Home Birth “Common Ground”?


It may be less well-known than the effort to find common ground between the pro-choice and anti-choice movements but it’s no less controversial, it seems.

The growing childbirth advocacy movement has highlighted the divide between those who would like to see expanded access to safe, state-regulated out-of-hospital birth and midwifery for women and those who oppose access to these options.

However, a new effort, nearly three years in the making, to bridge the divide is underway. According to the American College of Nurse-Midwives, a Home Birth Consensus Summit is being convened in 2011 and will bring both camps to the table in an effort to find areas of agreement with the ultimate goal of improving maternity care for pregnant, birthing and postpartum women and their babies.

In a statement about the summit, ACNM notes that the meeting will be facilitated by “the Future Search Network, a nonprofit organization that is internationally known for brokering lasting agreements and shared initiatives in highly volatile and polarized settings, around issues related to poverty, health care access, regional and ethnic conflict, and education. Future Search meetings produce a “Common Ground Agenda,” which articulates a shared vision and direction.”

It’s likely not shocking that this issue is considered “highly volatile,”  if you’re a regular reader of RH Reality Check or have ever been a part of the maternity care system as patient or provider in this country. Despite a steady stream of peer-reviewed, published, scientific studies on the safety of planned home birth and the widespread use of midwives in other countries as credible maternity care providers, mainstream medical associations like the American Medical Association (AMA) and the American College of Obstetrics and Gynecologists (ACOG) are fiercely opposed to any home birth options – licensed and regulated or not. Whereas a host of public health associations, nurses groups, nurse-midwifery organizations, certified professional midwifery advocates and even many individual MDs are working hard, daily, to pass state laws legalizing home birth and certified professional midwifery.

Progress is happening, though. ACOG recently revised its official position on hospital policies regarding the availability of VBACs (vaginal birth after cesarean section), after an immense grassroots advocacy effort by birth advocates and an agreement about the safety of VBACs from an NIH Consensus Development Conference on the issue. The issue is central to home birth access since many women interested in out-of-hospital birth desire less – or no – unnecessary medical interventions and most hospitals have banned even allowing a woman to attempt a vaginal birth, after having had a cesarean section for previous births.

The Home Birth Consensus Summit is hopefully the next step in this journey towards progress. That there is funding for it at all, is the first step in consensus building. The Transforming Birth Fund awarded a grant for the summit to an impressively diverse array of groups to convene the conference in 2011. According to ACNM, the grant proposal was spearheaded by ACNM’s Home Birth Section Chair, Saraswathi Vedam, and includes the Midwives Alliance of North American (MANA), the American College of Obstetrics and Gynecology (ACOG), the American Pediatric Association (APA), Association of Women’s Health, Obstetric and Neonatal Nurses (AWHON), Lamaze and more.

Home birth and certified professional midwifery are topics lighting some serious fires around the web, amongst not only mothers and providers, but seemingly anyone with an opinion on our health care system right now.

Hop on over to the New York Times Parenting blog, Motherlode, and you’ll find a recent post (and polarized discussions in the commenting section) on the fiery debate that’s been happening on yet another parenting site, Babble.com, over home birth access. As with abortion access, there is a contigent of those who do not want women to be allowed to access care. In this case, licensed, regulated home birth with a certified professional midwife – despite the fact that 27 states already have deemed this legal and safe. The discussion seems to devolve into whether or not women should trust doctors, whether or not women should automatically defer to hospital policies when it comes to hospital birth (ie, if the policy is to strap a fetal heartrate monitor on every woman, then it must mean it’s the right thing to do so don’t question it) , and why we can’t just put ‘newborn lives ahead of our own desire for a certain type of birth.’

But these claims seriously overlook the central issues for home birth and CPM advocates. Desiring and advocating for planned home birth options with a CPM is precisely about newborn health and the experience babies have during birth. Or, at least it is for many women. There are women, with healthy pregnancies, who desire a birth experience that is not automatically medical in nature because they know that evidence – medical evidence – points to the detriment unnecessary medical interventions may (though don’t always) impose upon a newborn’s health both in-utero and once he or she is born. As well, some women do see birthing at home, with a midwife, as an optimal birth experience – far from the bright lights and antiseptic environment some hospitals (though not all) provide. For women who wish to plan a birth at home, or at a birthing center, it’s not about a distrust of physicians so much as it is about a choice not to make it about physician-oriented care at all. Midwives are not medical doctors but they are care providers and care givers.

Motherlode writer Lisa Belkin writes,

Isn’t the obvious answer somewhere in the middle — a recognition that birth should be treated as a natural event, until it isn’t. And that it should happen in a homelike environment within a hospital, because when things go wrong they go wrong quickly?

However, finding common ground when it comes to maternity care isn’t that simple. Women in the US are more likely to die of complications resulting from pregnancy or childbirth than women in 49 other countries, including South Korea, Kuwait, and Bulgaria, yet we spend more on health care than any other country in the world, according to Cristina Finch writing on RH Reality Check. Simply creating a “homelike environment” in hospitals isn’t what will save women’s health and lives. We need to find the common ground that all women can stand on – women who desire a planned home birth, with a licensed, regulated professional midwife; women who desire to birth at a birthing center, without intrusive, unnecesseary medical interventions; and women who need the medical care provided by physicians and surgeons should their birth experience require it; finally, we need to create a common ground that respects the knowledge of both midwife and physician, the distinct models of care which both provide, and the desires and knowledge of our pregnant and birthing mothers who have a right to care which is, by state regulation and evidence-based research, deemed safe and legal. The Home Birth Consensus Summit is banking on finding that common ground, to save the health and lives of our mothers and babies.

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  • bastralbane

    You illustrate beautifully why attempts to find “common ground” so often fail… even your own language clearly demonstrates your contempt of the other side on the first issue you use as an example.  “Pro-choice and anti-choice” is a pretty good way to “other” an entire side of a debate.  Much like calling homebirth advocates “anti-doctor” or “anti-hospital”, isn’t it?  Lets hope those trying to find common ground in the birth realm don’t fall into those point-scoring, polemic traps.

  • amytuteurmd

    “As with abortion access, there is a contigent of those who do not want women to be allowed to access care.”

     

    That is a deliberate misrepresentation of the debate. I challenge you to find even a SINGLE mention of not wanting women “to be allowed to access care.”

     

    I realize that it sounds better to misrepresent the debate than to accurately characterize it. The issue is whether certified professional midwives are qualified to provide care anywhere, let alone at home.

     

    CPMs do not meet the licensing requirements of ANY first world country? How can that possible be acceptable?

     

    CPMs are HIDING their death rates. MANA (the Midwives Alliance of North America) the trade union that represents CPMs has a database of more than 18,000 outcomes of CPM attended homebirths. As you know, those outcomes have been analyzed and the death rates are known to the officials at MANA. They have publicly offered that data … but ONLY to those who can prove they will use it for the “advancement of midwifery.”

     

    Ms. Newman, you should be calling on MANA for the immediate and public release of the number of babies who have died in the care of CPMs. There is no legal, ethical or moral basis for hiding this data. Moreover, it is impossible for any woman to make an educated decision about homebirth without knowing the death statistics.

     

    If you truly care about the wellbeiing of babies and mothers (as opposed to the wellbeing of CPMs), you would publicly call on MANA to release their data. How about it, Ms. Newman? Are you ready to demonstrate your commitment by publicly calling on CPMs to stop hiding their death rates?

  • courtroom-mama

    I am very excited to hear about the home birth summit, and hope that all parties will come to the table in good faith. I’ll admit that the “Open Hearts” summit has made me a little bit leery of these events.

     

    The comment from the Motherlode blog that you referenced is a little troubling to me, because it doesn’t really see that there is a subtle difference between common ground and compromise. Surely, every birth attendant, regardless of credentials, shares a common goal of “healthy mother, healthy baby,” but the idea that this should lead to a compromise for any individual woman rubs me very wrong. Finding a workable solution is not about taking what a woman wants, and what others think she needs, and coming out somewhere in the muddy middle. Just as adoption isn’t an appropriate solution for a woman who does not want to be pregnant, niether is a “home-like” hospital or birth center appropriate for a woman who wants to give birth in her actual home.

     

    A search for common ground must necessarily be a conversation about how we can meet the demand for home birth services in the safest possible way. Simply ignoring the demand is irresponsible, and restricting access calls into serious question whether we consider pregnant women to be autonomous, rights-bearing agents. Neither should be on the table.

  • julie-watkins

    see here:

    http://www.rhrealitycheck.org/blog/2010/09/10/californias-forprofit-hospitals-pushing-csections#comment-50168

    I asked you before to comment on “two times a small number is still a small number!” That hasn’t changed.

    That is a deliberate misrepresentation of the debate. I challenge you to find even a SINGLE mention of not wanting women “to be allowed to access care.”

     

    … Ms. Newman, you should be calling on MANA for the immediate and public release of the number of babies who have died in the care of CPMs.

