“What outcomes are we looking at? In the developed world, everybody talks about death. What will happen? What if something terrible happens? Everybody’s worried about mothers and babies dying. But in actuality, mothers and babies—unless you’re in Mozambique where it’s a 1 out of 13 chance the mother will die—in the developed world that’s not really happening. Maybe we should be really looking at what type of care is producing optimality. Which babies and mothers are healthier. Not just at the moment of birth but long term.”

Saraswathi Vedam, speaking at Amherst College after being awarded an honorary doctorate. (You can read the entire talk at the Amherst College link above.)

This is a guest post from a “Post Modern Midwife.” 

21st century midwives who provide out of hospital maternity services are trained, educated primary care providers who often have relationships with physicians and other care providers to offer full scope care. A post modern midwife accesses technology as appropriate and consults in an independent fashion as necessary to provide evidence based care with great outcomes.

As the Big Push garners more and more visibility on a national mainstream level, and OFSB becomes more visible on a state level, there will be more citizens who see our publicity and legislative efforts and have visions of what I call “Little House on the Prairie birthin’”. We need to make clear that midwifery is not tribal woo woo, nor the practice of medicine, but its own independent field grounded in evidence-based practice.

Women with major health problems such as heart disease and type I diabetes which can cause serious complications in pregnancy and labor are not good candidates for out-of-hospital birth and will either self screen out or a midwife would screen them as too high risk for an out-of-hospital birth.

As well, every prenatal visit with a midwife is in fact a screening visit, looking for potential problems that could risk a women out of home birth. Because of this very intense screening process and preventative model of care, families with major problems or risk factors are not tossing the dice on a birth outside of a hospital.

Midwives monitor mother and baby via intermittent fetal monitoring and other assessment means, just as a hospital does. Problems do not fall out of the sky, they develop with plenty of time for response. The Obstetrical Standard of Care is “Thirty minutes from Decision to Incision”. Out-of-hospital birth with a qualified attendant in relationship with her community health services provides the ability to adhere to this standard.

It is important for the general citizenry to understand that the way to protect families is to provide regulation and mandate minimum standards of training and experience for midwives to ensure public safety. No one is trying to convince anyone who doesn’t want to have a home birth, we are just trying to show policy makers that the best way to protect families who choose out-of-hospital birth is to ensure that their providers are in a regulatory framework.

Newsweek.com has a brand new article about Birth Choices which references The Big Push for Midwives. The article does a good job of briefly analyzing the choices available to pregnant women in the United States and the pros and cons of each provider: obstetrician, certified nurse midwife, or certified professional midwife.

The article closed with this quote:“As a woman and a mom and an obstetrician, I feel strongly that patients should have choices,” says Dr. Anne Foster-Rosales, former chair of ACOG’s international committee. “But I think making it as safe as possible is very important.” Foster-Rosales has worked with mothers around the world, including in countries where most women give birth at home with untrained attendants. Because of what she has seen, she feels that it is important that home-birth providers not feel ostracized so that they can come to the hospital if necessary. Emergencies may be rare, but the course of an individual pregnancy is unpredictable no matter where you choose to give birth. Protect yourself and your baby by learning as much as you can.

Ohio Families for Safe Birth strongly agrees with Dr. Foster-Rosales’ sentiments. A good first step in helping home-birth providers not feel “ostracized” in Ohio would be to license them instead of prosecuting them.

A powerful medical lobby with strong financial backing opposes legislation which would legalize the autonomous practice of Certified Professional Midwives (CPMs) and protect birth choices for women and families. In many states where the practice of midwifery is not yet legal, midwifery bills are proposed in the state legislature every year. Midwives and parents work hard to gain support with limited resources. When their bills, year after year, fail to pass or even to reach the floor for a vote, the reason given is always the same.

“I understand the choice issue, but the only issue for the Department of Public Health is the safety of the mom and the baby,” Alabama State Health Officer Dr. Don Williamson said in a recent newspaper article. (The article on the Anniston Star website is for subscribers only, but the full text can be found here, after scrolling down past the “daily news” links.)

Safety was also the theme of ACOG’s recent anti-homebirth press release, which warned mothers of dire and catastrophic consequences that might result from birthing outside of the hospital and asserted that “choosing to deliver at home… is to place the process of giving birth over the goal of having a healthy baby.”

