services." 

In other words, our for-profit system not only rewards the overuse
of intervention even if it leads to more sick babies; in some cases, it
depends on it
.

So, if this system is broken, and this system is wasting public funds, and this
system is harming women and babies, why isn’t fixing it part of the national
conversation on health reform?

"We’re sitting here in the birth community
scratching our heads," says Susan Jenkins, an attorney who’s on the steering
committee of the Big Push for Midwives, a national campaign to license certified
professional midwives in every state,
and an advisor to the American Association of Birth Centers, both of
which are lobbying congress for inclusion in health reform bills.

"Here we’ve
got this huge sector of the healthcare dollar where we can save costs and
improve quality. And it goes beyond midwives. It’s about improving these really
horrible outcomes. Why isn’t anybody talking about this?"

It’s a valid question, and it begs another, more difficult question: Why isn’t
the women’s health community talking about this? Cesarean section is far more
dangerous and debilitating than vaginal birth, and 1.2 million American women
now go through it each year. Fully half of first time mothers are induced into
labor, which adds significant pain and risk. A quarter of women who give birth
vaginally still get episiotomies (cutting the vaginal opening during labor),
though the practice has been debunked by research for years. As if to add
insult to injury, women who’ve previously given birth by cesarean are
systematically being refused vaginal birth, or VBAC (vaginal birth after
cesarean): about half of hospitals ban it, which
essentially tells women they have no choice but to submit to scheduled repeat surgery.

You might think that one of these issues would come up at the recent round
table discussion on women’s health at the White
House , and yet you’d be wrong. In 90 minutes there was not one mention of the
rising cesarean rate or the rising maternal death rate, nor of VBAC denials,
nor of birth centers, nor home birth, nor any mention of midwives, nor were any
midwifery organizations represented among the 25 participants. The only
childbirth-related topic brought up was pre-term birth and access to care, but
no question as to the quality of the care itself. "There hasn’t been any
healthcare reform agenda put out by any national women’s groups that has
embraced birth centers and midwives and evidenced-based maternity care as a
prime element of health care for women," says Susan Jenkins.

!pagebreak!

THE
PREGNANT ELEPHANT IN THE ROOM

Early in 2008, long before Obama was even the Democratic nominee for President,
the women’s health community began organizing in anticipation of a new
administration. On the advice of former Clinton advisors, groups like The
National Partnership for Women and Families
, The National Women’s Law Center,
The Center for American Progress, Planned Parenthood, and the ACLU Reproductive
Rights Task Force
formed a coalition to hammer out what it would ask for from
the new administration.

"With Clinton, it was all thrown together very last
minute," says Lisa Summers, who was with the National Partnership for Women and
Families at the time. "We were told it would behoove the reproductive rights
community to come together as a coalition so when the new president is elected
we’d be ready to go to the transition team and say, This is what we want." The
coalition was unprecedented.

At the same time, the birth community was organizing like never before, with the
launch of The Big Push for Midwives, not to mention the growth of hundreds of
local consciousness raising groups and steady DVD sales of The Business of
Being Born
, with
national media coverage of a rising demand for midwife-attended home birth. The
Big Push has so far persuaded several legislatures to license and regulate
providers who had been previously considered criminals, and they’ve got active
or pending legislation in 18 states.

Their success is thanks in large part to
grassroots organizing, and to organizing across the abortion divide. "In Wisconsin
we had a pro-life legislator from a rural part of the state introduce our
legislation and one of the most liberal pro-choice senators from Milwaukee sign
on to support it," says Katie Prown of the Big Push. In Missouri, it was the
hard-right anti-abortion state senator John Loudon who snuck pro-midwife
language into a bill.

Obama wants a common ground issue? This is it.

By early spring, the coalition of women’s health groups had done initial brainstorming
and divided into issue areas. One was "healthy pregnancies." Summers, a
certified nurse midwife who had served as a director of the American College of
Nurse Midwives, was delighted to see this and immediately joined the group.
Coming from the provider community, Summers had a different perspective than
the other members, most of whom had backgrounds in reproductive rights law,
with one exception: a lobbyist for the American College of Obstetricians and
Gynecologists. Summers offered to reach out to groups like Childbirth
Connection, ACNM, and AWHONN, the organization for obstetric and neonatal
nurses, so more stakeholders could have input. The National Advocates for
Pregnant Women
and the Big Push connected with the group as well.

The Big
Push promptly sent a detailed memo that called for inclusion of Certified Professional Midwives (CPMs) as
Medicaid providers, an investigation into "the frightening increase in cesarean
surgery rates and hospital bans on VBAC," and stronger federal support for
breastfeeding, among other specific suggestions for federal and administrative
action. "Ultimately, midwifery, home birth, and birth centers must be included
in whatever healthcare reform plan is enacted," wrote the Big Push, "but these
interim steps to include all midwives and birth centers in Medicaid/Medicare
are greatly needed. Approximately one-half of all women giving birth are
eligible for Medicaid."

This was no small point, even then, in terms of cost
savings. Part of what’s sapping Medicaid funds are cesareans and neonatal intensive
care admissions; the need for both of these procedures can be reduced through increased access to midwives. "The irony is that
most women whose births are being paid for by taxpayers are being denied this
option," Katie Prown points out.

The final document put out by the coalition, "Advancing Reproductive Rights and
Health in a New Administration," which was presented to the Obama-Biden
Transition Team, includes "Support healthy pregnancies" as one of eight major
goals, with three specific recommendations:

  • boost funding for the Maternal and
    Child Health Services Block Grant,
  • reinstate birth centers as eligible for
    Medicaid reimbursement (a Bush policy casualty), and
  • end the shackling of
    incarcerated women during labor.

But there is no mention of CPMs (or any
midwives), the cesarean section rate, VBAC access, or home birth, or any
overarching statement on the sorry state of U.S. maternity care in general. The
same is true of subsequent blueprints for women’s health reform put out by the
Center for American Progress and Columbia University.

For birth advocates, the outcome was disappointing. "I was thinking about all
the policies that have driven the over-medicalization of childbirth," says
Summers.