    If someting happens infrienquently, doubling the risk means it might happen 2 in 100 times instead of 1 in 100 times. You’re so hungup on homebirths that you refuse to discuss why women feel they “have” to home birth. It is an “issue of access” if hospital prices are unaffordable.

    So now I get to point this out again: If, ballpark, a normal hospital birth is $XXXX K — or and if a homebirth midwife is $X K (1/4th or less) and if $15 K will risk lossing your home & $40K will make homelessness a certainty, then it’s logical for a pregnant woman to plan for a homebirth. IE, if the risk of bad complication is 1% (& I think it’s less than that) & the risk of becoming homless is 20%-100% (ie: 1 in 100 vs. 1 in 5 or 1 in 1 (for certain)), attempted homebirth is logical.

    Talking about “access” within this reality is not a lie.

  • jillunnecesarean

     

    “For women who wish to plan a birth at home, or at a birthing center, it’s not about a distrust of physicians so much as it is about a choice not to make it about physician-oriented care at all.” 

     

    A wane in trust in the patient-physician relationship (and at a societal level) has been explored and documented for decades, much of it attributed to a veil being lifted about the heavy-handed (over)marketing of the efficacy of physicians in the last century, the “consumer” movement in general and patient awareness that there are many factors that motivate treatment decisions and this can foster a sense of suspicion and distrust. Oddly, I was just reading a 1996 JAMA article about managed care that discussed how awareness of gatekeeping and incentives bred animosity and frustration.

     

    It is logical to assume that if a patient realizes that there are other forces driving “medical” decision making, they might look elsewhere for care in any specialty. I think you’re onto something, Amie, with your assessment that much of this has to do with realization that women are leaving physician-oriented pregnancy care for very rational, empirical reasons, much like when a patient is recommended the most aggressive treatment available in another scenario, such as back surgery, and decides that they would rather see how their body heals with physical therapy. Fortunately for patients, most physicians don’t seem to incur a narcissistic injury from this phenomenon and build an identity around it. In fact, most doctors that I talk to say about the same thing about home birth—it’s a woman’s right to do it, it scares me that someone would place distance between themselves and an operating theater, don’t do anything stupid and please don’t hold me responsible if you come in bleeding to death. Other than that, I don’t think most really pay it much mind, as it applies to such a tiny piece of the population.

     

    I look forward to the Home Birth Consensus Summit you mentioned. I had never heard of it until today.

     

  • amie-newman

    “That is a deliberate misrepresentation of the debate. I challenge you to find even a SINGLE mention of not wanting women “to be allowed to access care.”

    Dr. Tuteur, as I mentioned in the article about the Home Birth Safety Act in Illinois, and as I have known many women who did not wish to birth in a hospital, with an Oby-Gyn (though I myself birthed my children in a birthing center set within a hospital), there are women who will NOT have access to care when regulated, licensed midwifery and planned home birth are not options in their state. When certain factions block access to care that women are asking for – and which 27 states thus far have deemed safe and legal – then it seems clear  that you do not want women to be allowed to access care in certain circumstances.

    As for your death rate claims, I think it’s clear that regardless of what I say you’ll keep reiterating your statistics though there is consistent medical evidence which is not on your side when it comes to the safety of planned home birth with a licensed, regulated CPM. I would say you should focus your energy on getting the laws repealed in the 27 states which disagree with you, if this is how you feel.

    To be clear, I think there is common ground to be found here. For women with a healthy pregnancy, who wish to birth out-of-hospital, with a licensed, regulated midwife (who has strong ties to a hospital should a transfer be needed) we should ensure that there is safe, legal access. As it is in other developed nations. I think it’s critical though that we work together to make sure all women have access to the safe, regulated, high quality maternity care of their choosing – at home, in a hospital or in a birthing center. If we accepted that there will always be women, even a small percentage of women, who wish to birth out-of-hospital, with a midwife, we’d then be able to focus our efforts on the best, most collaborative care possible.

  • amie-newman

    I hadn’t read your comment before I posted mine to Dr. Tuteur. However, I believe you and I are both saying similar things. Starting with what women want when it comes to maternity care will lead us towards optimal care. Ignoring the demand, as you write, is irresponsible – as it is with any type of womens’ health care. Thanks for your eloquence!

  • amie-newman

    as usual you are articulating what I’m thinking in regards to this issue. This is about trusting women – as it is with any type of health care. We mus trust that women have the safety of their newborns and themselves in mind but that some women wish to birth out-of-hospital, some at home, some in a hospital, with different providers, as long as it’s safe, high-quality care. Many women are NOT getting that now but that doesn’t mean we shut off options. It means we listen to women, and we respond to women’s requests and demands. Thanks for the comment!

  • amie-newman

    I appreciate you taking the time to provide the information you did. It’s something Robin Marty wrote about on this site more than once. This is undoubtedly, for some women, about access to affordable care. I have heard from MORE than one midwife I know that some women who plan a homebirth tell the midwife they are terrified of the prospect of being transferred to a hospital solely because they just cannot afford it, with or without insurance.

    As well, it is clear that Dr. Tuteur wants nothing to do with common ground or collaboration. When we license and regulate CPMs we make planned home birth safer for women and we expand access to high-quality care.

  • amytuteurmd

    Ms. Newman, I asked you a very simple question and you are trying to duck it. Let me rephrase it to make it even simpler:

     

    MANA knows how many of the 18,000 babies in their database died at the hands of homebirth midwives. Don’t American women DESERVE to know what MANA knows?

     

    A simple yes or no will suffice.

  • amie-newman

    criminalize access to care are not against allowing women to choose a safe, legal procedure? Someone who considers themselves “pro-life” is not someone who advocates for making abortion illegal; it’s someone who understands that, as a society, we must weigh both the potential life of a fetus and the life of a woman. So I don’t call anyone who is anti-choice the absurd term “pro-life.” That’s why we have Roe v. Wade as the law of the land in this regard. Those who are AGAINST safe, legal abortion access are, by definition, “anti”-choosing abortion, no? As someone who advocates to ensure that women retain our constitutional right to decide for ourselves what happens to our own bodies, and the embryo or fetus growing inside, I am pro-allowing a woman to make a safe, legal decision on her own. There are certainly those who consider themselves “pro-life” who are against abortion but do not advocate making it illegal because they understand that this is how we ensure the death of millions of women globally, when accessing unsafe abortion care or not being allowed to access an abortion when a woman’s life is in danger. I do not consider these people anti-choice because while they may not choose abortion as an option for themselves, they are not opposed to safe, legal abortion access for others. 

  • meghan

    Amie, one thing that I think Dr Tuteur consistently misses is that physician-dominated pregnancy and birth care are utterly inappropriate as a model.  Outcomes in countries with regulated midwifery-managed pregnancy and birth, including home birth, are equal to or superior than ours, and, incidentally, less costly.  OB/GYNs are surgeons who train in pathologic pregnancy and gynecology, and you know what they say about “when you have a hammer..”

     

    Midwives are experts in normal pregnancy and birth.  We train with the assumption of normal, and the ability to identify when things veer from the scope of our practice. Physicians train with the assumption of disease and abnormality.  It’s a completely different perspective. We don’t want to be physicians. We don’t want to practice within the scope that physicians define as appropriate for us.  What Dr Tuteur fears is a loss of the medical hegemony around birth and, by extension, around women. 

     

    This is not universal. I’ve had the great pleasure of working with some amazing OBs (including, I suspect, in the birth center you mentioned) who understood that for normal pregnancy and birth, their role is one of watchful waiting.  When I was in midwifery school, my preceptor told me, “When you feel like doing something, sit on your hands for awhile, and see what happens.” OBs are trained to intervene, to rescue, to save, even in situations that don’t need salvation.

     

    The single most valuable thing I ever learned as a nurse, as a CNM, as a woman who has experienced two high-risk, high-intervention pregnancies and c-sections, is to question everything, and that in the end, you have power. You can withdraw your consent at any time.  You cannot be turfed in labor.  Your care providers have the responsibility to explain to you why they feel an intervention is appropriate, and to keep explaining until you understand.  You have the right, in the end, to make choices about your health care.

     

    Banning home birth drives it underground. I live now in a state without licensed direct-entry midwives, and am regularly appalled at some of the situations that creates. Women will have home births, just as we will have abortions.  Making them back-alley doesn’t do anyone any favors — including the OBs who may have to deal with the fallout from inappropriate home birth care, inexperienced providers and sheer bad luck.  Banning home birth doesn’t save babies or women. It creates a shadow system of care that falls apart when transfer is needed, or when complications arise.

     

    I believe in home birth. I believe in midwifery. I believe in our ability to birth our babies. I also believe  that without OBs, my children would not be alive.  I’m the anomaly. Not the home births that are successful.

