Won't Play Nice Anymore, Part 3

This question was raised on an email list I participate in: “if OBs are constantly feeling threatened by the angry mob that is the rest of us then how will we ever be heard, and how will we ever come to a consensus?”

(Let me preface all the rest of my comments with this: as women in this culture, we are from a very early age taught in very subtle ways to be nice, act nice, play nice, keep people happy, don’t rock the boat, whatever you do don’t be a bitch…..there’s a price to be paid for not being a good girl. We want people to get along and it’s hard to know exactly what to do when there’s no chance of that happening.)

This topic gets discussed by ICAN’s Board of Directors with some frequency — are we "too extreme", "too angry", "too whatever"….how do we get listened to and become more than just a "bunch of angry women"…. A starter Blaming the Activists — the topic is size acceptance, not birth, but it did resonate with me and the notion of being "angry" or "extreme".

I’ve been involved in some form or another with ICAN for about 9 years now. As my kids have gotten older, rather than getting less involved ("moving on") I’ve gotten more involved, on a larger, more "political" level, I suppose you could say. So I’m going to ramble a bit about where I’ve ended up on this topic…. I’m not sure I can put it all in a concise and succinct form.

On a very fundamental level, I believe there will be no change until the powers involved start either losing money, or believing that they will lose money. That’s the way our system works, that’s the nature of a for-profit system. It’s why I believe that the VBACban crisis will only be solved by the courts — because it will be only when VBACbans are ruled illegal (and thus, those who have them are open to prosecution) that they stop. If it were about asking nicely or not-so-nicely, if it were about facts, if it were really even about what women want, there wouldn’t be VBAC bans now. The hospitals that have reversed bans have done so because the publicity threatened their bottom line. That doesn’t mean we stop educating but it is why we have to be realistic. And when you threaten the bottom line for a large corporation….you will be tagged "radical", "extreme", "unreasonable", "shrill", "hysterical" and any other name they can think of to discredit you.

The status quo in this country for all birth issues is not OK. But, it is the status quo. Which means, if you challenge it, you are going to, once again, be labeled "radical", "extreme", etc etc etc. It means that, since most people in the country don’t look beyond the surface when it comes to birth, anything you say that conflicts with the conventional "wisdom “about birth (which has nothing to do with being wise) will make you seem crazy. If you challenge the pervasive techno-worship that characterizes all of medicine, you look radical. You ARE radical!

We are a pain phobic society. If you talk about the emotional fall-out from birth gone bad….you will make people very uncomfortable. You will make the people participating our twisted maternity "care" feel bad…often they will think you want them to feel bad. You will trigger very unwanted emotions in women who’ve stuffed their own trauma in order to survive. People will accuse you of wanting to make other women miserable, of wanting to push your own belief system on others, of intolerance, of just about anything they can to not think about what you are actually saying. Because if you are right, then people have to do something about it. If you say things that don’t have these effects on your listeners….then you are no longer be talking about the issues we are so concerned about. Change is tough….and there’s always institutional resistance to it. If the institutions threatened by the change we want successfully describe us by framing the issue as a personal one ("all OBs are awful people who are only out to get rich and don’t give a flip about women and babies") instead of as a criticism of a broken system ("ACOG is a protectionist organization looking out for the financial interests of their members at the cost of safety for mothers and babies") then it is very simple to marginalize us as a bunch of irrational, intolerant, angry women.

We can be polite to the new president of ACOG, we can write carefully crafted letters encouraging him/her to take on the challenges of the future, blah blah blah….but let’s be realistic here. The people who run ACOG are very politically savvy….and they (think they) know darn well exactly what they can get away with, they know darn well exactly who’s pocket they need to be in….and they have the money to do it. It isn’t about facts. It’s about money. Even if you want to blame "the liability crisis", it’s still about money. Why are they suddenly talking about legislating homebirth into illegality? With less than 1% of all births out of hospital, it certainly doesn’t impact the bottom line….but….now the midwives are getting organized (The Big Push). Now the mainstream is learning about how illogical maternity care really is (BoBB). Now ICAN is telling stories about insurance companies denying medical coverage and distributing information about how to fight a VBAC ban…someone has decided that the bottom line might just be threatened after all…. if ICAN makes any difference at all on the macro level, it isn’t going to be because we are nice. It isn’t going to be because we are nasty, either. It’s going to be because we are numbers. We are the only consumer based organization in this mess….and our biggest strength is you and others who support ICAN with their money and their time. Why? Consumers. Money. Votes. Money. It will be because we do threaten the bottom line and thus, force change. I think that ACOG and AMA understand us (and the midwives) just fine. As long as we aren’t a threat, they ignore us (and until very recently, that’s pretty much what they’ve done). When we are a threat, they will fight us. They will never accept us and willingly make the changes we want. Not because they are made up of bad people (I don’t think they are) but because they are a business.

