Shameless self-promotion time. My first article is up at The American Prospect, Delivering Affordable Healthcare, on the connection between midwives and health care reform.
Michelle Bartlett is not the typical Washington high-stakes health-care player. She's probably not on the radar of anyone in Congress or the Obama administration. Bartlett is a midwife in Idaho, but in the last few years, she's been trying her hand at lobbying. This came after a night spent in jail for using medication during a home birth she attended in 2000. Bartlett was the second midwife to be charged for this type of practice in Idaho, and thanks to her efforts, she will be the last in her state. "I've done a lot of hard things in my life, and giving birth was one of them," Bartlett says. "But giving birth to a law was really hard."On April 1, Gov. C.L. "Butch" Otter of Idaho signed legislation allowing certified professional midwives (CPMs) like Bartlett to administer medication during births. Unlike certified nurse midwives who are able to practice in all 50 states and generally work in hospital settings alongside obstetricians, midwives like Bartlett are referred to as "direct entry" midwives, and practice exclusively outside of hospitals, mostly in homes or birth centers. These CPMs spend three to five years training and meet the standards for certification set by the North American Registry of Midwives.
...
State licensing fights may be the first step for these midwives, but it's not their last. Now they're turning their attention to the federal health-care reform debate, and a look at the maternity-related health-care costs quickly explains why. Childbirth is among the top five causes for hospitalization, and the No. 1 cause for women. According to Childbirth Connection, Cesarean section is the most common operating-room procedure, and in 2009 the C-section rate hit an all-time high according to the Centers for Disease Control and Prevention, at 31.8 percent of all births. These rates account, in part, for the increasing cost of maternity care in the U.S. Maternal and newborn charges totaled $86 billion in 2006, 45 percent of which was paid for by Medicaid. The federal government is already footing a huge portion of the U.S.' maternity-care bill, and these midwives think they can help reduce costs significantly, and not just for low-income women.
Read the rest of the article here.
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"As a professional association tasked with protecting the business interests of its constituency (doctors), advocates say that the AMA sees midwives and out-of-hospital birth as a threat to its stronghold over maternity care in the U.S."
Miriam, instead of your customary attack on physicians, you may want to consider actually enlisting physicians in the home birth movement. If OB/GYN docs were encouraged to themselves attend home births, I believe we could have a revolution in the making.
"ob/gyns" that do home births are those good old time family doctors and very few (shoot. if any) of those practice any more.
""ob/gyns" that do home births are those good old time family doctors and very few (shoot. if any) of those practice any more."
Which needs to change!
The home birth movement, as represented by Miriam, has been casting this as a midlevel vs. doctor fight when in reality it is healthcare provider vs. patriarchal system fight. Many OBs would love to deliver babies at home if it weren't for the realities of liability and so forth.
"Many OBs would love to deliver babies at home if it weren't for the realities of liability and so forth."
Possibly true, but the AMA and the ACOG as organizations actively fight against allowing women access to homebirth services.
"Many OBs would love to deliver babies at home if it weren't for the realities of liability and so forth."
How do you know this? I've never heard anything like this but I'm very curious.
It's fantastically expensive for any doctor to do a house call, and even very expensive for private-practice doctors to visit their patients in hospital. American insurance programs, both public and private, tend to compensate doctors for the procedures they do, not time spent driving or waiting for a birth, so any house call is a huge hit out of the doctor's own pocket.
"American insurance programs, both public and private, tend to compensate doctors for the procedures they do, not time spent driving or waiting for a birth, so any house call is a huge hit out of the doctor's own pocket."
Fortunately we live in a time when all this just might actually change. Would I be too hopeful to wonder if the final "Obamacare" package includes incentives for home delivery for docs?
"ob/gyns" that do home births are those good old time family doctors and very few (shoot. if any) of those practice any more.
Midwives do not want or need physicians in the homebirth movement. The whole point of homebirth, for the majority of families/women that seek it, is to avoid the medical model of care.