"The payment system rewards providers for intervention and makes it
difficult to have an out of hospital birth. And it’s the workforce decisions
that have led us to have tens of thousands of specialists and six thousand
midwives. The government funds the vast majority of healthcare education, and
it is disproportionately spent on physician education."

The disappointment
notwithstanding, it wasn’t unexpected.

The American College of Obstetricians and Gynecologists has what it calls a
"longstanding opposition" to
home birth and what it terms "lay" midwives, by which it means any midwife who
is not also a nurse. Even in response to growing interest and attention to CPMs and home birth, the organization has only dug
its heels in deeper. "ACOG does not support programs that advocate for, or
individuals who provide, home births," says its 2007 statement on the subject.
In Missouri, the local physician group tried mightily to block the CPM
legislation, even suing the state over it (and losing).
ACOG argues that the issue is safety, though the research suggests that for
healthy women, planned home birth with a CPM is as safe as a planned hospital
birth, if not safer because of the reduced likelihood of potentially harmful
interventions. ACOG has also remained neutral on the rise in cesarean section,
and its policies are directly responsible for the de facto VBAC ban.

Naturally, during the meetings leading up to the blueprint, the ACOG
lobbyist was going to object to any recommendations that would expand the pool
and power of midwives or increase access to home birth. What’s perhaps
interesting is that the group listened. "It was pretty clear that anything contentious
wasn’t going to go anywhere," says Summers. "The lobbyist didn’t have to say
much, and the group really needed ACOG there, because people on the Hill would
say, ‘Well, what do the OB/GYNs think?’"

!pagebreak!

REPRODUCTIVE JUSTICE?

Of course, politicians aren’t necessarily asking
the right questions, but neither are the traditional allies of women’s health, perhaps because they have
historically been focused on contraception and abortion, to the exclusion of
other related matters, such as wanted pregnancies and childbirth. Though the
"healthy pregnancies" group was charged with naming top national maternity care
priorities for the new administration, its members came to the table knowing
very little about it.

"There was a learning curve," says Jessica Arons of the
Center for American Progress, who was part of the group. Amy Allina of the
National Women’s Health Network also served on the group and felt the same.
"Most of the groups who where involved don’t work on childbirth issues," she
says, and the goals that made the final cut reflected it.  Unshackling imprisoned women while
they’re in labor is a no-brainer. The concept of expanding midwifery care takes
longer to digest.

On top of the learning curve, there’s brand loyalty. "For the abortion rights
community, doctors are our heroes," says Jessica Arons. "Whereas for the
birthing rights community, the medical establishment is driven by malpractice
insurance concerns, and the bottom line of for-profit hospitals, and moving to
C-sections more quickly because they’re more expedient, and all sorts of
disincentives to providing care that’s best for women.  So there’s a tension there."

There’s
also a deeper, ideological hurdle. From the perspective of abortion rights
advocates, medicine and technology are good–they guarantee reproductive
freedom–and physicians who provide abortions protect women from harm. The goal
is to achieve broader access to care.

From the perspective of birthing rights
advocates, medicine and technology are overused and cause harm, and the goal is
to protect women from unnecessary use of technology during labor and delivery. Reproductive freedom is further secured by expanding access to midwives and providing support for
physiological birth.  With abortion, there’s no question as to the standard of care; with birth, it’s the care itself that needs questioning.

Arons
says that maternity care issues have been increasingly on the feminist radar,
especially in recent years as the reproductive rights movement has evolved into
a movement for "reproductive justice." In building the pre-Obama women’s health
coalition, "we wanted to show a commitment to a wider set of issues, including
pregnancy and birthing rights," she says.

"I think most of us recognize that a
woman’s ability to have a home birth, or a midwife assisted birth, or being
able to say no to a C-section, that all of those are clearly related to her
ability to decide whether to have an abortion. It’s all within the same bundle
of rights–to autonomy and self determination and informed consent and
privacy."

But birth advocates are frustrated that they don’t have more support from
groups they perceive as natural allies. "We’re not hearing a word from anyone
publicly that birth is an issue that the Democratic Party should embrace," says
Susan Jenkins, which seems like a tactical error as much as an inconsistency.
Eighty-four percent of American women experience childbirth, more than 4
million a year. "Making changes in the way birthing care is handled in the U.S.
would be one step that can have an immediate impact on a huge number of
American women," says Jenkins. 
"This could be a huge unifying factor for women across the political
spectrum." But reproductive rights groups worry about "issue creep," that to
expand the agenda to include issues like the cesarean rate or midwives could
water down their effectiveness in preserving abortion rights.

To be fair, the birth community hasn’t necessarily organized itself for optimal
influence. Some of the maternity care groups that were invited to the "healthy
pregnancies" meetings declined the invitation. A blueprint is due out from the
Childbirth Connection’s symposium, but not until late this year. In Washington,
the American Association of Birth Centers succeeded in getting birth-center Medicaid
eligibility into all the reform bills; and the Big Push for Midwives and MAMA
campaign
are undoubtedly creating buzz
about the potential cost and health savings of midwives and out-of-hospital
birth. But each is doing so separately, without the power of a coalition.  "There’s a long list of groups that
care about these issues," says Lisa Summers. "But there’s never been an
effective coalition for maternity care in DC."  Which raises another question: even if these groups
could  join forces behind one
blueprint, could it stand up to ACOG?

ACOG wields tremendous authority in Washington. And while it can be counted on
to protect women’s right to terminate a pregnancy, the group is actively trying
to limit women’s rights in choosing how, where, and with whom they give birth,
and actively opposing policy changes that would directly benefit women and
their families. It’s likely that the coalition of women’s health groups didn’t
anticipate the politics involved when it organized the "healthy pregnancies"
team. It certainly put these feminist groups in the awkward position of
facilitating what could be considered some very "un-feminist" advocacy.