Of course I’m angry. Doesn’t mean I’m wrong. (or irrational. or mean). What activist hasn’t used anger over injustice to motivate them? I defy anyone to name a successful reformer who didn’t have anger/passion/righteous indignation working for them….political/colonial independence. abolition. suffragettes. civil rights. apartheid. And all of those reformers were crazy, angry, radical, fringe activists too….we are in very good company. The people we are in opposition to (the "OB community") should feel threatened. Because that’s exactly what we are doing. Threatening their comfort, their safety zone, their livelihood. Not because we wish ill upon them as human beings but because we can no longer sit silently as ill is visited upon a larger and larger number of women and babies. Because if we don’t speak, no one else will. If that doesn’t make you mad….well….not much more to say. And certainly, no consensus to be had.

ICAN and the AMA

Statement of the International Cesarean Awareness Network
Regarding the AMA/ACOG Homebirth Resolution
June 30, 2008

The International Cesarean Awareness Networks (ICAN) condemns the recent resolution passed by the American Medical Association and put forward by the American college of Obstetrics and Gynecology suggesting that homebirth is unsafe and that legislation stating such should be passed by states.

The resolution is not evidence-based and, in its apparent suggestion that homebirth ought to be outlawed, threatens long-held standards of informed consent and patient autonomy. ACOG itself maintains that maternal autonomy is almost absolute. The resolution is also a clear conflict of interest, since AMA and ACOG have much to gain in driving women away from using home-based care providers.

The resolution ignores a solid base of evidence that consistently shows homebirth is safe for low-risk women.[i] It also ignores the fact that there is no evidence to support the notion that hospital-based deliveries are superior for low-risk mothers. In fact, while the obstetric community often touts the significant drop on childbirth-related deaths in the last century, little of this improvement has any relation to obstetric care practices, but rather the advent of antibiotics, sterile practices, and safe transfusions. Approximately 95 percent of women in the U.S. give birth under the care of an obstetrician in the hospital and with this care, the U.S. has the second worst newborn death rate in the world[ii], and ranks 41^st in maternal deaths among all nations [iii]

This resolution comes at a time when the physician community increasingly fails to deliver quality, evidence-based care to women and their babies. The most basic needs of laboring women – continuous labor support, food and drink, freedom to move, freedom from routine interventions, being allowed to push in an upright position, and immediate and unbroken contact with the newborn – are routinely ignored in U.S. hospitals. Additionally, major medical interventions such as induction and cesarean section are frequently used without true medical need.

For many mothers, the hospital environment fails to meet their needs, which is why some mothers choose to deliver at home under the care of a trained professional midwife. In our volunteer-based community, ICAN regularly supports mothers who were frightened or bullied into unnecessary interventions by their care providers or were never informed of the risks of interventions. Because of concerns over legal liability and convenience, physicians have prompted over 300 hospitals to ban vaginal birth after cesarean, forcing normal healthy women into cesareans they likely do not need.

Every woman has the right to evaluate the risks and benefits of various care providers and birth settings and choose what is right for her and her baby. Whether through legislation or institutional pressures, it is unacceptable for any professional trade organization to infringe on women’s autonomous decision-making process.

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[i] Johnson & Daviss, BMJ 2005;330:1416 (18 June), Fullerton et al., J Midwifery Womens Health. 2007 Jul-Aug; 52(4):323-33., Wiegers et al., BMJ. 1996 Nov 23; 313(7068):1309-13., Janssen et al., CMAJ. 2002 Feb 5; 166(3):315-23., Anderson & Murphy, J Nurse Midwifery. 1995 Nov-Dec; 40(6):483-92., Ackermann-Liebrich, et al., BMJ. 1996 Nov 23; 313(7068):1313-8., Declercq, Public Health Rep. 1984 Jan-Feb; 99(1):63-73., Duran, Am J Public Health. 1992 Mar; 82(3):450-3., Olsen, Birth. 1997 Mar; 24(1):4-13, Mehl., et al., Women Health. 1980 Summer;5(2):17-29.