Women want to avoid the increased use of interventions in their births, which result in a snowball effect, where the side effects of each intervention require ANOTHER intervention, until a cesarean section is indicated. In “The Colonization of the Womb,” Nancy Ehrenreich describes the snowball effect thusly:
“For example, there is evidence that a labor will be shorter and less difficult if the woman continues walking around as much as possible, yet routine use of fetal monitors prevents her from doing so. This lack of mobility, along with the supine (lithotomy) position in which many hospitals and physicians expect women to deliver, can thus actually contribute to a problem that tends to be perceived as emanating from the woman's body itself. If the drug Pitocin is administered to accelerate the “sluggish” labor, the pain of the contractions can become so great that the woman requires epidural anaesthesia, which, if not administered in the amount that is exactly right for her body (something that is difficult to know in advance), can produce such numbness that she no longer feels the contractions. Unable to feel her lower body, she may have difficulty pushing the fetus out, stalling the labor yet again. Moreover, her prone position can put more pressure on blood vessels that supply oxygen to the fetus, resulting in distress readings on the monitor. Eventually, as a result of all of these developments, a Cesarean section might seem necessary. Had the doctors instead left well enough alone, alternative health providers argue, the woman would usually have succeeded on her own.”
The interference of physicians in midwifery has already negatively impacted patient care. In order to be regarded as respected professionals, the field of nurse midwifery has had to yield to the desires of licensing organizations run by physicians and the obstetricians that supervise nurse midwives. As a result, they are frequently required to adhere to established medical protocols, procedures, and oversight that are not part of the midwife philosophy. As a result, nurse midwife care has in fact started to resemble the interventionist-prone care provided by obstetricians.
thank you. that was kinda what i was trying to say with my little quip.
im not going to see a brain surgeon for a minor headache and im not going to see a reproductive surgeon for a routine pregnancy.
Generalize much?
There are plenty of OBs who prefer more naturalistic approaches as much as possible. And there are others who (as shocking as this must be to you) defer to the mother's wishes... even if her wish includes elective c/s or lots and lots of drugs.
And yes, there are others who, like you, would override the mother's wishes and insist on one protocol. Which is just as bad, in my opinion, as the midwives and doulas who actually fire patients who want epidurals.
Finally there is the small matter of OBs having vastly higher training, qualifications and aptitude for when things go wrong. I'm sure even you could appreciate a doctor if your pregnancy had major complications... or would you rather die from blood loss from a prolapsed uterus just to prove your point?
haha, i'm not generalizing, but nice try. This information is based on a wide number of medical studies. I'm NOT denying anyone a choice, don't put words in my mouth. I'm against the one OB/GYN protocol as the ONLY protocol. Women should have choices, INFORMED choices. I just want to point out that cesareans are not some super easy surgery that is right for everyone. And neither are homebirths.
I think people (including doctors) forget that women have been doing this for tens of thousands of years. For the last several thousand, midwives were their best help. While I don't want to discount doctors, who have definitely done a lot to make sure that the vast majority of women survive, I also think we'd be foolish to throw out that history completely.
But weren't a lot of women dying during childbirth through a lot of those years? I'm not being cheeky, I really thought that the odds women dying during childbirth were pretty good back in the day.
actually, this is true, but not because of midwife care vs. doctor care. Infant and maternal mortality did not significantly decline until antibiotics such as sulfonamides and penicillin were introduced. This is evidenced by a comparison between maternal deaths between The Netherlands, where midwives were the primary birth attendant, and the United States, where physicians were the primary birth attendant.
Both countries experienced the same mortality rate decline in the 1930s when antibiotics were developed and used. In the 1930s, The Netherlands experienced 250 maternal deaths per 100,000, while the United States, had a maternal mortality rate of 700 per 100,000. In 1960, maternal deaths had declined to 60 per 100,000 in both countries. This suggests that the type of birth attendant had little to do with the decline in maternal mortality.
See: Loudon, Irvine, Maternal Mortality in the Past and its Relevance to Developing Countries Today, 72 Am. J. Clin. Nutrition 241S, 242S-243S (July 2000).
OBgyns belong in hospitals to manage high risk births. There is no reason a surgeon should attend a low-risk birth where surgery is very unlikely to be necessary. Good midwives have the necessary skill set for that, and to recognize when transfer of care to an OB might be necessary. A model of care like the Netherlands, where licensed midwives attend most births and transfer care to OBs only if they need to, would save our system a lot of money and improve outcomes for moms and babies.
We need a public option. I get so angry when I imagine how luxurious the insurance plans of our representatives are. Plans being paid for by our tax dollars.