  • gina-crosleycorcoran

    Banning or restricting access to ANY reproductive health choice does NOT stop women from choosing it – it simply makes it more likely to be lethally dangerous.  From back alley abortions to unnassisted homebirths for high-risk women, telling these women they’re “on their own” doesn’t prevent them from doing exactly what they feel they have to do, even if it’s taking a huge risk.  Why wouldn’t ANY provider who actually gives a crap about women want to HELP keep them safer, rather than washing their hands of them?  I thought providers took an oath to help people?  Putting their business ahead of reproductive choices isn’t keeping anybody safer, and the science proves that.  Shame on them for ignoring the vast body of evidence from their own collegues.

  • crowepps

    It’s been pretty well established that it isn’t possible to provide enough information to conspiracy theorists to satisfy them.

     

    Perhaps you’d like to provide American women with the fatality statistics for how many babies “died at the hands of” obstetricians and hospitals.  I believe in 2005 it was over 28,000, wasn’t it?  Golly, if we twist the statistics into pretzels so we can sound alarmists we can declare that more babies died “at the hands of” obstetricians than the total midwives safely delivered!  But of course, that would be a ridiculous distortion, wouldn’t it?

  • amie-newman

    As anyone who has been privvy to your volumes of comments on any and every web site related to this issue knows, you are consumed with the MANA information and your propagandistic, “how many babies…died at the hands of homebirth midwives” really does nothing to make one assume you’re interested in dialogue here.

    I realize you are consumed with self-reported data from MANA but we HAVE numerous studies here in the U.S., in Canada, in Britain and elsewhere to confirm that there are comparable neonatal death rates betweeen planned homebirth and hospital births but you choose to ignore those or explain away the statistics.

    American women are given access to MANA, as well. You can request the information on their web site:

    http://mana.org/statform.html

    Clearly, they are not “hiding” this information.

     

    When a woman visits a licensed, regulated Certified Professional Midwife she has the right – and SHOULD – request information on the midwife and the practice. What is the protocol for emergency situations? Does she work with an ob-gyn to facilitate hospital transfers if necessary? Look at her resume. Ask for references. Check with your state’s midwifery organization to ensure your midwife is credentialed. Then check with your state’s Department of Health and you can see if there are disciplinary actions filed against your midwife. Report after report has detailed the statistics and information collected by state governments on planned homebirth and CPMs. You can read the Washington State Midwifery Cost Study, if you’re in WA state or you can check out, for example, a Washington state study by the Department of Social and Health Services on the safety of planned homebirth.

    I 100% believe that women deserve the right to know how safe planned homebirth is with a Certified Professional Midwife. I also 100% believe that we have that information currently. It’s why 27 states allow for planned homebirth with a CPM. It’s why, for example, in Washington State, CPMs are covered under Medicaid to ensure even greater access to this type of care.

  • jillunnecesarean

    Meghan: “one thing that I think Dr Tuteur consistently misses is that physician-dominated pregnancy and birth care are utterly inappropriate as a model.”

     

    But this isn’t a fair assumption to begin with. Most women find it very appropriate, whether because they have a medical condition that requires a higher level care in pregnancy/birth or because it feels safer to them. Why try to deny their reality? We’re on RHRC… shouldn’t we be respecting and trusting the decisions that other women make?

     

     

  • jillunnecesarean

    I think all maternity care data should be readily accessible to consumers and the general public. Most states (can give and exact number later) only allow qualified researchers to access maternity care data, such as hospital-level cesarean rates. I’d like to see a day when all birth data is on the table.

  • amytuteurmd

    “I also 100% believe that we have that information currently.”

     

    You believe that we know the number of babies who died at the hands of CPMs in the 18,000 case MANA database?

     

    Well, if you know the number, don’t keep us in suspense! Exactly how many babies died at those 18,000 CPM homebirths?

     

    Or … will you simply acknowledge the obvious: we don’t have that information, MANA is hiding it, and you think it’s just fine for MANA to hide their own death rates from American women if those death rates are appallingly high.

  • mrsculpeppergmailcom

    Regarding access to care, it goes both ways. Under the current system some women will choose homebirth in part for financial reasons while others will choose hospital or birth center birth in part for the same financial reasons. Opening up each and every choice (home, hospital or birth center) to each and every woman regardless of her financial situation by requiring insurance (including medicaid which pays for 37% of US births according to Anderson et al. in Changing the US Health Care System: Key Issues in Health Services Policy) to allow women to feasably make choices without significant finacial restraints.

    Hospital birth generally uses every available intervention whether necessary or not. Quite often the use of technology and intervention is standard even when it is clearly shown to be of little benefit such as the use of <a href=”http://findarticles.com/p/articles/mi_m0689/is_6_52/ai_104079668/”>electronic fetal monitoring</a> for low-risk mothers or the routine use of <a href=”http://www.ahrq.gov/downloads/pub/evidence/pdf/episiotomy/episob.pdf”>episiotomy</a> yet we rarely discuss limiting access to hospitals and interventions.

    Perhaps encouraging limits on technology where not needed or wanted would make a difference. If insurance companies pay less for typical hospital births then maybe they would see fit to quit making women pay out-of-pocket for homebirth.

    Reducing the cesarean rate, increasing breastfeeding rates, reducing reliance on highly trained and highly paid sugeons for normal birth….these are three key areas that would reduce costs for hospital birth.

     

  • julie-watkins

    when I asked AmyTuteurMD about relative risks the first time. It bugs me that she uses such scare words and “it’s more risk” as if the decision should be a no-brainer, not taking into consideration the difference between absolute and relative numbers.

    My “information”, such as it is, is ball-park, order of magnitude numbers, based on what I can remember of what Robin & others have written here. I think they’re reasonable ballparks. What I don’t ever remember seeing from AmyTuteurMD is a order-of-magnitude comparision between the what relative “higher” risk she is claiming between hospital and home births verses the relative prices of home & hospital vaginal & cesearean births.

    Thanks for reporting on the Summit. I hope the AMA stops resisting.

  • crowepps

    When a woman visits a licensed, regulated Certified Professional Midwife she has the right – and SHOULD – request information on the midwife and the practice. What is the protocol for emergency situations? Does she work with an ob-gyn to facilitate hospital transfers if necessary? Look at her resume. Ask for references. Check with your state’s midwifery organization to ensure your midwife is credentialed. Then check with your state’s Department of Health and you can see if there are disciplinary actions filed against your midwife.

    I don’t think I know of any woman who requests ALL this information and does ALL this doublechecking on her OB/GYN.  Most women make their decision based on recommendations from friends.  I agree that seeking out all this information is a great idea, but it is an equally good idea to complete due diligence and check out ALL ones medical professionals.  Certain a request for protocols, references and a check on willingness to cooperate with others will get you labeled unwelcome and sent right out the door at clinics where the staff are controlling, paternalistic and arrogant, which can help winnow down the choices effectively!

  • crowepps

    At what point did being pregnant become ‘illness’ and who promoted that model?  If there is constant propaganda about how pregnancy and birth are unsafe for everybody and it’s ‘selfish’ of women to deliver at home even when their risk factors are minimal and those women ‘don’t really care about their babies’ because they’re not willing to go into debt then their choice of physician centered care may be a decision that they are manipulated into so that somebody else can make a buck.

     

    It seems to me that respect would dictate that people be given all the factual information established in actual reality in as neutral a manner as possible, then we should trust them to make up their own minds and respect their decisions.  No guilt tripping them for choosing differently than we would ourselves or proselytizing our beliefs to them or inflicting our conspiracy theories and issues on them.

     

    I find it really interesting that people get on here and bleat about how pregnancy never really risks a woman’s life and it’s better to wait around with fingers crossed in the face of horrible complications because that’s the ‘natural way’ and then reverse themselves and insist that women shouldn’t be allowed to have a natural birth at home because they’re resisting unnatural procedures like induction and caesarian and their significant downsides.

     

    You begin to get the idea that the problem isn’t what’s going on at all but instead an almost atavistic horror at the idea that women, both mothers and midwives, are independently DECIDING things instead of being told what to do.  How can anybody TRUST them when there’s no man around to supervise?  My guess is that if those midwives were male, there wouldn’t be anywhere near as much resistance.

  • meghan

    Jill:

     

    It’s considered appropriate because we’ve made it so. Midwifery care is the norm for low-risk women in most other countries.  The US pathologizes birth and pregnancy to such an extent that women are told the correct caregiver in pregnancy is not a midwife, who is an expert in normal pregnancy and birth, but an obstetrician, whose training focuses on the pathologies of pregnancy and birth.  Addressing the issues of birth in the US without addressing who attends birth is futile.  Bluntly put: obstetrical training in the US does not adequately prepare its graduates for unmedicated or physiologic birth.  That makes OBs inappropriate first-line providers for low-risk women.

  • arekushieru

    But, when you put it that way, no obstetrician would be able to meet that criteria.  It should read:  Addressing the issues of birth in the US without addressing what the necessary requirements are to address those issues during birth is futile.