[ii] State of the World’s Mothers: Save the Children.
[iii] World Health Organization, the United Nations Population Fund, the U.N. Children’s Fund, the U.N. Population Division & The World Bank.

Read ICAN’s response to criticism of maternal and infant mortality rate numbers.

Happier News

I love positive updates. Anyway, those of you who might read my blog/thoughts will remember that I was pretty scathing in my denunciation of a certain “Mr. Smith” who seemed to discount any likelihood that ICAN could bring something of value to a meeting devoted to controversies in maternity care. An admirable trait of Mr. Smith’s is that he isn’t afraid of controversy and he isn’t afraid to open up dialog that could be heated. And really, isn’t that the most important thing? Anyone with any sense knows that there will always be disagreement on some things, and differences of opinion on how any given crisis should be met and challenged and what the priorities for change should be. But through some very honest communication with Pam Udy, we’ve found that indeed, we do have something to offer each other and that our common ground is something we can definitely work in. I like that. A lot. And have to say, it does say something about Mr. Smith, that he was willing to reach out as he did.

So thank you Mr. Smith. Looking forward to the next conference!

(And if you know who Mr. Smith is, then you know and if you don’t, you don’t need to. Sorry :-)

Here comes the bus...

For a while now, there's been a big push to legalize CPMs (certified professional midwives) in Illinois, a state with a nasty reputation for persecuting midwives to the utmost extent possible. The women of ICAN have always had an uneasy relationship with "legalization" and licensure of CPMs....because unless the people pushing for legalization are very careful (and sometimes even when they are), usually the state requires a sacrifice to the gods of the medical association before agreeing to legalization. The big three sacrificial lambs are VBAC, breech and twins -- and sure enough, VBAC moms once again find themselves laid out on that altar, under the bus of licensure, hung out to dry while preserving homebirth for "low risk women". I think what really stings this time around is that the ICAN chapters in Illinois have been very active in supporting the efforts to get a licensure bill in front of the state legislature, writing letters, raising money and really getting out there for this cause. And now we find that for our efforts we get a pat on the back, a sympathetic "sorry about that" and a trip back to the surgical suite, since not only are homebirths after cesarean forbidden but we can't find a hospital to "let us" VBAC even if we want to go back into the lion's den. I'm sure the midwives are upset about this and I'm sure they feel like they had no choice. And maybe they didn't or maybe they did. After talking to a few people who know more about Illinois politics than I do, I realize that the situation isn't simple or even logical...so the story isn't nearly done, even if it might look like it. But I've got to say, I'm am SO tired of always being the one who gets locked out, when the women I represent need what a CPM can offer more than any other group out there. Still, while the International Cesarean Awareness Network can't support The Midwifery Licensure Act (Senate Bill 385, House Bill 385) as it is currently written, we are going to keep very close track of its progress, should it make any. Keep watching to see what you can do if the opportunity presents itself.

Won't play nice anymore, part 2.

The President of ICAN, Pam Udy, had a conversation with a person, I’ll call him Mr. Smith (name changed to protect us, the innocent), in which he told her that ICAN would never be welcome to speak at any event he organized because “we don’t have initials behind our name and no one wants to listen to women crying about their birth experience.” He believes that it is a priority to have an event where mainstream medical professionals (OBs, etc) would attend, so as to foster dialog between them and the “activists” who are concerned about the state of maternity care in this country. Pam quite coherently explained to him why it is important for ICAN to have a voice and why we cannot continue to let the “medical experts” have the last say in what is best for mothers and babies. He responded with a series of questions, which I have included below. More importantly to me, answering his questions allowed me to think through the role that ICAN does play versus the role that ICAN MUST play, if any of the things we all agree are problems are to be solved.

What makes us believe we speak for the majority of women?

Superficially, I don’t think we do, but only because the majority of women who’ve had traumatic births (not just cesareans) do not acknowledge that — for any number of reasons, but one big one is that they think they are the only one who feels that way and they are ashamed of it. If they knew other women are also unhappy, then they wouldn’t be ashamed. We are the voice telling women it’s ok to be unhappy about something that was a bad experience and that it doesn’t make them a bad mother to be unhappy, nor does it say anything about whether they love their child.