"Reproductive
justice is the recognition that all women–not just those ending their
pregnancies, but also those who decide to go to term–need to be protected from
punitive, ineffective, and unhealthy policies," says Lynn Paltrow of the
National Advocates for Pregnant Women. "To advance policies that are protecting
pregnant women who are going to term advances reproductive justice." The flip
side, of course, is that to acquiesce to policies that harm pregnant women
undermines it.

That
said, the coalition itself is a huge achievement, and the fact that pregnancy
and birth issues made it into the 
blueprint represents a major victory for birth advocates. But what now?
Now that this country is trying to envision a more just and economical health
care system, and the women’s health community is positioned to influence its
development? It would seem that if the reproductive justice movement recognizes
that birthing rights are cut from the same cloth as abortion rights, then it
should be working harder for them. And that means, for starters, reconciling
its conflicting interests with ACOG. Perhaps it’s not so different than a woman
standing up to her doctor: she risks being branded "difficult," but in the end,
it’s her body, her choice.

 


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

    Amy Tuteur,

    You have posted this exact same comment many times on this site. The views contained in it have been debated many times. This post that you are copying and pasting onto any post that touches on the subject of homebirth is now being considered spam and thus has been removed. If you have new comments to add to the specifics of a particular post we welcome them, but please do not continue spamming the site with the same post over and over.

    Thanks,

    Brady Swenson

    RH Reality Check

    • invalid-0

      “This post that you are copying and pasting onto any post that touches on the subject of homebirth is now being considered spam and thus has been removed…”

      Wow – speaking on the standpoint of appearances, not on the specific subject at hand, you lose credibility when you label the opposing view as “spam”. I don’t know how credible either party is but if you are in fact credible, the opposing view should pose no threat.

      • invalid-0

        The trouble isn’t that she has an opinion. It’s that she’s very well known and practically a troll. She doesn’t actually rationally discuss facts and she quite literally just posts copies of the same exact post, verbatim, to every article like this she stumbles across. It’s not her opinion that’s spam…it’s just that’s SHE is spamming, lol.

      • invalid-0

        Intelligent opinions, even if different from ones own should be listened to. This lady crosses the line. She attacks homebirth & midwives, says untruths, ignores questions that don’t have answers she wants others to know, and repeats the same rhetoric over and over. I am tired of hearing her. I am glad she’s been spammed. She does not dialog intelligently. I, for one, would be glad to discuss opposing views in a respectful manner, she is not respectful.

      • http://momstinfoilhat.wordpress.com invalid-0

        She disputes peer reviewed research and copy and pastes the same misleading, biased claptrap on multiple posts on multiple sites.

    • independentminded

      In many communities, even today,  homebirths have been the standard procedure, and plenty of healthy, happy children have  been birthed in their own homes, amid family and friends and in the familiar surroundings of home, rather than the often-cold, not always very safe or sanitary environment of hospitals.  

       

       While it’s true that high-risk pregnancies often mean high-risk births that must take place in a hospital, under the supervision of  medical professionals (i. e. nurses and doctors), many homebirths have been successful.   

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

        Farther down the comments section Jennifer Block has taken advantage of the fact that the data from my comment above was deleted to claim that it was incorrect. Since it was deleted, there is no way for readers to make an assessment for themselves even though being educated about birth means having all the data to evaluate.

        Let’s make it very easy for women to compare and contrast the claims:

        I challenge you to a public debate on the safety of homebirth in any neutral forum of your choosing, whether print, other media or a public appearance.

        We can address these specific points:

        1. All the existing scientific evidence (including the Johnson and Daviss BMJ 2005 study) shows that homebirth with a direct entry midwife has nearly triple the rate of neonatal death for comparable risk women in the hospital.

        2. American direct entry midwives do not meet the standards for licensing in ANY first world country. They do not meet the standards in the Netherlands, the UK, Canada, Australia, anywhere.

        3. The Midwives Alliance of North America, the group that collected the statistics for the BMJ 2205 study) has continue to collect safety statistic from 2001-2008. They are currently hiding those statistics from the public. They should be required to release those statistics so women can decide for themselves if CPMs are safe practitioners.

        4. According to the World Health Organization, the US has one of the lowest levels of perinatal mortality in the world, lower than Denmark, the UK and the Netherlands.

        I welcome publicly debating you or any other homebirth advocate in any neutral setting. I’m not holding my breath though; neither you nor any other homebirth advocate will agree to a public debate because you know my data is correct and my case is airtight. No one in the world of homebirth advocacy can risk the embarrassment.

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

    Indeed I’ve posted the same information before. That’s because I believe that women deserve to know it. However it has never been debated. That’s because there’s nothing debatable about it. It simply a recitation of the fact.

    Obviously, you are frightened by the truth. Rather than address the data and statistics that I posted, you simply deleted them. That’s as good as acknowledging that I am correct. Thanks for the validation.

    • invalid-0

      Research has shown the safety of homebirth, the safety of CPMs, the safety of birth center birth for low risk women. You are simply posting hate posts because you hate homebirth. You have been posting these posts for years! What you don’t show is the research that PROVES homebirth safety. You can’t even stand to read it, quote it, acknowledge it and there are no flaws in it. You hate that the research totally counters every single argument you’ve wasted your free time on “debating” as you call it. You are attacking homebirthers, midwives, doctors, legislators, families, children who believe in and use and pass laws making CPMs legal, set up new birthing centers, attend homebirths, back-up homebirth attendants, etc… You are not “validated”, you are being laughed at for knowingly being a ridiculous and annoying internet troll spamming every comment section with your twist on facts that no longer stand true. The research has won!! You’re wrong and it hurts I’m sure but please accept it and move on. Go enjoy some time with your family instead of fighting against what is a safe option all women (not just some) should have access to. It’s a beautiful, natural and safe experience I myself have enjoyed 3 times. The research and my own experience both prove you wrong. Again!

      • invalid-0

        Even though my VBAC ended up in a hospital, I was able to deliver vaginally with no interventions. I should be able to afford to pay the midwife I used without going into debt or putting my family at financial risk, without any repercussions when the hospital transfer occurred. Every woman deserves this right; not just the very wealthy.