No evidence is given to support this claim, because none exists. In fact, the existing evidence overwhelmingly demonstrates the safety and excellent outcomes of home birth with professional midwives for normal, healthy pregnancies. This evidence — including the CPM 2000 study, a prospective study of over 5400 planned home births which was published in the highly respected, peer-reviewed British Medical Journal — is dismissed by ACOG as “limited” and not “scientifically rigorous.” 

Ironically, ACOG’s opposition to out-of-hospital birth and animosity toward midwifery itself poses a great danger to the health and well-being of home-birthing mothers and their babies. ACOG’s statement is not entirely mistaken: obstetricians do offer expertise and surgical interventions that are life-saving for the very few mothers and babies who genuinely need them. While 80-90% of planned home births are safely completed at home, some mothers need to transfer to the hospital in order to access necessary interventions. In the CPM 2000 study, only 3.4% of women experienced a hospital transfer that was considered by the midwife to be “urgent”. But in those rare, urgent cases, professional communication between midwife and obstetrician and smooth and well-orchestrated transfer of care may make a critical difference to the health and safety of both mother and baby.

For this reason, countries such as Great Britain and Canada, where home birth has been well-integrated into the health care system, put a great emphasis on coordination between the home birth midwife, emergency response services, and hospital obstetric departments as a key component of safe out-of-hospital birth. For example, in British Columbia, Canada, a midwife attending a home birth alerts the hospital when she is called to the labor so that hospital staff will be aware and prepared in case their services become necessary. Midwives are trained to use and legally carry stabilizing medications and other emergency equipment to treat the mother or baby until they reach the hospital. If an emergency transfer becomes necessary, the midwife remains the most responsible caregiver during the ambulance transport. Obstetricians and midwives interact as colleagues to achieve the best possible outcome for both mother and baby in an emergency situation.

By contrast, the recent raid of an Ohio midwife’s home described in last week’s City Beat article was the result of a complaint filed against the midwife when she transported a laboring woman to the hospital. The midwife in question has many years of experience and, as a CPM, has obtained a rigorous, national credential which is legally recognized in many other states. The transfer was necessary for the health and safety of the mother and baby; the midwife acted appropriately in bringing them to the hospital; and a good outcome was achieved because of the midwife’s timely transfer. Had the mother been without a skilled attendant monitoring her labor at home, the situaton could have been tragic.

This midwife now faces prosecution, not because of any negligence of action on her part, but because a doctor believed that the birth should not have been attempted at home to begin with. Other women who would have benefitted from her skill and expertise may now face the unwelcome choice of birthing at home unattended because their midwife is barred from practice. Communication between midwife and physician is a vital step when transfer of care is necessary, but now, midwives attending women who need hospital care may be afraid to accompany a laboring woman to the hospital lest they also come under fire.

The prosecution of unlicensed midwives, though undertaken by the State, is initiated and urged on by the same medical interests that work tirelessly to oppose legislation that would enable midwives to practice legally in Ohio and elsewhere. While there are individual physicians who work with midwives in a collegial manner, respect their abilities, and support their continued provision of a much-needed service, the profession as a body seems intent on stamping out the “competition.”

In Ohio, nearly 1000 babies are born at home each year. Despite ACOG’s best efforts, families continue to choose home birth. If the safety of mother’s and babies was truly ACOG’s goal, they would take a position of working with midwives to ensure that no communication gaps or professional animosity prevents access to needed obstetrical expertise for those who cannot safely continue a planned home birth.  ACOG has systemically chosen to place their political agenda and business concerns above “the goal of having a healthy baby.”

At a party yesterday, a co-worker of my husband’s admired my new baby, who was peacefully sleeping in a sling. “I became a great-aunt this morning,” my acquaintance informed me. “My niece had her first baby.”

She continued, “It was very ironic — a few weeks ago she was in the hospital to keep the baby from coming early. But when he was allowed to come, she didn’t go into labor, so she had to be induced. And then he didn’t come in 24 hours, so she needed a Cesarean.” She added, “Of course, she was very happy to be done!”

Stories like this are as common as baby announcements. This article looks at studies and statistics from the U.S. and Europe and comes to some troubling conclusions. In most developed nations, the combined total of cesarean deliveries and induced labors ending in vaginal birth outnumber vaginal births after spontaneous labor.