Here's my suggestion: All U.S. Congressional Representatives and the POTUS/SCOTUS/VPOTUS and Cabinet should be required to have the insurance plan provided that is provided to the least of all citizens, even if that means no insurance. Then we'll see how fast reform happens. These people should be ashamed of themselves.
It's times like this that I wish I hosted my own show on MSNBC or Fox. Oh the questions I would pose and the heat I would apply.
P.S. Well done, Miriam.
my midwife-assisted, birth center births were about $3000 and my out of pocket was roughly 10%.
my sister in law's probably unneccessary c-section was over $15,000 and her insurance didnt cover as much.
every c-section/hospital admittance and stay that's avoided through the work of midwives and non-medicalisation-focused care saves countless dollars as well as bringing a more woman-centered view of birth.
Women should have a right to a scheduled c-section, in my opinion. There should be a health plan in place to guarantee that scheduled c-sections are affordable and accessible. That would be truly liberating.
Why would that be liberating? Most women, after researching the risks and benefits of a c-section versus natural birth, don't even want a c-section. Few c-sections are actually requested by the mother. http://www.ncbi.nlm.nih.gov/pubmed/17324176?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=2&log$=relatedarticles&logdbfrom=pubmed
It's liberating because it's short and virtually painless. Also, because you know excatly when and what will happen. For women with highly demanding careers this is an important factor.
I realize it's not for every one but those women who want a planned C-section should have it. The more choices women have, the better.
It's liberating because it's short and virtually painless.
the recovery time for a c-section is much longer than a vaginal birth.
also, because you know excatly when and what will happen. For women with highly demanding careers this is an important factor.
this seems more like a problem with society that needs to be fixed, not when my kid needs to be born. and often, it's women with demanding (read high paying) careers that have greater opportunity for longer maternity leave than a woman who needs to get back to work quickly because of little or no post-partum health benefits.
"the recovery time for a c-section is much longer than a vaginal birth."
-This is a huge generalization. I know many cases where it was just the opposite. There is, of course, a huge difference in recovery time for planned and emergency c-sections.
"and often, it's women with demanding (read high paying) careers that have greater opportunity for longer maternity leave "
-I'm sorry but this is also a generalization. For some people, it's like you say. But for others, things are different. That's why we should have access to different ways of giving birth.
then it is equally "generalised" to say planned c-sections are easier, quicker, harder, better, faster, stronger.
wow, so false! A cesarean section is serious surgery with severe potential complications. Women can die from infection, hemorrhage, and anesthetic accidents; infants can suffer fractures and neonatal birth traumas. The maternal mortality rate for cesareans is estimated to be two and six times higher than the rate for vaginal deliveries, and there are estimated to be 50-200 maternal deaths per year due to unnecessary cesarean sections! Cesareans have also been linked to a doubled risk of stillbirth after 34 weeks in a subsequent pregnancy. Additionally, cesareans are much more expensive than vaginal deliveries and recovery is painful and can take weeks; lifting even the lightest objects (like a newborn baby...) is often excruciating.
There is a huge difference between emergency and planned C-sections. What you describe has more to do with emergency C-sections.
My point, however, is that women are perfectly capable of assessing the risks and the benefits and making the choice that will be right for them. Having more choices available and covered by me health insurance would be a great thing.
you're wrong. elective c-sections make up LESS THAN 1% of all cesareans. That's not enough to affect the study results. The US has one of the highest c-section rates in the world, yet we rank second to last in infant survival among developed countries.
see: Gene Declercq and Judy Norsigian, “Mothers aren’t behind a vogue for cesareans”, The Boston Globe, April 3, 2006
Why would you want to deny Clarissa her choice? Presumably because she doesn't know what's best for herself, right? Do you know how degrading and insulting you're being?
It's like those natural-birthers who shun women who actually get epidurals... forgetting the irony that in the 19th century, first-wave feminists fought hard so that women WOULD get access to epidurals vs. Christian fundamentalists who insisted on natural childbirth.
A good reminder that paternalism is paternalism, whether it's wearing a clerical collar or a dye-free linen dress.
The motto of the home-birth movement should be: "Empowering women as long as they do what WE want them to!"
"Why would you want to deny Clarissa her choice? Presumably because she doesn't know what's best for herself, right? Do you know how degrading and insulting you're being?"