What makes us think our experiences are representative of most women’s experience?

There are quite a few studies that look at "satisfaction" after birth and it is quite easily demonstrated that if you look out farther than 3 months, women with interventive/surgical births aren’t very happy about it. But you have to ask them, they won’t volunteer that information (for the reasons listed above). Is this "most" women’s experience? I don’t know….but as the cesarean rate climbs higher and higher, it’s getting to be more and more women’s experience….do we have to wait until it’s a big majority before we say anything?

What number of women can we say we speak for?

I’ll answer that with another question — what is the threshold at which we have a moral obligation to speak? If only 5% of women identify as traumatized, is that too small a number? Is 10% big enough? (Would we be ok with 5% of all women being abused in a domestic partnership?) Or do we need to wait until over 50% of women have traumatic births before we are obligated to speak? If the cesarean rate is 30+% and half of those women are unhappy about having one (which I believe is a conservative estimate), are those 15% not important enough to speak to and for? If we know that cesarean surgery isn’t the optimal way to have a child, do we have any obligation to speak out about that? If a woman and/or the culture she lives in don’t perceive her experience as abusive and yet it is, do we keep silent? (Some cultures think its ok for a husband to beat his wife and children, so is it ok in that culture?) What about the babies? The evidence continues to accumulate that interventive births, including elective non-medically indicated cesareans are bad for babies — who speaks for them? Do we not speak, since they aren’t indicating that they are traumatized by their birth experience?

Do we only speak for the women who identify as traumatized? Or do we speak for the women who don’t understand that they were traumatized, and yet behave in ways that show they were? (Look at the studies that show women with cesareans elect to have fewer children). Many women in the cultures that allow for wife-beating probably think its "ok" for the most part, even if they really don’t want to be beaten. So we don’t say anything about it?

Mr. Smith doesn’t get to decide what the threshold is. I suspect the notion of setting such a threshold for some other issue would be repugnant to him (female circumcision? male circumcision? domestic violence? lack of access to medical care? hunger? homelessness? child abuse?). The notion that abusive maternity care isn’t in exactly the same category as other forms of abuse is beyond offensive to me. When Mr. Smith persists in calling us "angry women" as an excuse to deny us a voice, he is actively participating in the insidiously persistent patriarchal and misogynistic culture that has in the past considered things like violence against women, lack of political voice or power, lack of property rights, unequal pay, unequal educational opportunities, perfectly reasonable and defensible, and which STILL does condone versions of all these inequalities. I’d be willing to bet a sizable sum that Mr. Smith doesn’t identify himself as a narrow-minded misogynistic fool but the more I think about his "concerns", the more I do identify him as such.

The hypocrisy and willfully close minded attitude are astounding in someone who claims to be concerned about the state of maternity care and childbirth in the U.S. He can support a session titled "Why Men Leave: The Epidemic of Disappearing Dads" that identifies a condition called "Male Postpartum Abandonment Syndrome" and then complain that if we speak out, the MD’s won’t come? What exactly is it that he thinks we want to say? Mr. Smith has bought into the lie that we are a bunch of angry, hysterical women who are only reacting out of irrational emotion. And he conveniently doesn’t notice that the MD’s aren’t coming to these forum/conferences/congresses already, and that they aren’t likely to. Mainstream medical professionals aren’t going to attend something that bears no resemblance to what they must believe is reality (that what they do is necessary and right and to do otherwise would be unethical and unsafe). A sprinkling of MD’s speaking on various birth-friendly topics at this last event certainly didn’t prove me wrong. I’d go so far as to say that my talk on uterine suturing techniques is more likely to attract an MD than any talk on water birth or male PPD. And yet, I’m sure my initials aren’t the letters Mr. Smith is looking for. It is interesting to look at a list of speakers from this last event, to see just what collection of “initials” Mr. Smith did find acceptable:

Karen H. Strange, Midwife
Barbara Harper, RN
Dianne Garland, RM
Cornelia Enning, Midwife
Laura Erickson, LM, CPM
Sarah Buckley, MD
Kathy Forrister, RN
Ellen Margles, CNM
Duncan Neilson, MD
Sandra Bardsley, RN, LCCE
Robert Newman (who’s implied Y-chromosome seems to be the right letter)
Mark Fisher (of a Prime Insurance Corporation and owner of a Y-chromosome)
Robbie Davis Floyd, PhD
Yeshi Neumann, CNM
Carol Penn, DO
Amy Gilliland, Doula Trainer and researcher
Marcy Axness, PhD
Joe Dispenza, DC
Alan Huber (Y-chromosome anyone?)
John W. Travis, MD
Susan Roberts, ND
Stephanie Cave, MD
Eneyda Spradlin-Ramos, BA, LMT, CD
Judith Rooks, CNM, MPH
Zina Bakhareva, MD
Jose Louis Grefnes, MD
Fernando Molina MD
Nils Bergman, MD
Jeanette Schwartz, RNC
Beth Genly, CNM
Zinaida Bakhareva, MD
Bianca Lepori (an architect! and no Y-chromosome — how open-mined and daring)
Nikki Lee, RN, IBCLC
Joni Nichols, BS, MS, CCE, CD (DONA), (CBI)
Jose Louis Grefnes, MD
Yves DeSmedt
Isabelle Gabriells
Veerle DePauw, MD
Sandy Williamson, CNM, MSN
Richard Morris, Administrator
Lonnie Morris, CNM
Anna Verwaal, RN, CD
Susan Jenkins, JD
Karen Strange, CPM
Anna Verwaal, RN, CD

11 MDs. And then a collection of other professional degrees/certifications that will not impress your average Fellow of ACOG in the slightest, not to mention a few that have no degree/certification that I can see. Don’t get me wrong, I’m not doubting that these presenters are very knowledgeable or even experts in the topics they are presenting (I’ve heard many of them speak and they are extremely knowledgeable in their fields of interest/expertise) but the excuse that we don’t have "initials" after our names is a smokescreen behind which Mr. Smith is hiding his prejudice and fear.

It is about time the established "birth activists" quit their vaguely masturbatory inside-crowd-only exercises in preaching to the choir and realize that they’ve been doing exactly the same thing for decades now and things are only getting worse for the women and babies they purport to care about. It is about time they realized that without the consumer, they are going to continue to cycle through a round of conferences and congresses and forums every year or two, saying the same things over and over and over and making absolutely no difference whatsoever and never registering at all on the mainstream radar screen (medical or otherwise). They actually need us a lot more than we need them, since frankly, I can’t see that they’ve helped us much with all their pontificating about safe birth and birth choices and how to have a satisfying birth experience, etc etc etc. We can offer them something new, something different, something that isn’t the same old same old ineffective inaction. We don’t have to tell our sob-story birth stories…we can speak just as knowledgeably on any number of birth topics (from the academic/scientific to the alternative and controversial) as any "doula trainer" or "LM" and thus gain both acceptance from the old guard and wider "name" recognition as an organization that is much more than a “bunch of angry women". We bring in the consumer — the women who’ll write the letters, switch providers, picket hospitals, support the struggling midwife and her independent birth center, vote with their feet. That’s something the experts haven’t managed to pull off yet and I don’t think they can. The consumer, the woman who doesn’t have any qualifications other than a scar, on her belly, perineum or heart, is the KEY, without which, all of this is just a bunch of self-proclaimed experts in an irrelevant discipline complaining about an unacknowledged crisis, to which they have no answers anyway. Women weren’t emancipated and given the right to vote by a group of trained constitutional lawyers, experts on social change and experienced activists. It happened because the women who were affected by the injustice decided to stand up and do something about it. If we ever see real change, it will be because of us, not the trained experts.

So once again, it’s time to stop being nice. Quit worrying about what people “in power” might think and just do what is right. There has NEVER been any social change for good that didn’t require regular, ordinary people to stand up and say no, no more. For me, that includes both the medical mainstream and the established birth activism community. No. No more. You can’t marginalize us anymore and you can’t accomplish anything without us. So quit blaming us for the problem on the one hand (“women just don’t bother to educate themselves/care/think for themselves) and then refusing us a place in the fight on the other (“no one wants to listen to a bunch of angry women”). You can’t have it both ways. Right now, you haven’t got anything worth a protectionist attitude anyway.

Won't play nice, anymore.