  • http://www.friendsofiowamidwives.org invalid-0

    Increasing women’s access to homebirth is an easy way to substantially reform healthcare without creating more costs. The midwives are there: simply let us use them by including them in our insurance plans!!

    Dr. Amy, your views are available to anyone in search of them. There is no such thing as clear cut “fact” when it comes to the interpretation of scientific data: there are competing interpretations that women should have available as they make individual decisions about health care. I carefully researched birth options before committing to homebirth and found that the data overwhelmingly favors the safety of homebirth with a trained professional. My pregnancy was healthy, my birth was safe, and the entire experience cost about as much as a really nice TV or computer. However, I had to put my birth on my credit card because it was not covered by insurance. No one is saying that all women should have homebirth; it should simply be available as an option competitive with the “typical” birth available: that of a high-tech hospital.

    Federal healthcare reform MUST include midwifery! It is a dramatic oversight NOT to! Come on, DC!

  • invalid-0

    Homebirth with a certified provider is a proven better option for low-risk pregnancies, the statistics are there in the British Medical Journal, Here is the conclusion of the study “Planned home birth for low risk women in North America using certified professional midwives was associated with lower rates of medical intervention but similar intrapartum and neonatal mortality to that of low risk hospital births in the United States.” In this study over 5,000 midwife assisted homebirths in North America were used to gather data.

    The fact is obstetricians are surgeons, and when an issue arises in pregnancy or labor they go with the tools that they have learned which is to intervene with needles, drugs and knives. Midwives have a different set of tools that include patience, support and low-impact interventions such as use of herbs in place of medication and massage instead of epidural.

    The biggest difference between OBs and midwives is that OBs get paid more for administering C-sections, whereas midwives get paid the same flat amount no matter what.

    Good point, when will the feminists and women’s health advocates embrace the issue of choice at the start of pregnancy alongside choice at the end of pregnancy?

  • invalid-0

    Good article, and the time is right for all of us to come together. I want to address the important concern of some about the “issue creep.”

    After coming to support abortion access after many years in anti-abortion politics, I would like to think that serious coalition building will strengthen the reproductive justice movement.

    Speaking for myself, I can only embrace abortion rights in the context of rights for all pregnant women and human rights. Part of what kept me in the anti-choice camp was the lie that pro-choicers are only baby killers, while right to life is about women and is the civil rights movement of our time, so they say.

    Frankly, I disagreed that the anti-abortion movement was for women or rights for anyone who was not white, male, and Christian. Still, there was no place for people like me within women’s health advocacy because I was not considered 100% pure on every single matter, as others viewed it.

    Finally, I learned of National Advocates for Pregnant Women, strong women representing different constituencies. Seeing a coalition that firmly stands for choices for all women, this is what brought me into reproductive justice advocacy.

    I want to encourage this coalition building and my hope is that it boldly move forward in unity and with the passion that gives strength to those who pursue what is right.

  • invalid-0

    One thing that wasn’t mentioned in the article is that natural childbirth often allows infant and mother to experience a deeper bonding and a more estatic joy than can be found in the cold, drugged world of hospital birthing.

    The shutting out of midwifery is just one example of what is wrong with the health bill as it currently stands. Every health modality that is not solidly in the allopathic camp of medicine has been shut out. In most of Europe, China, India and many other countries allopathy and holistic alternatives work together. But in this country thanks to the hostile AMA, big pharma and the health insurance industry a whole host of healing modalites are excluded from consideration. Although they are usually cheaper, less invasive and often more effective.

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

    “ACOG has also remained neutral on the rise in cesarean section, and its policies are directly responsible for the de facto VBAC ban.”

    Over the last few years, it has also spent what seems like an exorbitant amount of time addressing the ethics of maternal request cesarean sections. Many do not find the ethical question of offering unnecessary surgery to low-risk women excessively troublesome but are appalled by the complete and total disregard for choice and evidence when it comes to VBAC and unnecessary cesareans. Would it be reasonable to say that it is easier for a woman in the U.S. today to elect for a cesarean section than to just give birth normally or to refuse the recommendation of an unnecesarean? Are we there yet?

    One thing I’ve observed in online discussions, in comments on my blog and on the site’s Facebook fan page is that women really, really want the option to VBAC and want to do so without the unsubstantiated over-inflation of the risks of uterine rupture (which can also occur in an unscarred uterus) that is, whether consciously or not, used to terrify and thereby coerce a woman into surgery. It seems like a primary cesarean sneaks up on women who were not aware of the widespread abuse of the cesarean section by care providers as a means of buffering themselves from litigation. The banning of VBAC is a human rights violation. Refusing to attend the birth of a woman with a scar from a previous cesarean (which is proven to be safe) while systematically working to squelch access to out-of-hospital birth adds up to trying to force women into unnecessary and unwanted surgeries.

    Some of think that’s nuts.

    • http://labortrials.wordpress.com invalid-0

      Jill, you ask:
      “Would it be reasonable to say that it is easier for a woman in the U.S. today to elect for a cesarean section than to just give birth normally or to refuse the recommendation of an unnecesarean? Are we there yet?”

      I assume these questions are “merely” rhetorical. But yes, we’re there. I’m living this scenario right now – 36 weeks pregnant with twins, easy complicated-free pregnancy, one scar from an unnecessary cesarean nearly 5 years ago, risked out of homebirth by a state board that regulates (read: limits) access to homebirth midwifery, and now being strongly encouraged to accept routine practices and most recently surgical procedures that have not been proven to improve outcomes.

      I’m just NOW being told that a breech baby B means that a repeat cesarean is prudent. I’m just now being told that my OB’s insurance does not cover breech delivery even though he’s an old enough doc to have had the experience with breech birth. I’m just NOW being told that I’ll have to push in the cold, brightly-lit OR. It’s becoming MORE evident that my OB won’t commit to attending this birth if he’s in town but not on call, effectively abandoning me to the “tribe,” unaware and uncaring of my birth plans, my history, the HIGH level of research that I have done in preparation for these babies, etc. He’s been a great pre-natal doc, but he’s really let me down here at the finish line.