WOW. I NEVER said I wanted to deny her a choice- I simply stated facts, to counter her totally ridiculous assertions. There is nothing insulting or degrading about correcting people who try to spread dangerous lies, thanks.
"It's like those natural-birthers who shun women who actually get epidurals... forgetting the irony that in the 19th century, first-wave feminists fought hard so that women WOULD get access to epidurals vs. Christian fundamentalists who insisted on natural childbirth."
No one is shunning anyone. I just hate to see people perpetuate medical myths. Knowledge is empowering.
"A good reminder that paternalism is paternalism, whether it's wearing a clerical collar or a dye-free linen dress. The motto of the home-birth movement should be: "Empowering women as long as they do what WE want them to!""
you obviously didn't read a word I said. I provided medically researched studies and assertions. Knowledge will help women make the decision that is best FOR THEM. Not bullshit assertions and rude comments about the home birth movement. educate yourself.
"It's like those natural-birthers who shun women who actually get epidurals... forgetting the irony that in the 19th century, first-wave feminists fought hard so that women WOULD get access to epidurals vs. Christian fundamentalists who insisted on natural childbirth."
the natural/gentle/home birth movement came out of second wave feminism and social justice movement when labouring women were routinely shaved, enema-ed and left to labour and birth without their partners. hell, i had a book written by an ob/gyn in 2004 say "ask your doctor for an enema!" even though the practice had all but been abandoned as unnecessary and degrading. they were cut because they were "too small" and sown back up to stay small for their husbands. the wondrous effects of "twilight" left them completely unaware they had even give birth.
Because it would give them a choice. It may not be the right choice for you or for me, but it may work for someone else.
I was glad to hear that the professional associations of midwives are getting involved in the healthcare reform debate. Right now, more and more insurance plans are refusing to cover maternity care, even under the group plans many people receive through their employers. I checked to see if a woman could buy an individual insurance plan covering maternity care, and I could not find a single one available in my state. Now compare that to the 100% coverage available to any woman willing to be under/unemployed in order to qualify for medicaid. It looks pretty attractive, especially when you want to be able to provide all of the medical care your baby may need, even if that means months in a neonatal intensive care unit. Right now, women that want the best for their children cannot purchase what the government will give them for free, and that is just illogical.
Counterpoint to homebirth advocacy (warning: it's by an OBGYN and it's not polite):
http://skepticalob.blogspot.com/2009/07/homebirth-kills-babies.html
http://skepticalob.blogspot.com/2009/06/homebirth-midwives-are-quacks.html
http://skepticalob.blogspot.com/2009/05/how-wealthy-white-women-have-turned.html
Really the whole blog is a good read, though some of the stories are very upsetting, and obviously if you're an alternative health aficionado you should probably stay away.
In addition to the articles, I would read the comments to each. There are plenty of homebirth advocates present to argue their case.
Reading that made me really upset, and also confused. There are conflicting studies that say homebirth is just as safe or safer, such as this one:
http://www.news.com.au/adelaidenow/story/0,,25344753-2682,00.html
Google "home birth study" and you'll find multiple ones going every way.
Those blog posts, which are insulting to qualified CPMs (there are plenty of obgyns who are quacks, too) and full of dumb scare tactics, are essentially anti-choice propaganda. Pro/anti choice does not just mean abortion. A woman should have the CHOICE of how she gives birth to her child, no matter her age, income, etc. If you want an elective, sceduled c-section and all the pain medications in the world, fine, that's your choice, but you should research and talk to your doctor or midwife about all the pros and all the cons. If you want an unnassisted, unmedicated completely natural homebirth, fine, that's your choice, but you should research and talk to your doctor or midwife about all the pros and cons.
Honestly, I don't know very much about this issue, but Dr. Amy's tone is incredibly disrespectful. Talk about lack of bedside manner...
Midiwfe-assisted birth is just as safe as doctor-assisted birth, and is actually a lot healthier in a lot of areas (morbidity, which is injury/pain/recovery rate), is much lower with Midwives).
see: Rooks, Judith Pence, Midwifery and Childbirth in America(1997).
you need to qualify your above statement with respect to patient population.
what do you mean? As in, for low risk births? Midiwives screen their potential clients to ensure they are right for a home birth- low risk. And they actually do a great job of screening. When you compare low-risk births at hospitals to midwife-assisted births, they are just as safe, and have a much lower incidence of interventions and morbidity than hospital births.