“Nice” isn’t a term that I am generally described with, to be honest. Yes, sometimes I am described as compassionate, caring or sympathetic. Often I am described as rational, even-tempered or reasonable. You’ll hear passionate, strong-willed and stubborn used upon occasion too but really, rarely do people describe me as “nice”. That’s ok with me, I’ve never consciously aimed at “nice” as a personal descriptor. But like most women in this culture, I still struggle with the “be a nice girl” problem – you know, wanting to be liked, not wanting to cause trouble or difficulty, wanting people to get along, not wanting to offend. Like most women, a lot of what I’m really thinking in my head doesn’t get put out there for public consumption. And in some ways, ICAN has struggled with this dynamic, I’m sure in large part because we are an organization that is almost exclusively women. It hurts us when we are characterized as “hysterical angry women”, because that’s not at all who we are. We don’t want to be controversial, not really. We are all about choices and options, really wanting more than anything for women to have both the choices and the knowledge to make them when it comes to decisions during the child-bearing years.

The problem is, being nice isn’t going to work anymore. And I think I’m going to like that, even as it catches my breath sometimes. There’s a lot going on in birth politics right now – Ricki Lake’s The Business of Being Born is making more of an impact than I ever expected it to. ACOG released an updated statement about homebirth, the really interesting part being that for the first time ever, they supported the idea of births occurring in free standing, independent credentialed birth centers (they’ve always opposed that in the past). They accused women who plan homebirths of being more concerned with fad and fashion that with the safety of their babies and themselves. ICAN countered with probably the most strongly worded Press Release I’ve ever seen from us. And the responses to our statement were wonderful. I think it’s about time someone “publicly condemned” ACOG for their misogynistic and dangerous policies. The AABC recently released a statement about why they are not going to revisit the VBAC study and why they do not recommend birth centers allow women to plan VBACs in a birth center. They determined that we aren’t exactly “high risk” but we certainly aren’t “low risk” either…and made sure they repeated several times the warning that any birth center who did allow VBACs at their facility needs to consider whether it’s worth jeopardizing “low risk” births. I can’t help but wonder about the possible connection between the two statements, especially since most birth centers affiliated with AABC are owned/staffed by Certified Nurse Midwives, who have aligned themselves with ACOG in a (probably futile) attempt to save themselves from extinction (once ACOG turns its sights on them). So, in our new “say it like it is” mode, we pointed out that AABC is sacrificing the women who need them most, the women who will support them when ACOG comes after them, and that once we’ve been picked off, they will come next. We got a lot of good feedback from that and a call from AABC too….seems maybe they want to work with us – on what I’m not sure, since they haven’t said anything about rethinking the VBAC issue.

Sometimes there is confusion about ICAN being a “homebirth” organization – we are absolutely NOT that. Do many of our members have homebirths? Yes, that’s certainly true. Do many women who want a VBAC have no real option other than a homebirth? Yes, that’s certainly true too. If we appear to be a “homebirth organization” it’s as much a result of the lack of other choices as anything. What we really are is an organization devoted to promoting a full range of birthing options for all women, regardless of history. In the process of working on the DC premier of The Business of Being Born, I had to consider and then respond to a request from ACNM for co-sponsorship or some other major degree of collaboration. And honestly, it was a no-go from the beginning. This is an organization that has systematically repudiated (and abetted in the persecution of) non-nurse midwives. Now, don’t get me wrong, I’ve met many individual CNMs who are wonderful women, who believe in birth and support their sisters the CPMs. I’m talking here about institutional biases. The whole issue of why they have such a problem with non-nurse midwives is complicated and basically not relevant to this discussion. What I’d want to encourage ACNM to consider is the big picture of the future – women are going to require attendance from midwives who are not tied to obstetrics. If ACNM really wants to promote autonomy for their members…if what they really want is the ability to be true midwives and not the handmaidens of the obstetricians….then they need to rethink their alliance with the obstetrical community. Perhaps, joining with other midwives, as scary as that seems, would be a better long-term strategy. Because really, there’s no reason to believe that ACOG will leave the CNMs alone. They already eliminate them from hospitals or actually attending births whenever they can. The Big Push might be for non-nurse midwives, but the CNMs will benefit from it too, if they just let themselves actually be midwives and stop worrying about how to preserve their place in the current dysfunctional medical system. I believe that we are approaching a moment when organizations will have to step up and take sides. The question is, whose side will you be counted on? I’d love to retire the term “medwife” and have midwife attended hospital births be something that is available to any woman who decides that’s the plan she needs to make. Really, I’d love to see medicine, even in the form of “nursing” be forever banished from the practice of midwifery. Hey, I dream big, if nothing else.