    Besides, I’ve found the general trend to be the pathologizing of women who choose to receive pregnancy care and give birth at a hospital instead of at home.  For centuries, at least, it has been that way.  

    And, I believe, whatever misinformation has been spread about home-births, has been an *indirect* result of an exponential growth in the gap between societal haves and have-nots.

    Anyways, I am about to say something that might make me unpopular, here, but, I believe, that except for the homospecial (if that’s even a word) aspect, gestation WOULD be considered an illness.  And, isn’t pregnancy’s lack of status as an illness, the reason that anti-choicers give for their opposition to abortion? 

  • arekushieru

    Jill, it seems a few commenters, here, haven’t been able to read your screen name, in full.  Unnecesarean seems to indicate that you are an advocate for what the topic of the article is actually about, after all.

  • arekushieru

    And/or we must trust that women have their safety in mind? 

  • jillunnecesarean

    Meghan, it’s not my personal preference (I, too, found it to be overkill), but I think that the majority of women want to give birth in an environment in which they have access to epidural anesthesia, which obviously doesn’t preclude midwifery care. Is the assumption that low-risk women want “unmedicated or physiologic” birth in significant numbers accurate? I’m thinking it’s not. My point is that it’s not necessarily the long-term historical marketing of the OB-as-the-perfect-provider, one-size-fits-all plan that drives consumer demand for hospital birth, but other factors like access to epidurals, social acceptability, covered by Medicaid, no knowledge of any other option (if the option even exists in their state), and so forth.

     

    My concern, like yours, is that women who do want midwifery care or just a vaginal birth are finding that their options to do so in hospitals disappearing as cesarean rates climb. Courtroom Mama’s call to focus on “consider[ing] pregnant women to be autonomous, rights-bearing agents” as our common ground means (to me) that women can be trusted to make decisions about their personal health care, whether they prefer a heavily medical environment or their own home with a midwife (or the “muddy middle,” as CM called it). Is that too fluffy? Simplistic? 

  • crowepps

    Unfortunately, women sometimes don’t get to individualize their health care decisions – if they choose a birthing center they are cut off from some technology they might want and if they choose hospital birth because they want an epidural they commit to “hospital policy” which may forbid VBAC or include judgmental staff who conduct a secret blood test for drugs and call social services their ‘suspicions’.

     

    The problem as I see it is that the meme of child birth is woman versus fetus, with ProLife ideologists envisioning their role as providing medical care to the fetus in spite of the woman’s “selfish” desires to control the birth experience.  Before women will have the right to make personal care decisions, some providers will need to be retrained in the fact that the woman is the patient and she gets to have control over decisions for both herself and the fetus.

  • amadi

    I think that the majority of women want to give birth in an environment in which they have access to epidural anesthesia, which obviously doesn’t preclude midwifery care. Is the assumption that low-risk women want “unmedicated or physiologic” birth in significant numbers accurate?

    But why is that the case? Is it because women have been inculturated (TV, movies, the “my pregnancy/labor was so awful” stories women inexplicably delight in telling their newly pregnant friends) to believe that pregnancy and childbirth, especially childbirth, are fraught with danger and drama, ugly, frightening and unbearably painful? Is it because women are told by everyone that the “most important thing” is a “healthy baby” while the real risks of epidurals (and the realities of the cascade of interventions and risks of everything that all too often follows those epidurals) are underplayed?

     

    That might be “reality” but it’s not one that we need to accept as an unchangeable status quo. It’s nothing more than a starting point.

  • leslie-battles

    Obviously mid wifes meet the licensing requirements of many states.Are you worried that mid wifes will take business away from you and other doctors.Woman have had babies at home for millions of years and yes babies die at hospitals and at home.What is the percentage of babies who are borne at hospitals die in hospitals?Why doesn’t  the AMA release that info?The AMA comes across as a bunch of greedy pigs

  • arekushieru

    Um, I think you have that entire first paragraph, completely backwards.  >.>  <.<

  • fuzzy

    Twice a small number may well be a small number—until it is YOUR infant that is dead at birth and you realize that it may well have died of something preventable.

     

    This is the same contingent that RF their children until they are 8 in a carseat, because of some nebulous connection between FF and injury, and yet blithely ignores the very real risks of homebirthing.  As someone who would have been a homebirth tragedy had I bought the woo, I think that it is grossly irresponsible to present homebirthing as a safe option.  I had a perfectly normal pregnancy and uneventful early labour.  However, since I was in a military hospital, the corpsman had a shiny new gadget—this was 29 years ago!—and asked my permission to try out his external fetal monitor.  No pit.  No pain meds.  Labour wasn’t particularly bad….when we discoved late decels and FHT of 45.  Onwards to crash high-forceps delivery:  there was no-one qualified to give anesthesia for a section.

     

    I have a healthy adult daughter at this point with near-genius IQ.  Trust birth?  Oh hell no……  Safe?  Look at the 3rd world statistics, or ask why the women in countries where homebirthing is common are pleading for hospitals.

  • meghan

    When the larger culture’s assumption is that you’re going to have an epidural and see a physician, that’s what many women want. When to step outside that requires a rejection of the entire birth norm of our culture, that’s difficult.  The medical model does not improve outcomes — in fact, can worsen them. If physiologic (aka, best practices) birth, which neither precludes an epidural nor appropriate interventions, is to become the norm — which it needs to if outcomes are to improve — then midwifery is the model that needs to happen.  Continuing physician-dominated birth in the absence of evidence that that’s a safer model is damaging. It’s not about “birth preferences”; it’s about what’s safer for mothers and babies. Post-dates inductions at 40w0d?  Not safer. Routine amniotomy? Not safer.  Routine epidural use? Not safer. We don’t do women any favors by offering substandard care and presenting it as the norm, or as best practice.

  • meghan

    Comparing birth stats in the developing world with home birth safety in countries with established backup care and advanced hospitals available is like comparing riding in a car with no seatbelts in those same countries with riding in a car with advanced safety features. While one’s child’s birth is always clear in your mind, the data supports home birth safety for low-risk women.  Bad outcomes happen in hospitals too — some of them iatrogenic.  I’ve seen them.

  • meghan

    Also, I think it’s important to remember that for low-risk women, EFM doesn’t improve outcomes. I can’t tell you how many stat or crash sections I’ve seen that have resulted in a baby who is perfectly pink and crying, with good blood gases. High forceps, on the other hand, are known to be associated with peripartum complications, so I would count yourself more lucky that your daughter — and you — didn’t have one of the iatrogenic bad outcomes I spoke of earlier.

  • amytuteurmd

    MANA knows how many babies died among the 18,000 CPM attended births. They just don’t want you to know. Apparently, Ms. Newman thinks that’s dandy.

    Ms. Newman claims that American women have all the information they need. They shouldn’t trouble their pretty little heads over the dead babies MANA is trying to hide.

    Is that the impression you want to leave us with, Ms. Newman, that American women DON’T need to know how many babies die at homebirth? That they wouldn’t benefit from finding out the truth?

  • meghan

    Considering that there have been several high-quality studies done of planned home birth in places where it is both legal and regulated, that data seems less useful, though you do like to shake it around like a chow dog.  Is the entire Dutch obstetric community hiding its research as well?  Did Mona Lydon-Rochelle falsify her data?  Here’s a tip:  You’re wrong. It’s okay; it happens to everyone. But fear-mongering and shoddy lit reviews?  Not helpful to evaluating best practices.

  • amytuteurmd

    “that data seems less useful”

     

    How dare you suggest that grown women should not be allowed to know exactly how many babies died at the hands of CPMs? How dare you substitute your judgment on what is “useful” for the judgment of women themselves?

     

    Stop pretending! We all know that those statistics are being hidden because they show that an appalling number of babies died at homebirths with CPMs. Otherwise MANA would have published them and sent out a thousand press releases to boot.

     

    I simply cannot fathom how a site that exists to support reproductive rights can produce a blogger and commentors that think that women have no right to accurate information about the death toll of homebirth.

  • amie-newman

    If you need the MANA statistics so fervently, please work with your state legislators and figure out a way to make it happen. Please, please, please stop commenting on blogs and link yourself up with SOME organization already. If you are so obsessed and concerned why are you at home writing endless blog posts and not connected to an organization that can help you?

    Do I think women should have access to statistics from MANA? Yes. It’s important that we have all of the information about how safe planned homebirth with a CPM is. But it’s not the only information out there and women ALREADY have access to the peer reviewed, scientific studies the world over that shows the safety of planned homebirth with a CPM for healthy women.

    Do I think that 27 STATES would not have legalized and agreed to regulate and license CPMs and legalize planned homebirth without sufficient data? No.

    Do I think that state Departments of Health would not allow CPMs to be covered under Medicaid, in some states, without assurance that they are practicing safely as well? No.