      Yes, it’s easier to ask for a cesarean than to say no to one that’s offered, recommended, or supposedly required. The abuse of women’s reproductive rights continues to escalate – we are denied access to technologies and/or treatments that we deem appropriate for some things just as we are denied the ability to say no to technologies and/or treatments that we deem unsuitable for our particular situations.

      ~ Kimberly

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

    By the way, that typo in the subject of the previous comment was also very “unwated.”

  • invalid-0

    The most effective way to ensure that the concerns of birth advocates are at the tables in Washington where these discussions are taking place is to GIVE MONEY TO CHILDBIRTH CONNECTION (www.childbirthconnection.org). Donate money and encourage everyone you know to donate money and ask them to earmark it to hire a lobbyist to represent birth issues! Money talks, ladies! For about $65,000 Childbirth Connection could hire a lobbyist to make sure that these issues are being represented from the perspective of those concerned with the full range of issues connected to appropriate care during birth; access to midwives, birth centers, and home births, and proper, sustainable levels of compensation for midwives, insurance coverage for birth education and labor support are some of the issues that could be addressed.

    I live in a relatively small community that manages to raise over 7 million dollars annually to care for the needs of its members. Is it possible that we birth advocates could put our money where our mouth is and raise $65,000 from donors across the country? Go online or make the call and donate today, and encourage all the moms you know to do the same. Let’s see what we can do!

    • invalid-0

      The MAMA Campaign (Mothers and Midwives in Action) is a large coalition of midwifery and consumer organizations that have mobilized for this specific purpose! The organizations in this coalition are the following:

      • NACPM: National Association of Certified Professional Midwives
      • MANA: Midwives Alliance of North America
      • CfM: Citizens for Midwifery
      • ICTC: International Center for Traditional Childbearing
      • NARM: North American Registry of Midwives
      • MEAC: Midwifery Education Accreditation Council

      The coalition has hired an excellent lobbyist team and have been working tirelessly in Washington DC for the last couple of months to make our congressmen and women aware of the cost savings and myriad benefits of covering Certified Professional Midwives under federal Medicaid. Midwives and consumers from all over the country have flown in to lobby their senators and representatives with the MAMA Campaign.

      Childbirth Connection is an amazing organization and deserves every bit of support we all can give them. But the time is right now this minute to be active in DC and on the phones with our congresspeople, and the MAMA Campaign is already mobilized and taking action. They need our immediate support and dollars to pay this fantastic lobbyist. Please consider lending your voice to the coalition and donating at MAMAcampaign.org!

  • invalid-0

    Why should it surprise you that the doctors who support a woman’s right to abortion are the same ones who refuse to give women choices when it comes to birth. It just proves that, far from being women’s rights advocates and heroes, they are simply in it for the money…whichever way it comes.

  • alison-cole

    Having worked in abortion care for 6+ years, I can tell you that many, many (most?) abortion providers are in it for the women. The doctor I work for, and others who I have met through my work, support midwifery care and out of hospital birth — the full range of reproductive choice. Others are less informed, and coming from a medical mindset need some education to embrace a non-medicalized conceptualization of birth. And, as is the case with the general public, some doctors who provide abortion are jerks. Some midwives are jerks too, but I still support midwives and midwifery care.

  • invalid-0

    The reason OB/GYNs are scared of VBACs and are so quick to suggest medical interventions is because if there is a complication or bad outcome, then the patient will likely sue. Even if no one is at fault, people want someone to blame when something tragic happens, especially if it involves a child. So physicians are extra careful to disclose all possible risks, which some here interpret as designed “to terrify and thereby coerce a woman into surgery.” Many OB/GYNs pay six figure annual malpractice premiums. Yes, the system is broken, but you can’t expect the OB/GYNs to change without addressing the malpractice issue as well.

    • http://labortrials.wordpress.com invalid-0

      You write: “So physicians are extra careful to disclose all possible risks…”

      I am 36 weeks pregnant and have YET to be presented with information regarding the risks and benefits of VBAC or cesarean. In fact, the only reason I have a copy of the hospital’s VBAC consent form is because I knew to ask for it. (It sucks, by the way. Completely inadequate.) They do not have a cesarean consent form – women are such sheep that they just agree to sign the “invasive procedure” form that is presented to them when they are in the throes of labor and terrified of what’s happening to them.

      I have yet to meet an OB that knows the major studies, the quality of research done on things like cEFM, cesarean surgery, breech birth, VBAC, or questions the status quo. There’s no incentive to support or penalty for not supporting the natural physiologic unfolding of childbirth. We have to wish on stars that we’ll end up with a supportive birth TEAM at the hospital.

    • invalid-0

      I must also disagree that most women who VBAC and something goes wrong will sue because we want someone to blame, especially in this climate.

      In order to VBAC, you darn well better know your research and be taking responsibility for the outcome, because chances are if you don’t you’ll be bullied into a repeat section.

      The real problem is the medical establishment insisting they know our bodies better than we do. The current VBAC-lash is due in part to this, IMO…that when VBAC was all the rage, insurance companies and doctors forced it on women who didn’t want to take the risks, or women who did but felt something wasn’t right and a section needed to be done. Then viola, when something didn’t go right, they were sued. They blame VBAC, but the issue is not VBAC so much as it is failure to listen to the true expert, the birthing mom.

      In this environment where VBAC is villianized and we are told we’re selfish wanting a birth experience at the expense of our babies’ health, believe me if we choose a VBAC it is after much thought and research, and we (the experts, remember) truly believe it to be best for our babies. WHEN will the doctors listen to the mothers, who are the true experts on their own bodies? All good doctors realize that the patient knows the most about their own body, it seems, except OBs. Somehow, pregnant and laboring women are not quite mature or rational enough to be afforded full decision-making status over their own bodies, which sounds a LOT like discrimination to me.