Aside from the preponderance of studies that show homebirth is just as safe if not safer than hospital for low-risk women with experienced attendants, you also have to keep in mind the following when listening to doctors talk about homebirth:
(1) Most OBs do not have the skills to do a homebirth that many hombirth midwives have. OBs rely on technology, nurses, medications, and surgery to get things done, and because of this ever-increasing reliance over the years have lost a lot of the hands-on skills needed to safely manage a homebirth (using a dopler instead of a CFM, catching babies/untangling cords when mom is pushing in an upright position, relying on observations of the woman's behavior/palpating to make assessments, certain techniques to free shoulder dystocia, etc). This is the same reason you would not want to have a vaginal breech birth/vaginal twins delivery with an OB -- they are not trained to do this anymore, they just do a c-section when a baby is breech or with multiples (obviously there are exceptions). So its only natural OBs think hombirth is dangerous -- they are thinking of THEMSELVES overseeing a homebirth, which indeed would be dangerous. Not so with a midwife trained to do these things whose been doing homebirths her entire career. Also, in natural childbirth there are very few obstetric situations that are true emergencies (i.e., travel time to hospital = death), however, when you add pitocin/cytotec/other inteventions used by OBs to the equation, there are more life-threatening emergencies caused. Hence, OBs see more life-threatening emergencies because hospital protocols cause them.
(2) OBs have an ENORMOUS financial and professional dignity incentive to preserve the current US system, and they are fighting a battle against the HUGE weight of evidence that many of their practices are non-evidence based, harmful and extraordinarily costly. We have TERRIBLE infant/maternal morbidity and mortality in this country. We spend by far the most on maternity care. No other developed nation relies on OBs to manage normal pregnancy. They are defensive...their livelihood/status as professionals is at stake...they have been pushing practices not supported by evidence for years. They are not objective.
I encourage you all to pick up Jennifer Block's book "Pushed". Extremely well argued and well cited examination of these issues.
The reason the issue is confusing is that there are two different variables: where the birth takes place (hospital, in hospital birthing center, free standing birthing center, home) and who assists in the birth (MD, DO, CNM, an unlicensed midwife, no one at all).
I hope that in the future insurance companies will begin to cover birth doulas, as having one "decreases the overall cesarean rate by 50%, the length of labor by 25%, the use of oxytocin by 40% and the request for an epidural by 60%." And those stats are from a study by MDs. Klaus, M., Kennell, J., Klaus, P. Mothering the Mother.: Addison-Wesley Publishing Company, 1993.
Here is an article talking about different types of midwives is a good starting point.
http://www.mymidwife.org/nurse_midwife.cfm
I agree with the option of choice. With that said, I also believe that elective c-section applicants know exactly what they are asking for. Many believe that it is a simple routine procedure with little or no risk and even benefits. It may appear to have benefits on the surface but hospitals and doctors are very reluctant to actually share the true stats on how many complications ("simple" or "complex") may arise in relation to c-sections.
The problem as it is now is that many women don't have the option to chose midwives. We shouldn't be attacking women who want c-sections. I disagree with that, but I think its better to inform than attempt to persuade. Many in the natural birth movement like myself feel that c-section rates are dangerous, many times unnecessary, and costly.
If we stopped to think that many women who elect to seek OB care and even elective c-sections over home or natural birth have an innate fear of birth. This woman talks about avoiding pain. We need to spread the word that birth pain isn't so terrible and unbearable. One way to do this is increase access to midwifery care. We should offer the option for birth to empower women instead of striking fear and panic into their hearts and minds.
I want to clarify. We shouldn't be attacking women with c-sections. I disagree with the attacks, not the the idea that we should stop attacking. Poor wording and I apologize.
how many women actually chose c-sections because of fear of pain from vaginal delivery?
I'm honestly asking - I don't know the answer. I can only say that most women I came across who wanted elective c-sections wanted to do so because of convenience. They could plan when to give birth and that was that.
A smaller group were unwilling to risk some of the complications of vaginal delivery - particularly the urogynelogic complications that very few people ever seem to talk about, or some of the sex-related sequelae....