With less than half of all babies “coming in their own good time”, births drop dramatically on weekends and holidays, and fewer births happen at night — even though, as the article notes, “many studies have shown that women’s natural hormonal cycles tend toward labor starting at night.”

Despite the risks of inductions and cesareans, the article finds a way to put a positive spin on obstetric convenience. Having babies during “banker’s hours”, the article tells us, is actually safer. According to a recent Texas study, “Particularly among hospitals that delivered about 4,000 to 7,700 babies [in a 3-year-period], there was a 51 percent greater risk of death for a baby born on a weekend than on a weekday.”

Sounds alarming, doesn’t it? The Texas study article advises parents to be to “shop” for their hospital, choosing one that delivers more babies and has a better-staffed neonatal nursery just in case their baby needs special care.

At least parents weren’t advised to schedule their birth during the week to avoid weekend staff shortages. Induction increases the already high risk of Cesarean section, and non-emergency Cesareans increase neonatal mortality by 70 - 90%.

The issue of increased neonatal mortality on weekends has been debated for years, with conflicting findings in different studies. Reduced staffing on weekends is generally blamed for the “weekend effect”. However, some of these studies have noted that pre-term and low-birth weight births are over-represented in weekend births — probably because preterm births are least likely to be affected by obstetric practices which lead to the higher rate of births on weekdays. A 2003 study found that after adjusting for birth weight, the weekend increase in neonatal mortality was no longer statistically significant.

Expectant parents need more options than shopping for the best neonatal intensive care nursery and scheduling their induction for the most convenient weekday. In the hospital setting, the Midwives Model of Care has been shown to reduce inductions, cesareans, and preterm and low-birth-weight babies. As for me, I’ll stick with a CPM who makes house calls — even on weekends and holidays.

The National Center for Health Statistics released the birth data for 2006 today. Their press release focuses on the increase in births to teens and unmarried mothers, but buried near the bottom is this nugget of information:

“The cesarean delivery rate rose again in 2006, to 31.1 percent of all births, a 3 percent increase from 2005 and a new record high. The percentage of all births delivered by cesarean has climbed 50 percent over the last decade.”

At this link, you can access state-by-state preliminary data in pdf format. Ohio, Kentucky, and Indiana all experienced an increase in their cesarean rate. Ohio now stands at 29.3%, Kentucky at 34.5%, and Indiana at 29%.

In an emergency, Cesarean delivery can be life-saving. But in the United States today, the Cesarean rate is almost one in every three births — despite the overwhelming evidence that such high rates of surgical birth actually exposes mothers and babies to unnecessary risk of complications. This article cites a recent British Medical Journal study that warns of the risks inherent in non-emergency Cesareans.

“Overall, Caesarean delivery doubles the risk of severe maternal morbidity, and elective procedures add another 30% to the risk, they said. Caesarean delivery also doubles an infant’s risk of a prolonged stay in the ICU.”

“Any net benefit from the liberal use of Caesarean delivery on maternal and neonatal outcomes. . .remains to be demonstrated,” according to the study’s authors.

Goodman, S. (2007). Piercing the veil: The marginalization of midwives in the United States. Social Science & Medicine, 65(3), 610-621. [Abstract]

Summary: This qualitative case study analysis illuminates the forces behind the underutilization of midwives in the U.S. maternity care system and the process of their professional marginalization. The researcher identified two prominent midwifery services that had good outcomes and were connected with prestigious and influential institutions. One was a university-affiliated hospital practice that had provided uninterrupted midwifery service to the community for nearly five decades. The other was a birth center in continuous operation for nearly 30 years and hospital-owned for the final seven. Both practices were threatened with closure in 2003. In the case of the university-affiliated practice, the midwives ultimately maintained their ability to practice but the hospital imposed restricted clinical practice guidelines resulting in an 84% decrease in the number of midwife-attended births and a number of midwives leaving the service. The birth center practice closed abruptly in a decision handed down by the hospital without the involvement of the center’s Board of Directors. In order to understand the circumstances behind the closures, the researcher conducted 52 in-depth interviews with midwives, nurses, service administrators, childbirth educators, policymakers, and physicians and reviewed archival data such as email correspondence, policy statements and memos.