    Do I think that – if you were so concerned with maternal and newborn health you’d actually figure out a way to address how to improve our maternity care system (meaning HOSPITAL and Ob-Gyn care) for all women instead of focusing myopically on blocking safe access to care, according to half of the state’s in our country, for a small percentage of women?  Yes.

    Please feel free to continue posting endless comments about MANA’s statistics here. It’s  honestly not what this discussion is about and as hard as you try and derail it, it’s not actually happening.

    If we want to improve maternity care in this country, address issues like our rocketing c-section rates – rates much higher than is deemed safe by the WHO, completely unacceptable health disparities where African American women are four times as likely to die from pregnancy and childbirth than Caucasian women, a system where unnecessary medical interventions are endangering the health and lives of our mothers and newborns, and an unaffordable system of care, we need to work together to make that happen. I’d love to see us focus on those issues, and allow a small percentage of women who wish to plan out-of-hospital births with a licensed, regulated CPM, have access to safe care and move on.

  • amytuteurmd

    “Please, please, please stop commenting on blog”

     

    I know. It way too hard for you and others to come up with credible responses, so it would be so much easier if I didn’t keep presenting evidence that blows your claims to smithereens.

     

    But I am going to take your advice anyway and retire to my own blog:

     

    http://skepticalob.blogspot.com/2011/01/amie-newman-thinks-its-okay-to-hide.html

     

    Feel free to comment. Of course, my comment system doesn’t hide people who are so impolite as to speak the truth, so you might end up reading something that contradicts what you believe.

  • catseye71352

    I am forcibly reminded of one GYN who _insisted_ I take HRT when I hit menopause even though she KNEW I had had issues with the Pill when I was younger.

  • meghan

    ” if I didn’t keep presenting evidence that blows your claims to smithereens.”

     

    Tuteur:

    When you do such a thing, I’ll be happy to read it. As it is, you prattle on incessantly, arguing the same points over and over, regardless of how relevant they may (not) be to a real discussion.  The bottom line is the same: You aren’t doing anything to improve maternal health in the US.  You’re blogging, and frankly, your blog posts are the internet equivalent of self-congratulatory wanking. You’re not in practice. You’re not involved in any useful way with policy setting. People in the birth community — including your peers — don’t consider you an authority. You don’t do research. You don’t publish. You don’t do peer reviews. Yet you consider yourself an expert, and all of us who differ with you mere peons.

    So, what’s the sound of one hand clapping again?

  • meghan

    How is gestation any more an illness than, say, digestion, or breathing?  In both cases, things can go wrong, and interventions can be needed — but in the majority of cases, they aren’t needed.

  • fuzzy

    Ask the L&D nurses what they think of homebirth transfer.  There simply isn’t always time to transfer….seconds are brain cells and while functioning grey matter may not be necessary for a decent Apgar, they sure are needful a bit later in life.  Data supports the trauma to an infant brain from prolonged pushing, and the data in no way supports the safety of home birth for low-risk women:  3 times as deadly as hospital birth for a lower risk group?  If that is your idea of safe, I wonder that you don’t happily go out and eat mercury.

     

    Again, the numbers that you quote are not accurate….and, to borrow someone else’s analogy, if the plane doesn’t land safely, no one cares about the stewardess. 

  • fuzzy

    Agreed, the high forceps was risky—but I had nixed the opportunity for an epidural earlier, and this being an out of the way military hospital, the one and only available anesthesiologist was tied up elsewhere—in, I do believe, an emergency app’y…

     

    The crash sections with a pink and healthy infant—-would you rather that the kid be blue and limp?  The purpose of a crash section is to get the kid out BEFORE it turns blue and limp.  EFM indicates a problem, not a disaster.  Trust me, with a 3x nuchal cord too short to allow her head to engage, it would’ve been a disaster.  I’m just as glad for a OB who was trained to assist in out of the way places, and therefore had knowledge of alternatives and was able to help.  A dead baby or one brain-damaged would certainly have been a bad outcome, no?

  • arekushieru

    That’s not the assumption I see as representative of the larger culture.  By and large women DO choose physician-assisted hospital births.  However, I believe it’s not a representation of said larger culture, but, rather, a representation of society, something completely different.  The larger culture actually exPECTs women to give birth in relative anonymity and isolation based on the fundamentals of the patriarchal paradigm, as it is.

    I don’t think the question is about what is safer.  The question is about what do women *choose*, what risks are they willing/unwilling to take, given the necessary information that they require and request.   After all, if a woman chooses to give birth, even in the event it would likely result in her death, as a ProChoice woman, I completely support that choice.

  • crowepps

    The stillbirth rate in this country is way too high, but there isn’t any evidence AT ALL in most cases that those deaths were caused by “something preventable” arising out of the woman making bad choices.

     

    There is NOTHING that will prevent all stillbirths.  NOTHING.  If all the births are at home, if all the births are in the hospital, if all the births are ceasarean, there are STILL going to be stillbirths, because some fetuses are not viable, just as there are always going to be malformations and resulting disabilities.

     

    Trying to win an argument by guilt tripping women with accusations that allowing them to make their own choices will increase the likelihood their baby will die is totally irresponsible and part of the current meme : ignorant willful woman ENDANGERING helpless baby whom medical staff are there to RESCUE from ‘evil Mom’.  Any theoretical increase in safety for baby which might result from forcing passive women to OBEY the (expensive) whims of medical staff will be far outbalanced by the safety risks that arise from medical staff being contemptuous of women.

  • arekushieru

    Because you are confusing two things altogether… that shouldn’t be.  I am talking about the process, you are talking about the effect.  If we were able to exchange something other than oxygen and carbon dioxide, as well as the latter, through our lungs, in order to function, it would still be called breathing.  If something outside of our species were able to attach to a human female’s uterus, as well as that of our species, and use it to function, the former would be called a parasite, something that causes an illness, not gestation. 

    Besides, I never said it WAS an illness.  Like the death penalty, pregnancy has a very fine line in which it can be called something else.  In the case of the death penalty, it keeps it from being called murder.  In the case of pregnancy it keeps it from being called an illness.

  • crowepps

    I think I was the one who originally brought up that pregnancy isn’t an illness, and I did so in reference to the insistence I was seeing that childbirth should be PRESUMED to be an emergent medical emergency requiring the intervention of technology and drugs overseen by a highly trained doctor and staff, and the patient who is going through the process should just do what she’s told.

     

    If you think about it, shifting to the meme that the pregnancy is that of the fetus and the childbirth process is all about the health of the fetus because the patient is the fetus, then the woman involved is just a wrapper.

     

    ‘We can all just be thankful her ability to make selfish choices during the pregnancy didn’t do TOO much damage to the precious infant.  Let’s investigate to see if she is worthy to take it home when there are wonderful couples out there willing and able to pay big bucks for healthy infants’.

     

    Nobody expects wrappers to have an opinion or make decisions, or for that matter that anybody will care much if the wrappers are damaged or thrown away.

  • arekushieru

    And you explained your position very well, in this comment, and a less recent one.  Completely agree, crowepps!

  • veronica-h

    There are also women, like me, who are frightened to return to the hospital because of the way we were treated. The first and only time I gave birth (so far) was such a confusing and scary time for me. I ended up going to the hospital like everyone tells you is the “right thing to do” because “everyone does it” and “nothing will go wrong.” In my case, I felt I was shuffled through the system. They made my decisions for me. They didn’t give me the opportunity to ask questions. They didn’t tell me what options were available. I had a perfect pregnancy with NO complications. Both my baby and I were healthy. But they gave me pitocin to “speed things up.” I had labored on my own at home to 6 CM but they still gave me pit??? I can still feel the spot in my back where they put the epidural (at the time I was given no other option for pain treatment and knowing better now I am appalled!) And, although my daughter was fine and my labor was progressing well, and quickly, they inserted a monitor just under the skin of her scalp, breaching her last line of defence, her skin, without my knowledge – because it was easier. As I sat there holding my baby for the few seconds before they demanded to take her from me…

     

    I felt used. I felt like the precious bond with my daughter would be broken. I was scared. And the hospital atmosphere did nothing to make me feel any better. Then, I realized I couldn’t move my legs due to the epidural. That was the pinacle of my fear. I could not even get out of the bed to go get my daughter. Now here I am planning for the next baby (even though I’m not pregnant yet) frightened to death that this will happen again. And what are my options? Do hospitals offer women the opportunity to make their own choices? NO! Those that do aren’t readily available to the majority of birthing women. So, after reading all this, including the comments, I felt I had to say something. I have to speak up for women like me who have been silenced by the hospital system and OB/GYN’s with closed minds who get stuck on one point, like Dr. Tuteur. Women have been giving birth at home for as long as there have been women. Face the facts that women should have the choice to have their birth as they please. No one should fear birth, the coming of their precious baby. I don’t have all the facts. I can’t quote anyone but myself. But I know that keeping women from birthing at home in their own peaceful environment, fearmongering… that’s what you’re really doing, Dr. Tuteur… serves no purpose. Thank you, to all those who have the voice and words that I can’t seem to find. And thank you for fighting for my rights. It feels good to tell my story. Now let’s change it for my daughter. <3

  • crowepps

    The birth of my son happened in a ‘production line’ OB unit and I remember well the feeling that I was on an assembly line being hustled through, especially the disgust and fury with which one nurse was filled because another staff person had failed to prep me for delivery to her satisfaction.  That was almost 40 years ago and I still cringe when I remember — her rage really terrified me.