More Thoughts on The Business of Being Born

More thoughts on my experience at BoBB.

Most of the showings that I’ve heard about included a panel discussion afterwards and this showing was no different. It was a pretty diverse group of caregivers – a midwife who works out of an independent birth center, a midwife who works out of one of the local hospitals, a midwife who works as a homebirth midwife and an OBGYN who works out of the big teaching hospital in town. There were quite a number of young, as yet childless women in the audience; I hope that they did get something from the movie and discussion. There were a couple of moments that really struck me – first, the homebirth midwife said something that I’d never thought of quite this way – somehow the discussion had moved to how a transport from home to hospital is handled and how providing seamless care with the OB and midwife working together rather than as adversaries is what we need to work toward but don’t in fact have in most circumstances. Those of us who do a lot of work in homebirth often hear from hospital based caregivers that they know homebirth is unsafe because of the “disasters” they see when a woman transfers in. Of course, the obvious response to that is that they never see what the majority of homebirths look like, since those women never go to the hospital and of course the transfers are complicated or difficult – that’s why they are transfers! But this midwife made the point that as homebirth supporters, we only see the messes from the hospital – and it’s true. We don’t see women planning homebirths who loved their hospital experiences. We see the women who were unhappy, traumatized, discounted, injured in the hospital….it behooves both “camps” to realize that we don’t see each other’s successes very often, if at all.

But the really telling conversation surrounded a statement made by the OBGYN. Now mind you, I do believe that this woman is fairly supportive of unmedicated, uninterfered with birth – I can’t imagine she’d agree to participate in this sort of event if she were a “section everyone of them and be done with it” sort of OB. Early in the discussion, she made the statement that “unmedicated labor and birth are the safest choice for all women and babies”. That’s pretty bold. But one of the younger women called her on it – if you took an oath to do no harm and you believe this, how then can you support women demanding an epidural at 1 cm or demanding a cesarean for no medical reason? And the OB gave the standard blame the woman response – “oh, it’s not because I push for the medication/surgery, it’s the women who are driving this. The women are demanding the epidural in the parking lot, the cesarean on demand. Of course I tell them the risks to having that epidural at 1 cm but they don’t want to hear it.” Given the esteem with which most women hold their OBGYNs, I fully believe that if the OBGYN community (or even individual doctors) were truly committed to reducing the intervention rate, it would come down. And I hear too much from doctors and nurses, read too much on their message boards, to really believe that they “love it” when a woman comes in wanting a natural birth and want to do everything they can to help her achieve one. More than anything, I got the feeling that she was like my 4 year old daughter – she wasn’t lying because she wanted to tell an untruth, she was lying because she really wanted what she was saying to be true.

I was impressed by the honesty of some of the panel members when I asked about the cesarean rate and the difficulties women face when they don’t want to have another cesarean and what they were doing about it. After the short but awkward pause that followed my question, the midwife who works out of the independent birth center pretty much laid it on the line – in this state, if you want a VBAC, you have to stay out of the hospital. The VBAC rate in 2006 in this state was 1%. (I’d bet the majority of those were out-of-hospital, to be honest.) She’s helping by attending VBACs at her birth center. The homebirth midwife is helping by attending VBACs at home. Interestingly enough, the midwife who works out of the hospital and the OBGYN didn’t answer the question. I suppose that is a good indication of what they are doing to help. I can cut the hospital based midwife some slack, she’s probably more than eager to attend VBACs but she may well be constrained by hospital policy – she did talk to me quite a bit afterwards and took my information and was very excited that ICAN had a presence in the community. The OB didn’t stick around to talk to me.

I made some good contacts – a couple of local ones who have pledged some support to the DC BoBB showing and a contact with someone from MANA, who was also very excited about the DC BoBB showing. All asked that I keep them in the loop. Believe me, I will.