In both cases, the publicly articulated reason for the attempted or actual closure of the midwifery services appeared to be reasonable. In the university-affiliated practice, the hospital claimed that too many of the women in the neighborhoods served by the hospital were high-risk and midwifery care was therefore unsafe. In the case of the birth center, the hospital reported that the decision to close was prompted by a 400% increase in malpractice insurance premiums. In neither case did the hospital provide any documentation or other evidence to support these rationales for closure. Interviews and analysis of archival data revealed that the midwifery services represented competition to the hospital, local physicians, or both. The case of the university-affiliated midwifery practice was particularly overt: the hospital had recently paid a multi-million dollar fine for double-billing the Medicaid program for births attended by midwives - once for the midwife and again for the consulting physician. When this fraudulent practice was discovered and the hospital was censured, midwives became a source of competition rather than income. In the case of the birth center, five-fold growth in the number of birth center births over the time the hospital had ownership may have appeared to be siphoning business away from the hospital’s labor and delivery unit. Despite these potentially powerful economic and political motives for closing the midwifery services, the public were led to believe that the decisions were driven by rational concerns about safety and liability. The author concluded, “In the cases studied, institutions successfully altered maternity care and diminished midwifery services without accountability for their actions. In fact, the elimination of midwives seemed to be a rational decision when framed in the context of patient safety and the rising cost of medical malpractice” (p. 9).

The author explored aspects of the U.S. health care system that facilitate professional marginalization of midwives. The most problematic is the way the U.S. medical education system is funded. Hospitals essentially get paid twice for care provided by medical residents because they can bill directly for the care and also receive large subsidies from the federal Medicare program in exchange for providing residency opportunities. The more residents a hospital employs, the more federal money they get, so there is a government-imposed disincentive for hospitals to employ midwives. Furthermore, in many states midwives must have formal practice agreements with physicians in order to obtain licenses, liability insurance, reimbursement, or hospital privileges. This requirement makes midwives dependent on their competition in order to gain access to employment. Finally, midwives’ reliance on low-tech care practices result in lower utilization of medical devices and services that may be separately billable.

Significance for Normal Birth: Advocates for improvements in maternity care are often at a loss to explain why childbearing women cannot access care providers who support normal birth. Normal, physiologic birth, it would seem, must be less costly than technology-intensive birth. Solving this paradox requires an understanding of the political and economic forces that foster dependency on high-cost obstetrics to the detriment of women and babies. While this study is small and focused on two specific examples of midwifery service closures, it provides important insight into the systemic forces that hinder women’s access to midwifery care despite a large body of evidence that midwives provide equal or better care than physicians with lower reliance on costly technical interventions. The study documents how our market-based health care system safeguards the interests of the medical profession which can often be at odds with those of women, babies, and society.

Radical, systemic reforms are needed if the United States hopes to achieve a high-functioning maternity care system, characterized by effective, high-quality care, universal access, and cost containment. Evidence from countries with excellent maternity care outcomes suggest that eliminating barriers to midwifery care must be a priority. Birth advocates can begin by calling for accountability and transparency from hospitals and maternity care providers.

I recently heard from some newly-married friends who have just learned they are expecting their first baby. They wrote asking for advice in planning for a safe hospital birth:

It doesn’t look like a home birth will be possible because there is no available midwife, so we’ll be having the baby in the hospital. I don’t want to be pressured into a C-section because we hope to have many more children in the future.

So my questions for you are:
1) What would you consider a necessary reason to have a C-section? (Breech? 36-hour labor? Placenta previa? Fetal heart decels or failed nonstress test?)
2) What would you consider a necessary reason to have an episiotomy?
3) What would you consider a necessary reason to have an epidural?
4) What should we look for in a doula?
5) Any other advice?

You’re wise to be thinking about this now. With Cesarean rates approaching 30% in most of the U.S. (Ohio included), the vast majority are not medically necessary and as you probably know, the risks of Cesarean compared to vaginal birth increase significantly with additional pregnancies. Also, one Cesarean will make it much more difficult to find a practitioner willing to work with you for a vaginal birth in future pregnancies.