  • crowepps

    Judging by the responses to this post, the Home Birth Consensus Summit needs to beware of letting people from the ideological extremes waste everybody’s time while they make themselves the center of attention by insisting that nobody gets to do anything unless they PERSONALLY are convinced it’s okay.

     

    Maybe that should be a standard strategy in common ground discussions — just as a for instance, if as a recent poll showed 94% of parents aren’t worried by their teenagers carrying condoms, and 82% of the Catholic laity thinks condoms are okay, and it’s obvious to even the most challenged that there’s no way condoms can ’cause abortions’, it doesn’t make a whole lot of sense to designate huge amounts of the speaking time at common ground discussions of birth control to people railing against condoms.  The mass acceptance of condoms ought to be part of the base on which the conference is established, with the fringe groups given no more than 10% of the available time.

     

    Common ground discussions will never work when they are attempts to persuade ideologues to shift their extreme positions, because the ideologues hold their positions to support other aims.  Common ground has to start with a recognition that NORMAL behavior is established by the way the majority of people are actually acting.  Laws that try to change the current behaviors of MOST people so that they instead act in the way that small minorities would prefer that they should are doomed to be disobeyed.

     

    The recent common ground discussion hosted by the Catholic college, for instance, ended up being about “should people be allowed to have sex without becoming parents” which is a question already conclusively settled by the fact that almost everyone who has the opportunity to do so uses birth control at some point in their lives  — the “never used birth control” contingent is about 2%.

     

    Recognizing that the actual reality on the ground is that the vast majority of people have conclusively answered that question with “YES, we want to have sex without becoming parents right now”, why would the agenda be structured so that it wastes everybody’s time discussing the ‘contraceptive mentality’?  That makes the same sense as having a conference about obesity and the ‘morality’ of doing a gastric bypass and then spending most of the time discussing “should we eat?” because there are representatives there from the 2% of the population that are anorexic.

  • eternalskeptic

    Thank you for your post, bastral. bane. 

    Amie, I normally find your work here a refreshing change from the mean-spirited vitriole that’s come to characterize this site.  But attaining common ground will require less combative language.  Besides, it’s a little disingenous to employ the “anti-choice” term when it doesn’t specify the choice in question: Abortion.  I can’t speak for bastral.bane, but I don’t take issue with the term “anti-abortion.”

  • prochoiceferret

    Besides, it’s a little disingenous to employ the “anti-choice” term when it doesn’t specify the choice in question: Abortion.  I can’t speak for bastral.bane, but I don’t take issue with the term “anti-abortion.”

     

    Well, it’s pretty obvious that they aren’t really anti-abortion, since they support policies that increase abortions (i.e. reduced access to contraception, lack of comprehensive sexual education, among others). They much more consistently support policies that deny people reproductive choices. So “anti-choice” is a much more accurate descriptor for them.

  • arekushieru

    Just wanted to add, though, that one of the reasons I do fear birth, is because of the greater similarity that midwifery holds, for me, to the larger culture’s wish that women do so in relative anonymity and isolation, without voicing their collective fears and need for pain control and the subsequent seemingly ‘naturalizing’ of the movement’s push towards such pregnancy and delivery care.

    One of the scenarios that recently happened to two of my cousins seems applicable, here.  My cousin was due in the middle of December with her second child and planned to have a hospital birth.  But, on December 1st, of last year, she went into labour and gave birth on the kitchen floor.  They had to rush her to the hospital.  It seems that it would have taken much longer to get the care she needed if she had gone with a midwife, instead, but, if you take something completely different from that, that would still make sense to me.  (As a bit of an interesting and sentimental side note to lessen the level of morbidity that might be present, here, I am going to add that a year ago December 1st was the day my cousin’s dad – my dad’s older brother – had passed away, so, we’ve passed on the thought that my uncle was somehow involved in the birth of my cousin’s child.)  

    And, although I detest anything that seeks to further rather than remediate the situation, I think it is natural to fear birth. 

  • eternalskeptic

    Which reproductive choice?  Abortion.

    If somebody states that they oppose abortion because it’s an unjust killing, then they are against abortion, or anti-abortion.  Even if they disagree with you on contraception and sex ed.  (And I happen to agree with you on those issues). 

  • meghan

    Fear isn’t a good place from which to make decisions. It’s disempowering. Fear keeps us from thinking clearly. Respect birth — absolutely.  Mother Nature isn’t a kindly hippie lady strewing flowers in her wake.  Respect birth, respect its power, but remember that we are meant to birth our babies, and the majority of birth practices in the US aren’t shown to be safer or better than alternatives. 

    EFM doesn’t improve outcomes for low-risk women, physician care doesn’t improve outcomes over trained midwifery care, not allowing women to eat or drink in labor doesn’t improve safety, routine episiotomy doesn’t prevent extensive tears — the list is long.  There’s a difference between making an informed choice and fearing all other alternatives.

    I had two cesareans without labor.  That was my choice — first because I had a breech baby, and second because I had nonreassuring fetal testing in the setting of several major complications.  My patients have chosen medicated and unmedicated births, they’ve chosen elective cesarean and home births, and I honestly don’t care what their choices are. I care that they have those choices, and that they make informed choices. I’ve had patients afraid of labor and others afraid of the hospital. Any choice can be the wrong one when it’s made from a place of fear instead of knowledge and power.

    I’ve cared for literally thousands of pregnant women, as a nurse and as a midwife.  I’m not afraid of birth, but I damn sure know where the misoprostol is and how to resolve a shouldr dystocia.  Respecting birth doesn’t mean fearing it. 

  • crowepps

    I have held long discussions with people who make it clear that choice is indeed what they oppose.  It’s okay with them if DOCTORS decide a particular abortion is absolutely required.  It’s okay with them if SOCIETY decides a particular abortion is okay.  What they are unalterably and insistently opposed to is any instance whatsoever in which a pregnant woman makes a decision to end a pregnancy, because that makes her a BAD MOTHER.  A good mother always dies along with her fetus and in their view women who are not EAGER to do so should be forced to do so, because being a bad mother, even involuntarily, is in their view a capital crime and deserves the death penalty.

     

    It would certainly be easier to discuss this subject if there was a way of conceptualizing it that wasn’t based on the false framing of “two sides”.  Even using phrases like “sliding scale” or “mushy middle” assumes the discussion starts at the two points in the extreme (although the pro-choice side is actually part of the middle; a pro-abortion, nobody should be having children at all extreme is rare outside of rabid environmentalists).

     

    Even the birth control issue is very complex — there is nobody ought to ever have sex because bodies are vile and icky, there is sex only in marriage but no birth control at all of any kind whatsoever because everybody ought to WANT 18 children, then there are ‘only when married’ and ‘okay for everybody’ factions in each category of  ‘natural’ birth control is okay, ‘barrier methods only are okay’, ‘hormonal birth control that stops ovulation is okay but not IUDs’, ‘both are okay’, etc., etc., etc.

     

    MOST people individually have incredibly nuanced positions about what they choose for THEMSELVES.  It makes public discussions of the issues incredibly more difficult when people at any point on the scale, obsessed with the ‘Truth’ of their own particular One Big Idea, ignore nuance, refuse to recognize other people have a right to different beliefs, and insist that their personal approval of everyone else’s behavior is the only acceptable solution.  ProChoice advocates have to quit letting the total whackaloons on the other side define “the problem”.

     

    Editing to tighten up the Wikipedia description considerably, contrast and compare the behavior of a favorite extremist ProLifer with this list of common behavioral features of dysfunctional family members:  “Lack of empathy, understanding and sensitivity toward some family members while expressing extreme empathy toward other family members perceived to have “special needs”; denial that behavior is abusive; inadequate or missing boundaries for self; disrespect of others’ boundaries; extremes in conflict; unequal or unfair treatment of family members”.   Sound familiar?

  • prochoiceferret

    If somebody states that they oppose abortion because it’s an unjust killing, then they are against abortion, or anti-abortion.  Even if they disagree with you on contraception and sex ed.  (And I happen to agree with you on those issues). 

     

    So they say they’re anti-abortion, except that they’re really not. Got it.

  • arekushieru

    And I never stated anywhere that we should make our decisions based on fear.  I just stated that it IS natural to fear birth.  Just because women’s bodies are developed with uteruses and vaginas doesn’t mean that they should (or would) automatically accept the way their bodies were designed.   Unfortunately, that actually sounds much like something that a ProLifer would tell me.  And it is one of the other things that has put me off birth, entirely.   The only way, now, that I would ever have my own children, is through egg donation or with some form of ectogenesis, if it is ever developed.