      And partly, there’s this thing called maternal-fetal conflict…the theory being that the *selfish* mother will save herself at the expense of her infant’s life. WAKE UP PEOPLE!! I don’t know one woman who wants her baby to die so she can live…although I know a few who might be willing for that to happen if they had to choose between allowing their baby to die (which happens naturally in childbirth sometimes, and might happen after birth anyhow if baby is not compatible with life) and leaving their other children orphans or motherless. How is this different from abortion? It’s not. It’s the woman’s right, let her choose. (And I’m not in favor of abortion except as it coexists with a woman’s right in all birth choices, so please don’t make assumptions.)

      Anyhow, moms that abort their babies sometimes (possibly always?) believe they are doing what is best for those babies, based on the circumstances, and I am not going to argue that. My argument would be however, that with easy access to abortion, women that carry to term are carrying wanted babies or have acquiesced to the pregnancy on some level (even if it was not planned or wanted in the beginning). Why can’t we assume that a woman at term wants what is best for her baby???? What about that is so hard to believe???

      It is only when we stop discriminating against women and listen to their intuition, assuming that they want the best for their babies, that we will see the lawsuits decrease. As long as doctors all but promise if you just do it their way you’ll have a perfect healthy baby, then we’ll continue to see lawsuits. If we let the unnecessareans run their full course, we’ll eventually start seeing more lawsuits for those, too.

      Just my $0.02.

  • invalid-0

    This article only makes me feel more strongly pro-life. I completely agree that childbirth is so over-medicalized. All the interventions cost our country money while providing inferior outcomes for women and babies… lose-lose situation. Likewise, abortion harms both women and babies… the emotional and psychological effects of abortion hurt women terribly. This article makes me see even more how “trust the doctor, he is your friend” has taken over reproductive care: both in abortions and in childbirth. Women and children are losing on both fronts. What would benefit women emotionally, physically, and psychologically would be supporting every pregnancy with the kind of care that gives positive results due to low interventions (and abortion clearly fits the definition of an “intervention”), supporting women in rearing their children by building stronger local communities and families, and helping women who don’t think they can care for their children by exploring the adoption option. Since birth control and then abortion have become legal, childbirth practices in this country have only been decreasing.

    This all confirms it for me: the more interventions into pregnancy, the more harm that comes to women and babies. It makes perfect sense to me that pro-life legislators have been the ones introducing bills that serve to protect women’s and babies’ health (physical and emotional) in childbirth.

    And Amy Tuteur is so a troll, lol… she’s argued with me somewhere before, I think on a forum regarding infant formula vs breastmilk, was it?? Her name jumped out at me and I think she must just search around for places to paste her “studies” in.

    • invalid-0

      “Since birth control and then abortion have become legal…”

      Oopsie! I think you’re supposed to be a tad more discreet about the your anti-contraception views, lest you freak out the majority of the population who approve of it and reveal your true anti-woman anti-sex authoritarian agenda.

  • invalid-0

    Why does birth seem to get lost in the abortion debate. I clearly see how the two are kissin’-cousins, but birth is being overshadowed. Women are being stymied and preventably injured (babies too) by the anti-family provisions that are currently in place around institutional birthing, and not by choice. Birth is about (illegally enforced) restriction of choice through coercion and lack of informed consent. If both sides of the abortion debate agree that women have the right to informed consent and informed refusal, bodily autonomy, and the right to safe, best-practice care, for themselves and their babies, then it’s time to quit trying to push abortion agendas along in the same stroller as birthing.

    • invalid-0

      Thank you! I agree.

  • invalid-0

    Divide and Conquer.

    • invalid-0

      Egg. zactly.

  • invalid-0

    I don’t have enough room to detail my experaince as a pregnant woman without health insurance here, but I find it extremely hypocritical that a group of doctors would dismiss deliveries performed at home as “unsafe” when many of these same doctors refuse to even allow a woman without insurance or with Medicad an appointment. If their care is truly superior then they are discriminating against women of color and poor women by not allowing these women to access their services. Midwife care is better because it does not contain these biases.

    • invalid-0

      yes, Brooke, I’ve been there too. Been hung up on and thrown out of several dr.s waiting rooms (& once after waiting 2 hrs for my turn!), for not having $, never been thrown out of a midwife’s house! It is really sad they pretend it’s about safety when it’s really about $!

  • invalid-0

    the emotional and psychological effects of abortion hurt women terribly.

    Much as you would like it to be otherwise, this just isn’t true for most women who have abortions.

    While I’ve spoken with a few guilt ridden religious right women who go on and on and on about how their abortion messed them up for life and while it’s really clear to me that they are messed up most of my women friends who have had abortions report relief and no, absolutely none of these effects. It’s my belief that the religion, not the abortion, injures you folks emotionally and psychologically.

    The people I know who were injured psychologically were those who carried children to term and than were forced or coerced into giving the child up for adoption. Their guilt and sorrow is lifelong.

    I wish that y’all wouldn’t pretend to be concerned about the health and welfare of women when it’s abundantly obvious that you are not.

  • invalid-0

    For low-risk women, birthing out of hospital with a midwife is the safest choice for women. Research shows out of hospital birth is safe for mother and baby and that in-hospital births increase the chance the mother will have interventions and a cesarean.

    Having more access to midwives, homebirth, birth center birth options would allow the U.S. to save billions of dollars in healthcare costs!

    Here is a summary of one recent study on homebirth safety in Europe:

    Researchers say giving birth at home with a midwife is as safe as doing so in hospital. But with less interventions and less chance of vaginal assisted delivery or cesarean!!

    The researchers say a home birth assisted by a trained midwife is just as safe for low-risk mothers and their babies as a delivery led by a midwife in hospital.

    A study of 529,688 low-risk women in Holland who were in the care of a midwife at the start of labor – of these women 321,307 (60.7%) planned to give birth at home and 163,261 (30.8%) planned to give birth in hospital and for 45,120 (8.5%), the intended place of birth was unknown.

    The nationwide study set out to compare home and planned hospital births, among low-risk women who started their labor in primary care and the team found over a seven year period that there was NO DIFFERENCE IN DEATH or serious illness among either mothers or their babies if they gave birth at home rather than in hospital.

    The research was carried out after figures showed the country had one of the highest rates of babies dying during or just after birth.