(btw, I am neither a proponent of vaginal nor caesarean delivery - I definitely believe in the case-by-case evaluation!)
spelling error. I meant "urogynecologic"
Most of the deep lacerations/incontinence problem arguments pro-elective c-section people make are unfounded. These problems are often caused by the lying-down position in labor, the use of forceps, doctor-directed pushing, pushing when you have an epidural, or episiotomy.
What I'm saying is, many of these problems are caused by interventions, not the act of vaginal delivery. We can improve how most women experience vaginal delivery to minimize these problems - the only answer is not major abdominal surgery. Plus a study which compared nuns to women who had had babies showed that even with all these practices being common, incontinence levels were not higher among the women who had had babies. DOn't have the sitation but its in Jennifer Block's book.
I totally agree with you. When women are presented on the one hand with the mainstream american vision of vaginal birth (screaming, strapped to machines, IVs in arm, wearing a hospital gown, random strangers doing vaginal exams, being screamed at to push all in an unfamiliar, alienating place with a 30% chance of c-section anyway) and a quick surgical procedure on the other, its no surprise they pick option 2. It should go to show all of us how horrible mainstream maternity care is in America that some women choose major surgery over the other option.
It does not have to be this way...after having my first kid in the UK, I can tell you all that in most rich countries it is SO MUCH BETTER. Not perfect, but better. I urge everyone to write to their senators and congresspeople to support reforms to maternity care like the ones discussed in this article. The lack of midwives in the USA is the most obvious difference between here and countries with cheaper, safer, more dignified maternity care.
the most robust study comparing two treatment modalities would be the randomized clinical trial, which for obvious reasons would be either ethically dubious or downright impossible to do for the question of whether a home birth versus hospital birth works in the best interest of mother and baby.
which of course, means that what's left are retrospective studies, or cohort studies (or both), which lend themselves to all sorts of bias. The simplest example of this would be because it is impossible to randomize pregnant women to either home or hospital, you end up being unable to control for a ton of variables that could affect the ultimate endpoint or outcome. Socioeconomic status of the women involved in any study is an example of a potentially huge confounding variable, but is generally not very well controlled for without randomizing.
The thing is, people who have been there when the shit hits the fan will tend to err on the side of greater medical intervention, and people who have supervised situations that started off uncomplicated and end uncomplicated (for whatever reason, be it skill, science, or luck) will tend to err on the side of less intervention. Who is right? One could say the first group is biased because they always see the scary things. They don't know when to leave well enough alone and stop worrying. Another could say that really, the second group is biased by always seeing the simple things. They miss the red flags because they don't know what they don't know. Clearly both sentiments are correct. Evidence to support both are countless in all fields of medicine, not just obstetrics.
If only it was easy to predict who will have a simple delivery versus who will have a scary delivery. I don't think there's any doubt about what to do for the indisputably high risk pregnancies - multiple gestations, pre-eclampsia, congenital malformations, mothers who are very young or relatively old, or who have complicating preexisting medical comorbidities...etc. Those people go to the hospital, as they should.
As for everyone that we designate low risk, it would be cool to just let this group choose to stay home if they want. But as the saying goes, everyone is uncomplicated until they are complicated.
It's tough. I don't know if we can ever truly answer this question. What I wish is that instead of trudging up the old home versus hospital debate, I wish we could support a reasonable middle ground. Perahaps....Comfortable, home-like birthing centers in a hospital staffed by midwives, communicating with the obstetricians next door, who can be there at a moment's notice if the proverbial shit hits the fan. Or some sort of similar arrangement. I know a few hospitals that do this and it tends to be pretty popular.
Everybody (and I mean EVERYBODY) needs to put their pride aside and just compromise for the sake of the patients involved.
I don't think we need to know which is "right." We just need to make sure each is reasonably safe, and let women decide for themselves after they educate themselves on the pros and cons of all the alternatives. The problem is that right now, women don't have that choice! Direct-entry midwifery is illegal or heavily regulated (to the point of making it almost impossible to practice) is many states (I think 19+ right now). We need to allow midwives to practice their trade.
And in many ways, this is NOT a choice for some women. Women might not have access to Ob/Gyns, may not be able to afford it, or may not want to give birth in a hospital for personal or religious reasons. Hospital births often result in a lot of morbidity problems (pain, long recovery time) and some women cannot afford to take time off to recover from serious surgery.