    Shouldn’t women be able to choose their risks?  Or, are we going to say that pregnant women are the only ones unable to choose what risks they are willing to take, whether it is choosing to have multiple children, choosing to give birth even though they are risking their lives, choosing to have an abortion after a previous c-section, even though there is a high likelihood that it will rupture the uterus, etc…?  It’s the right to medical privacy that everyone else has. 

    So, yes, provide all the information that women will need, but don’t take their choices away from them, don’t base solely their right to medical privacy on outcomes. 

     

  • crowepps

    Just about every pregnant woman I’ve ever known was afraid of labor.  The more those around them respected their agency, the more information they were given, the more control over the process they had, the better they were able to DEAL WITH their fear, but that didn’t make it disappear.  It doesn’t seem to me like it’s very helpful to tell someone who says they’re afraid the equivalent of ‘you’re DESIGNED to tolerate excrutiating pain while you deliver so don’t be such a sissy’.  Haven’t we had enough centuries during which women were told to stuff their valid and understandable emotions?   If women are having caesarians for no other reason than because they don’t want to suffer the pain of labor, the solution to that is not to scold them for being immature or selfish or ‘not caring about their baby’ but instead to come up with a more effective system of pain relief.

     

    Considering the fact that medical staff are willing to alleviate the torment of a guy’s stubbed toe with a no-questions morphine drip , I’m a little tired of hearing, ‘you’re a WOMAN, you can stand LOTS more torture than this before it kills you!’

  • meghan

    What you’re repeatedly missing is that the right to make decisions is the core of the argument against fearing birth.  And fear isn’t helpful. I fear bees — irrationally, and out of all proportion.  Should I leave it at that? Or work through that fear, knowing that it’s irrational?

    Women have the right to informed consent.  The “informed consent” in pregnancy and birth is an empty shell.  Women are told, “You want that, don’t you?”, risks are downplayed  and in the end, what the provider wants usually prevails.  If you really think that’s not the case, you’re very uninformed in what birth in the US looks like. I want women to have choices: choices to continue a pregnancy or not, choices on care provider, choices on prenatal testing, choices in birth place.  If these choices are made based on fear, that sets women up for second-guessing themselves later. Just as the decision not to have an abortion, based on the fears promulgated by the antis, is not an informed one, so are decisions around pregnancy that are based on fears created by popular culture and bad medicine.

    Do you think it’s more empowering for a woman to have an epidural because she’s afraid of labor, and to birth her child unable to move from bed or use the bathroom?  Everything in life has risks, and it’s the full knowledge and assessment of those risks that leads to empowered decision-making. Birth culture in the US does not do that. We are not biologically so different from women in the Netherlands, in England, where the birth outcomes are better using less technology, not more.  The largest lie of medicine is that it can eliminate risk, and the more interventions, the more machines and technology and lab work, the lower your risk.  There is no way to eliminate risk, there is no way to eliminate pain.  Continuous fetal monitoring for low-risk women was intended to reduce the rates of cerebral palsy (in itself something of an ableist goal), and it never has — but the c/s rate has increased from less than 10% in the 1970s to 34% today. Technology is a tool, but it’s not a tool without risks.

  • meghan

    Pain in labor is not comparable to other pain, which is the result of impending or actual tissue damage.  The nursing and pain literature make a distinction between pain and suffering.  But think about this for a little bit: If all the popular culture told you was that birth was excruciating and that was your expectation, what would you expect your pain level to be? 

    Women in labor hurt.  Women who are birthing hurt. Women who have birthed hurt. But in our culture, it’s often only acceptable to ask for drugs. People are uncomfortable seeing another’s pain and want it to go away as quickly as possible. But does that help the woman?

    In my experience of many, many labors, medicated and unmedicated, women will know the point at which pain has become suffering for them.  Preparation for birth needs to include time to review the risks and benefits of all pain control options, because labor isn’t always the best time to absorb information. If a woman wants an unmedicated birth, I’ll do my best to help her have that. If she changes her mind, I’ll be paging anesthesia before the next contraction. But to assume that pain medication is the only civilized or kind response to someone saying, “I hurt” is disrespectful of her and of her pain. 

    I don’t have a horse in the epidural v. unmedicated race. I do have a problem with assuming that women are too weak to work through their labors, and with assuming that pain medication has no down side. Neither of those are true.

  • crowepps

    Labeling women who don’t want to be in pain “weak” and unwilling to “work through their labor” isn’t very respectful either.

     

    Pain is pain.  It doesn’t matter whether it’s caused by labor or some other major body stressor like dancing ballet or playing football.  Some people will tolerate the pain because they dislike the side effects of pain relievers or because they feel heroic for tolerating pain, and other people see the pain as a pointless side effect to what’s actually important and would just as soon risk the side effects and eliminate the pain. 

     

    People who want lots of praise for their ‘heroism’ or who have some sort of quasi-religious belief in how ‘natural’ processes are superior are free to wallow around in all the pain they can handle.  It is reaching when they insist that others are obligated to admire them for doing so unnecessarily or that people who do not share their beliefs are deficient.

  • crowepps

    Continuous fetal monitoring for low-risk women was intended to reduce the rates of cerebral palsy (in itself something of an ableist goal), and it never has — but the c/s rate has increased from less than 10% in the 1970s to 34% today.

    Reducing the rates of cerebral palsy is an ABLEIST GOAL?  You know, my sister has cerebral palsy (1940′s) and my son-in-law has cerebral palsy (late 70′s) and my two cents worth of opinion is, even though people with cerebral palsy are absolutely every bit as valuable and important to society in every way as people in perfect health, I’d just as soon that we didn’t unnecessarily cause damage to any more kids than we have to because having a physical handicap is something which, totally aside from discrimination and prejudice and all that stuff, IS A HUGE PAIN IN THE TAIL for the people who can’t physically do what they want to do.

     

    In addition, the rate of cerebral palsy from ALL causes is currently .002%, NOT 35%, and the “slight rise” recently is believed to be from the increased survival chances of premature babies, since the shorter the pregnancy, the greater the chance of disability.

     In another study, the incidence in six countries surveyed was 2.12–2.45 per 1,000 live births,[8] indicating a slight rise in recent years. Improvements in neonatology, or the medical specialty which is involved with treatment of neonates, have helped reduce the number of babies who develop cerebral palsy, but the survival of babies with very low birth weights has increased, and these babies are more likely to have cerebral palsy.

    http://en.wikipedia.org/wiki/Cerebral_palsy

  • meghan

    I never labeled women as weak. The assumption that they cannot labor, if they choose, presupposes weakness. It’s the larger culture you need to take issue with, not me.

    There is a physiologic difference between pain caused by tissue damage and labor.  Ballet and football cause pain because they cause tissue damage. 

    You don’t get a gold medal for laboring unmedicated. I don’t get one for having a c-section.  It isn’t about that. It’s about the larger issues of control and fear about women’s bodies, and I’ll admit I’m fairly appalled that people espousing a supposedly feminist viewpoint aren’t disturbed by the routine violation of the right to informed consent.  As I said repeatedly, I don’t care what women choose. I care that they have an informed choice and support from the larger community for their decisions. You’ve clearly not spent a lot of time listening to women not being consented for care, or hearing how the provider leads the client to the endpoint they, the provider, desire. That’s not feminism. That’s the assumption that women don’t have the right to full information about the care they’re consenting to.

    Honestly, the best informed consent I’ve ever seen has been in abortion care, certainly not in birth care.  How many women do you know who say, “The doctor saved my baby!  She had her cord around her neck!”  or “My labor was just too long.”, when in reality, a third of infants have a nuchal cord, and there is no scientifically-validated length of labor?  We relinquish power to physicians and hospitals willingly, happily, but their interests and ours are often not the same.

  • meghan

    Read the comment I made before replying: c/s is “cesarean section”.  “CP” would be cerebral palsy. And yes, the cesarean rate in the US is currently 35%. Arguing a point I’m not making isn’t really the way to score points.

    I have a child with autism, and there are larger issues of eugenics at play when we continue to use a technology that is known to present maternal and fetal risks in an effort to avoid disability.  CEFM doesn’t improve fetal outcomes in low-risk mothers, but it certainly does increase cesarean rates.

  • crowepps

    Thanks for the correction — I did indeed misunderstood what you meant and apologize for what must have seemed a weird tangent. 

     

    But you misunderstand my reason for being here.  I am not trying to “score points”, I am trying to have a discussion.  It would certainly help me (and other non-professionals here) in understanding your comments if you would say things in laymans’ language instead of using acronyms.

     

    I agree with you that using fetal monitoring does not improve fetal outcomes.  I agree with you that the caesarian rate in this country is ridiculous.  Attempting to prevent birth injuries which give rise to some forms of cerebral palsy cannot have anything to do with ‘larger issues of eugenics’ since eugenics is a theory that ‘the race’ can be improved by eliminating heritable diseases.  Birth injuries are not heritable.