    The chief researcher said they found that for low-risk mothers at the start of their labor it is just as safe to deliver at home with a midwife as it is in hospital with a midwife.

    • independentminded

      I also believe that  this:

       

      in-hospital births increase the chance the mother will have interventions and a cesarean.

       

      is not altogether true.  Here’s why: From what I understand, a prolonged and difficult labor, whether it be an in-hospital or at home , and whether it culminates in  some sort of assisted birth (i. e. caesarean section, forceps, or suction cup), either indicates the presence of some sort of problem(s), or the potential for problems somewhere down the road.  Coordination and movement actually begin in utero, during fetal development, and babies with various neurological problems (i. e. CP (cerebral palsy), autism, ADD/ADHD, and various other learning/developmental disabilities, and even epilepsy) have much more difficulty passing down through the birth canal, thereby requiring some sort of assisted birth.  

       

      Inotherwords, the above-mentioned problems are innate, and

      the hardwiring of people afflicted with such problems take place in utero, during fetal development, and nobody knows why.  So, inotherwords, the person afflicted with such problems is programmed like that well before birth.  It’s all too easy, particularly in today’s litiginous society, to point fingers and blame the problem(s) on the difficult birth, but it’s actually the other way around;  a prolonged and difficult birth results from the problem(s)

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

    Thank you for getting rid of that “assumption” she made. People always claiming to know how others are affected…The ones emotionally and psychologically scarred…are those that really don’t have a choice.

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

    Great comment, Brooke. I have seen many a poor woman totally disrespected or pushed to a specific hospital without having insurance. This is a known practice in a certain part of Florida.

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

    Well, choice IS choice…either you support choice and options, or you don’t. What the anti-choice community gives is choice for some and under certain circumstances….which is, by nature, anti-choice.

  • invalid-0

    I agree. However, when the choice being exercised is to attempt to include abortion agendas in maternity reform, we go off-topic and into limbo-land. We can CHOOSE to set maternity rights onto it’s own platform. The last time I took a look at the Medicare list of procedures, it was alphabetized from A-Z. Cesarean, which should have been near the top of the list, was not. It was hiding way down behind W for Women’s Health, just like hysterectomy. Cesarean section is THE most commonly performed surgical procedure in the US, and hysterectomy is #2, and, I repeat, these procedures were not even on the list. What needs to happen is a shift change away from grouping all women’s health issues behind the title Women’s Health in practice and in public discourse. Maternity choice is not about abortion. There is a relationship, but not enough of one to be able to group these two issues together.

  • invalid-0

    I don’t mean to come off as one of Tudor’s flying monkeys here, but this really isn’t applicable to the US. It has the possibility to be though. In the Netherlands they have fast access to transport to hospital, and a long history of midwives and doctors collaborating and making beautiful harmonies together. IF this type of access to transport and positive collaborative professionals were available to American women, then we’d be poised to set up a similar system here. The bad news is that the AMA and ACOG want the field to themselves, and the system needs to shift in order for the power to be placed back into the hands of women. Another concern is that the Netherlands is lacking the diverse range of ethnicities that makes America the country it is, so this study is limited in that respect; however, it is ridiculous and racist to say that homebirth should be restricted because of it. If any nay-sayers pipe up to complain about the (lack of) education of the midwifery workforce, well, how about my personal tax dollars can be spent on continuing education for DEMs so they would be qualified to work in Europe if they chose.

  • http://buy1.discountgenericshop.com/map.html invalid-0

    how’s the personal opinion could be spam?

    • invalid-0

      Here’s how…this *unlicensed* btw doctor posts the same post with the same stats every time she sees a homebirth supportive article online…she refuses to engage in true debate with statistics, but resorts to name calling to forward her agenda. Ms Block has tolerated this for a long time before taking this step, and has not removed other dissenting or partially-dissenting opinions from the comments…just this one from someone whose comments can be seen all over the www.

  • invalid-0

    What Jessica said is true. What you said is also true, as far as disabilities go, but overall, there are way more unnecessary interventions in the hospital. No body’s on the time clock at home like they are in the hospital. No one’s in a hurry to induce at home like they are in the hospital. Inductions alone increase chances of other interventions mostly epidurals & C/S’s. Check your stats. Jessica is right.
    And, while a compromised baby sometimes does need more help getting out, often they can be birthed without interventions too.

  • jennifer-block

    I just want to clarify that as a writer I am not involved in moderating these comments, and I had no part in the decision to pull Amy Tuteur’s. That said, I understand why they are being considered spam. Tuteur does post the same comments, verbatim, to any story regarding midwives or home birth. Her argument is
    simply that the researchers are wrong and that she is right. The statistics she quotes do not come from peer-reviewed, published studies; rather, she claims she’s done her own
    epidemiology, and that hers is correct, even though she’s not a researcher and hasn’t published. For more on this and the "home birth debate" in general, see my new piece on Babble.com.

  • jennifer-block

    I’d love to see more dialogue about where maternity care
    fits into the reproductive justice movement. That is the focus of
    this web site, and why I submitted the story here. I don’t
    think non-scientists "debating" the science does a service to
    the science or the women caught in the middle. (To quote a brilliant comment from over at Babble: "Who IS ‘winning’ the homebirth debate?  Probably not women or babies, since they’ve become contested spaces rather than people.")

     

    Science is an ongoing inquiry, and researchers and epidemiologists
    continue to study maternity care, and to pursue the big questions–place of birth, birth attendant, etc.–without
    the ability to randomly assign women to one or the other and achieve
    the "gold standard" Randomized Controlled Trial. Nevertheless, a great deal of information exists, a vast evidence base on which to
    determine best practices, and a large body of evidence on midwife-attended birth in non-hospital
    settings. It is my role as a journalist to report on that evidence base–that is, published, peer-reviewed study, and published, peer-reviewed critique of that study. 