So, the bottom line is we need to legalize midwifery so that women are actually able to make a choice.
as the proposed middle ground will also utilize the skills of midwives, it would also benefit from legalized midwifery. not mutually exclusive...
i agree that homebirth should be a choice if it can be reasonably safe; however - though this is a bit speculative on my part - I would bet that MOST women do not fall under the exceptions that you present given that as it is most women give birth in a hospital setting.
It would be nice to offer women three levels of care: low risk (at home with midwife), low to intermediate risk (hospital setting with midwife staffing and standby obstetricians), and high risk (obstetricians only).
I still think that a majority of American women would choose that level of care that falls somewhere in the middle.
let me rephrase that:
it would be nice to offer women three levels of care:
low risk to intermediate risk (at home with midwife OR in hospital with obstetrician)
low to intermediate risk (hospital setting with midwife staffing and standby obstetricians)
high risk (hospital setting with obstetricians only).
thanks.
from the research I've seen, many many women can use midwifery safely. And once again, it should be a choice. If the woman wishes to have a homebirth with a midwife who has been accredited by a midwife organization, and that midwife has assessed her to be low-risk, what's the problem?
As for having a midwife-assisted birth in a hospital- this already happens. It's called nurse-midwifery. And this is NOT a good middle ground because as I mentioned in an earlier post, when doctors supervise in a hospital, the care and intervention rate reaches that of a regular doctor-supervised birth! This is not a good solution. As I have said, dozens of studies have analyzed the performance of midwives and found them to be just as safe for low risk births, and they are very good at screening for those. And midwives are also trained well in seeing the early signs of birth complications, so they are able to transfer a women to the hospital with plenty of time to address any issues.
CNMs in hospitals are not necessarily supervised by OBs. Many practice autonomously and are free to practice as they choose (no IV, intermittent monitoring etc) and consult with the OBs if they see potential complications that require intervention by an OB. The level of autonomy CNMs have at a particular hospital depends on state law and hospital policy.
From the content of some posts, it is apparant that some people have been misinformed about their choices for childbirth. This is a rampant problem in our society, likely due to our education on the topic of human developement is substantially hindered in schools by a preoccupation with avoiding sexual topics, the misrepresentation of childbirth by the media, the fact that the majority of women have never seen a birth until they have a baby, and the vast amount of lobbying by the various factions of the medical establishment.
First, you have a lot of choices about who assists you and where you have your baby! (And yes I mean you!) Even in a smaller city like Toledo, Ohio there are hospitals with traditional labor and delivery floors, five hospitals with birthing centers, a freestanding birthing center, and CNMs that perform births at home.
Second, these options are often covered by the major private insurance companies. Private insurance companies would rather you go to a freestanding birthing center for $3500 than a hospital for $10000. Ohio Medicaid also covers the freestanding birthing center, but as Medicaid is a state program it may be different in other states. You can discovery your options by going to your insurance company's website - most have a "find a doctor" search. I have Aetna, and there are several CNMs in town that covered by my plan.
Third, despite what we have all scene on tv, most major complications in labor are predictable. Pregnancy lasts a long time, and the reason for prenatal care during the period is to monitor the progression and anticipate the problems. Many high risk situations, such as a prior c-section, twins,the attachment of the placenta near or on the cervix (can cause hemorrhaging), and pre-eclampsia are caught by routine tests months before labor starts. Breech presentation can be determined simply by feeling the women's stomach in the final weeks, and this is why it is standard for a women to see her midwife/doctor every week. Therefore, when you go into labor after proper prenatal care you and your healthcare provider will have a very good idea what to expect. You will have the information you need to decide if a c-section will be best for your baby or a water birth at home. Sure, minor things may go wrong, like some vaginal tearing, but you don't hemorrhage from that and a midwife will just give you a few stitches.
can i tell you 99% of births as depicted in tv, movies and other media drive me bat-shit crazy.
they've ruined movies ive watched - i lurved episode 3 until the birth of luke and leah. the obgyn-bot had a forcep for a hand for cripes sake!
and while insurance companies are getting better about midwives, im my experience, many, if not all practice in hospitals - which might not be desirable, especially if you are looking for a midwife to avoid the typical hospital birth experience. for my last birth, the midwife was covered, but the birth center i delivered in was not (there are similar problems in hospitals where the ob/gyn will be covered, but the anethsialogist will not, or the hospital is covered but not the ob/gyn).