  • crowepps

    The assumption that they cannot labor, if they choose, presupposes weakness.

    You are the one including the presupposition that women who do not choose to labor must be weak.  The “larger culture” has all kinds of other beliefs which you explicitly reject.  Why would you choose to include and perpetuate this particular one unless you agree with it?

    You’ve clearly not spent a lot of time listening to women not being consented for care, or hearing how the provider leads the client to the endpoint they, the provider, desire. That’s not feminism. That’s the assumption that women don’t have the right to full information about the care they’re consenting to.

    Free and voluntary consent can only arise from nonbiased, value-free factual information that would allow a pregnant woman to make her choices without having being nudged to choose in a way that suits the beliefs of the person providing the information.  While I will agree with you that ‘standard’ consent as done by medical professionals may be lousy, you should at least consider the idea that some ‘feminist’ professionals also do a really lousy job of providing unbiased consent.

     

    It is normal to believe that one’s own beliefs and opinions, chosen through life experience and self-education, are “correct”.  It is very difficult to set those beliefs and opinions aside and just provide the underlying information in an unbiased way so as not to ‘steer’ the patient’s decisions.  It is easy to confuse the actual information with the beliefs and opinions and mix them up together.

     

    Someone whose belief system includes the presumption that there is a Them and Us, as in “their interests and ours are often not the same” is going to have to be very careful not to allow her attitude toward “them” and “their interests” color the information provided to the patient and needs to be wary of assuming that she and the patient form a valid “we” because both of them being women does not necessarily mean that the patient’s interests and hers are the same, particularly if the provider has a strong ideological stake.

     

    I’d like to make it clear that it is not my intent at all to say that you personally are doing any such thing.  The point I am trying to make is that if we agree it’s wrong for medical professionals to patronize their patients by making decisions for them, then those of us who believe woman’s agency is important and who want to promote women’s agency have a compelling obligation to recognize and control our own biases because we are aware of the damage caused by assumptions on the part of providers that everybody should do things my (right) way.

  • arekushieru

    My mom has a high pain tolerance level.  At the time she gave birth to her first and second child, the larger culture did indeed presuppose that labour wasn’t all that bad because it was important to our culture’s patriarchal structures that women forget the pain once they had given birth (which is, actually, still true, today), yet, until recently, she has said that it was the worst pain she had ever had.  Imagine how bad the pain must have been in order to be second-worst only to exposed nerve endings being stimulated by a chordoma on one’s spine…. 

    It is not acceptable in our ‘culture’ to ask for drugs, it is acceptable in our ‘society’.  Culture is how we regulate a population.  Society is how we relate to that population.  Big difference. 

    I think you are missing the point, entirely.   Your perspective seems to only see this from the provider’s point of view.  While crowepps and I are both looking at it from the patient’s perspective.   You are focussing on whether the proVIDer is right to be concerned about someone’s pain.  We are  focussing on whether the PAtient is right to be concerned about their pain.

    I don’t think that fear of pain implies a weakness.  In fact, I think it implies just the opposite.    

     

  • arekushieru

    Ballet and football cause pain because they cause tissue damage.

    And what is tearing of the vagina, if not tissue damage?

    It’s about the larger issues of control and fear about women’s bodies, and I’ll admit I’m fairly appalled that people espousing a supposedly feminist viewpoint aren’t disturbed by the routine violation of the right to informed consent.

    Again, I’m getting this sense of cognitive dissonance.  Once more, you seem to be coming from the perspective of what the provider sees, not what the woman sees then go on to say this:

    You’ve clearly not spent a lot of time listening to women not being consented for care, or hearing how the provider leads the client to the endpoint they, the provider, desire.

    I am sincerely confused.

  • arekushieru

    You can’t eliminate risk, neither can you eliminate fear or pain.  But that wasn’t what we were arguing for, anyways.  Pain and risk (and fear) are healthy, as long as you don’t let them control you, after all.  Neither were we arguing that decisions be based on fear.  I do believe we were actually discussing ways to limit and reduce that fear.  Yet, as I’ve stated a couple of times, already, you seem to be coming from the position that the fear isn’t valid, if it came about a certain way, that it must be narrowly focussed  through the lense of the perspective of the care provided TO women and that it must be looked at collectively (not individually), and not whether or not they may truly want that care, regardless of how it came about.  

  • arekushieru

    Again, I don’t care about outcomes, I care about what women truly want.

  • meghan

    Your definition of eugenics is correct. However, the concept of “social eugenics”, where “lesser” people are not born, has troubled feminist thinkers (among others) for more than a quarter century.  The idea that using CEFM, or avoiding vaccines, will somehow provide you with a perfect child, does fit that category.  Think about the routine 20 week ultrasound.  I do think it’s valuable information, and I also support the right of a woman to choose abortion under whatever circumstances she sees fit.  However, the idea that a clean ultrasound somehow promises a perfect baby devalues the children who are born or become “imperfect”, just as using continuous fetal monitoring routinely on low-risk women accepts a significant increase in the cesarean rate as the “price of doing business” — and that business is identifying potentially injured children.  The problem is that the cost/benefit ratio is never explained when a “standard” intervention begins, and women often will say, “Do what you think is best. You’re the doctor/midwife; I’ll do whatever you say.” That is disempowering for the woman and challenging for the provider, who will take all responsibility for a less-than-perfect baby.  That model of infant-as-perfect also drives malpractice suits, where an injured baby will almost always receive a larger award than a dead one.

    All of us are temporarily able-bodied. I could have a brain injury tomorrow and end up with CP. It concerns me, as the parent of a child with a disability, that we see the disabled as “other”, as something to avoid at all costs, no matter what that cost is.

  • meghan

    And I think you’re tremendously underestimating how much coercion and sheer bullying happen under the guise of “informed consent”, or even under a very human desire to make pain go away for others. Truly informed consent is essential to a woman making her own decisions, just as it is in any other medical situation. Instead, just as with state-mandated pre-abortion counseling, you get an individual’s take on the situation, wrapped up in their belief that they’re right.

    What women choose is paramount to me. I’ve gone to the mat with physicians many times for a woman’s right to choose not to have a c-section, or not to have an intervention or test done, but in all cases the woman needs to be thoroughly aware of what she’s choosing. CHoice is a responsibility as well as a right.

  • crowepps

    I have been aware of ‘natural’ childbirth since way back when my first child was born in 1971, and also aware of how some childbirth fundamentalists sought to shame and blame women who did NOT choose it.  I am also well aware of the paternalism and coercion and bullying that seems to be an inherent part of obstetrics, particularly when the process is ‘hospital assembly line’.  I really do get your point and understand where you are coming from.

     

    What I do not seem able to get across, however, is that I believe there is a POSSIBILITY that when the ‘labor pain isn’t pain/labor pain is natural pain’ True Believers insist that if the patient really truly was meeting her Responsibility to True Womanhood she would OF COURSE choose drug free, vaginal birth, etc., that individual take on the situation might just be slightly biased towards their presuppositions and wrapped up in THEIR belief that they’re right.  I think we all do this, and since we do not do it deliberately or out of malice, we have to be careful to monitor ourselves for it.

  • crowepps

    I have a real problem with anybody thinking they’re entitled to a “perfect baby” as well as with anybody thinking that they can pressure their child to perform athletically, scholastically, artistically or esthetically to fullfill the parents’ dreams.  Having kids isn’t supposed to be about assauging the parents’ emotional neediness but instead about the parents meeting the children’s needs.

     

    Those 20-week ultrasounds do more than screen for ‘perfect baby’ — they also identify gross physical abnormalities incompatible with life AND identify problems which might be corrected by surgery prebirth (some bifidas and heart abnormalities have been successfully corrected).

     

    Ultrasounds were not invented/in common use when I had my children.  You went through the pregnancy and found out if something was wrong at delivery.  Finding out there was a gross abnormality/dead fetus after going through labor expecting a healthy baby was just absolutely heartbreaking not just because the parents had no chance to prepare emotionally but because they also didn’t have a chance to prepare their friends and wider circle for the disastrous outcome expected.

     

    Having a lot of experience with handicaps in my family, both physical and cognitive, I don’t believe the disabled should be avoided because they are ‘other’.  I also don’t believe they’re ‘symbols of their parents sin’ or ‘punishments from God’ or caused by the mother seeing something scary during the pregnancy or any of the other ‘traditional’ foolishness that creates stigma.  However I continue to believe that it’s a bad thing to INCREASE the number of disabilities by neglecting reasonable mitigation efforts because being disabled is inconvenient FOR THE DISABLED.

     

    I suppose we could demonstrate to each other our total lack of prejudice by allowing more babies to be damaged during birth.  Wouldn’t that a little hard on the babies?  Wouldn’t doing that really be All About Us and how great we are because we’re not prejudiced?