     

    It is absolutely fair for non-scientists (myself included) to question research, and for personal experience to inform opinion. But, seeing as this is a public health issue, there are important questions for the community as a collective to answer. Such as, Do we have the right to tell women where,
    how, and with whom they will give birth? If we recognize that pregnant women
    have the right to determine their own healthcare (as all adults do),
    and that standard care may not serve their best interests, then does the health care system have an obligation to support their
    informed choice of an alternative? Should it be providing broader access to those alternatives? Should it be reforming standard care to reflect best practices? The science doesn’t answer these questions. We as a
    society do.

  • invalid-0

    Midwives have much, much worse rates of perinatal death and neurological injury. And that goes for nurse midwives, as well. The untrained lay midwives are far worse still.

    Stop harping on the “infant death rate”. That include deaths up to a year old. Things that have nothing to do with birth. Talk about the *Perinatal* death rate, (and standardize it for different countries if you compare).

    The truth is is that midwives are so bad that your baby won’t make it out of the womb alive. Midwives don’t know how to monitor and they adon’t call for help until its far too late. They are obsessed with preventing c-section, not helping you. Your babe will be counted as a stillbirth, not an infant death.

    US Doctors’ rates are 1/10 of midwives for stillbirth caused by failure to monitor and react to fetal distress. There’s not many left to die as infants if you go with a midwife.

    Midwives take the easiest patients and have much worse otucomes with them. Then, they act as if physician and hospital rates, which include medium and high risk patients (including the problems that midwives create through neglect), are somehow their fault.

    If you standardize for patient risk, you are no more likely to have intervention with a doctor. But, your baby is much more likely to survive and not be brain damaged.

    The only people who would benefit from having midwives and payors. Pregnant women bear the brunt.

    • hapabe

      I should probably know better than to bother replying to such a nonsensical– even provably false– comment, but I am doing so in order to say, "Really?"  Choice #1: a doctor who attaches fetal monitors* to dozens of women at a time, to be monitored largely in absentia by a team of busy nurses from a screen at a nurses’ station.  Choice #2: a homebirth midwife who stays in the same room as the laboring mother nearly the entire labor, monitoring the mother and baby periodically in a variety of ways (including by doppler, etc).   Hm.  Clearly that doctor is doing the better job of monitoring!

      Of course, the very reference to pervasive and invasive electronic monitoring belies the "fact" that "you are no more likely to have intervention with a doctor," but then, logic is hardly on "Anonymous"’s side.

       

      *Leaving aside their notorious rate of false positives. 

    • crowepps

      The truth is is that midwives are so bad that your baby won’t make it out of the womb alive.

      This hysterical exaggeration asserting that ALL midwives result in ALL babies dying during delivery pretty much guarantees that nobody is going to believe anything else in this post since just about all of us know at least one person whose healthy baby was delivered by a midwife.

       

      My daughter had one uneventful hospital delivery and one uneventful delivery by the midwife at a birthing center.  She probably could have had the baby at home and it will would have been uneventful.  She was screened as low-risk and easy delivery and very much preferred the privacy and peace of the birthing center over the crowded, assembly-line atmosphere of the hospital.

       

      Certainly the neutral sounding phrase "if you standardize for patient risk" ignores the fact that the documentation of "patient risk" is done by the exact same doctor/hospital staff with a financial interest in pressuring the patient into a costlier caesarian.

  • clydweb

    Nice piece, Jennifer. I totally agree that choice in birthing is part and parcel to choice in any other reproductive health decision. It has been my experience, however, that it is the birthing community that has been skittish in openly supporting a woman’s right to abortion. But as a doula and an abortion advocate, I fully support efforts to coalition for reproductive justice for ALL women – whether they decide to keep or terminate a pregnancy.

    Great article.

    http://www.birthingjoy.net/blog

  • sydneycove

    I’ve been a part of the homebirth "movement" for close to 9 years, since my late teens. I’ve been pro-choice regarding abortion and other non-pregnancy reproductive rights since I was old enough to have reproductive processes of my own. I’ve also got a different perspective than many of my 20-30 something contemporaries. I had my beautiful, peaceful, midwife attended home waterbirth with a midwife first, 6 years ago. I had my empowering, lonely, physically painful and cleansing clinic first trimester abortion with a physician 10 months ago. I am grateful for both experiences, however… Jennifer, I am not sure we can illuminate the reproductive rights blind spot regarding birth until women in American culture really get that they deserve more. A lot more. Reproductive rights, for many hard won historical reasons, focuses primarily on the choice for basic access to SAFE care (ie aseptic technique, appropriate training with the tools, etc). Midwifery and homebirth advocates focus on the slippery issue of QUALITY of care in addition to clinical skills. All the way to the top of Maslow’s hierarchy of needs. Very few women having an abortion in America are having a peak experience (whether they COULD be is another issue, which I am interested in). I was suprised to learn that complete anesthesia during my abortion was an option, and chosen by about 90% of the women who came to the clinic. I asked for the stats, I was curious, and I guess naive. I do believe the people in the clinic cared very much about the service they were providing for the women, they were coming from another perspective about what good service is – sterile technique, pain control and relief, clinical explanation of risks/benefits, and quick turn around. Also physical safety from protesters was a big concern, and handled really well. Many women having an out of hospital birth ARE having a peak experience, which I won’t go into here, clearly there is a whole different bio-neruo-psycho process going on there. So my wondering is, with the irritant of omnipresent ACOG and it’s agendas and now psuedo-study, and the fast approaching deadlines to "git-r-done" as they say, with health care reform, how do we make that bridge to a more global view of what constitutes womens reproductive rights on a national level? Because I believe all women having all types of reproductive experiences from menarche to menopause deserve access to quality, safe, psychologically supportive and empowering care. Let me preface my next thought by saying, I’d like to say something a little bit smartass: Couldn’t we solve this dilemma if we had some research to show that abortions with midwifery-model care had better clinical outcomes than those provided with typical physician protocol, actual clincial procedure requirements controlled for continuity? Of course, that’s just a theory I’ve come to, and doesn’t give answers, only more questions. And we know what ACOG would say to that idea. In the mean time, I continue vote with my financial contributions to both "sides" of my health care beliefs in hopes of change for the better.