In my experience having babies, talking to other people about their births, and providing labor support, the most important factor in your birth experience is actually only indirectly related to how well-informed and prepared you are and what plans you make for the birth. I believe that being extremely careful in selecting your primary caregiver for the birth is more important than anything else you do to prepare for your baby’s birth. (But be sure to find out whether the person you’ve chosen will actually be there for your birth. Some practices rotate who is on-call.)

When interviewing possible providers, ask for their specific Cesarean rate. Most hospital-based midwives (CNMs) have a rate of 10% or less, out-of-hospital midwives (CNM or CPM) tend to be even lower (3-7%). 10-15% is great for a ob/gyn. If your ob is performing surgery on one in every three or four of their patients, that’s not very good odds for you. Ask about their suture rate for vaginal births, not just their episiotomy rate (if they can’t, or won’t, give you an actual number, that is probably a bad sign). Some practitioners will agree not to do an episiotomy but really have no idea how to avoid tears. (My own opinion, not backed up by any studies, is that your best bet is a waterbirth with the mother’s hands only guiding the birth of the head, but that’s probably not possible in the hospital; your second best bet is finding a practitioner — usually a midwife — who takes pride in an intact perineum and rarely needs to suture.) If you possibly can, ask the labor and delivery nurses about the ob or CNM you are considering. They know which ob is “the episiotomy queen” and which doctor’s arrival prompts cracks of “Elvis has entered the building”.

If you have a CNM or ob who you can trust, then you will not need your doula to be “second-line defense” against procedures that you don’t want. If your goal is an unmedicated birth, you need a doula who can be focused on non-pharmacological pain relief and physical / emotional support, because most hospitals are not set up to facilitate the parents who don’t want an epidural and the labor and delivery nurses don’t have much to offer besides pain meds (or time to do the one-on-one, ongoing labor support that is needed).

There’s a tendency in some natural-childbirth books and childbirth education classes to really emphasize the husband / father’s role in labor support and I have seen some men who because of this feel left out or inadequate by their wife’s desire for another woman’s support in labor. A good doula will help the husband effectively help his wife rather than coming between them, but from my perspective after 6 births, the labor support provided by a midwife or doula is very different and not to be confused with the husband’s participation in childbirth. Not all men are naturally good at labor support or naturally inclined to a particular interest in it. I love my husband and I do like to have him there when our babies are born, but his presence is honestly as much for him as for me; I “need” my midwife there much more than I “need” my husband. Not everyone feels this way of course and some husbands are much more “into” the process of their childrens’ births than mine is but there aren’t a lot of voices out there saying that you can still have a great marriage and a lovely natural birth even if the husband is not the ideal Bradley coach, so I thought I’d mention it.

There are a very limited number of “absolute indications” for C-section — placenta previa or abruption, cord prolapse, shoulder presentation. But that doesn’t mean that every C-section that is not done for one of those reasons is therefore unnecessary or preventable. There are so many factors in an individual situation that you can’t always come up with a protocol that will guarantee the right decision. For instance, I would not consider a breech presentation an indication for a C-section — UNLESS I was absolutely unable to find a practitioner who was experienced and comfortable with doing a breech birth. Having a breech baby with an inexperienced doctor or midwife who was nervous about doing a vaginal breech birth might be a lot more risky (for that birth and that baby) than a well-planned C-section. (So you see, again it comes down to trusting your caregiver.) Prolonged labor is a common justification for Cesareans. I would tell you that as long as baby’s heart tones are good and mother is able to eat, drink, and rest, labor can continue as long as it needs to (and I’ve had some long ones… grand multips often tend to have long start-and-stop labors.) Once you go to the hospital, however, your ability to eat, drink, and rest is often severely restricted, and there can be a lot of pressure to have the baby within a certain time frame.

The same is true for other interventions: there are occasions when, used appropriately, they are extremely helpful; they all tend to be grossly overused in modern obstetrics; figuring out when they are appropriate is not always a matter of applying a cut-and-dried formula; and medical management of labor can frequently create the necessity for the intervention. Your birth is not necessarily going to follow the textbook and determining if, when, and how it is appropriate to intervene in a particular labor is not always a straightforward matter. If anything unexpected arises, you are ultimately dependent on the wisdom and experience of your care provider, and if having a birth with only the minimum necessary intervention is important to you, your first concern should be finding a doctor or midwife who shares that motivation.

What advice would you share with first-time expectant parents? Have your say in the comments.