Finally saw The Business of Being Born

I finally had a chance to see The Business of Being Born, Ricki Lake’s documentary about birth and midwifery care in the U.S. I’d heard a lot about it and I’ll be the first to confess that initially, I was very cynical about the whole thing – it seemed like more of the same preaching to the choir was going to be about all we could expect. Well, it turns out that I was wrong, much to my delight – it seems that a lot of people have seen it and it seems that some people are a bit rattled by it (If anyone doubts that, just read ACOG’s latest statement on homebirth and their supposition that it is a choice made to be “trendy and fashionable” – they never quite mention Ricki or the movie by name but I can’t think of anything else that would provoke that sort of language.) Anyway, one of the criticisms that I’d heard from various sources was that the movie ended on a bad note, with the director Abby (who was unexpectedly pregnant during the filming and thus became a subject of the film as well) ending up with a cesarean, instead of the homebirth she’d planned. There has been some discussion of how she talked about “maybe this was just the way he needed to come” as if she were totally fine with the outcome and this was in direct contradiction to the message of the film. Maybe it’s just because I see her with the eyes of a woman who has shared the experience of an unwanted cesarean completely derailing plans, maybe it’s because I’ve spent so much of my life listening to and walking alongside other women as they journey through life post-cesarean, but it was incredibly obvious to me that Abby was NOT ok with the cesarean at all, and that at 8 months post-cesarean (not very long at all) she was still wrestling with trying to make sense of the experience. Even though her cesarean probably was the best choice for her baby, even though her cesarean wasn’t a doctor convenience or institutional protocol cesarean, but in fact, her baby was sick and needed to be born quickly, her grief and loss were real and understandable. I was sad with her while also being thankful that her boy was healthy and thriving 8 months later. Her experience actually illustrates how safe homebirth really is, because her midwife knew when they needed to go to the hospital, because the prenatal care she got might have been the reason her baby did survive, because planning a homebirth doesn’t mean refusing to change plans when it becomes in the best interest of mom and baby to do so. It is very common (and very wrong) to assume that those of us who work against the rising tide of cesarean surgery are opposed to any cesareans at all – nothing could be farther from the truth. Obviously there are times when a cesarean is life saving and we are happy that they are available and reasonably safe. More than anything, I think what I oppose is the normalization of cesarean surgery – and the refusal to acknowledge the loss that having a cesarean entails (I’d argue the loss is there even if the woman doesn’t perceive it) even when it does save the life of the mother and baby.

So I hope the next movie is about VBAC and the struggles that we post-cesarean moms face when we try to plan a normal, non-surgical birth the next time. And I hope, if and when Abby does get pregnant again, she is able to plan and have the birth of her dreams. The birth that is both what she wants AND the best birth for her and her baby.

Happiness

I had an AHA moment today. We are currently in the midst of a teaching series at my church about happiness – the ancient wisdom of happiness, to be specific. A lot of the teaching comes from Proverbs and Psalms and the basic gist of it is that the ancients had a much better idea of what brings happiness than we do. The tie in to us moderns is that fairly recently, the scientific study of the psychology of happiness has come into its own….and the psychologists are finding that the things they’ve discovered that create happiness just happen to be the same things ancient writings recommend. Today, we looked deeper at “acts of kindness”. The basic lesson was that people who give sacrificially (and we aren’t just talking money, not at all) are just plain happier. AND that in our modern world, to really give and make a difference, we often have to join together with other people in our acts of kindness. (The environment was the example used – the things that we can do as individuals can seem totally insignificant but if we as a group start treating our environment with kindness, you can see a real difference being made). So, what was the AHA?

ICAN. Of course :-) I’ve recently changed my role with ICAN somewhat – I’ve stepped down from my job as the email list administrator and am concentrating solely on my advocacy work. And while I’m in no way minimizing how important the email list is (it’s a life line for many women) I’ve never been happier in my ICAN work than I am right now. Because I can see, as I work with the other dedicated women who are really giving sacrificially to ICAN (and the women and babies we serve) that we can make a difference, we ARE making a difference. But it wasn’t without sacrifice that I got to this point – in a very real way, giving up the email list was a personal sacrifice for me…the time I spend on line and on the phone and at meetings….that’s a sacrifice. And of course, it’s the sacrifice that brings the happiness. This isn’t just some spiritual/religious thing – this is supported by actual scientific research. Giving makes you happy, sure. But giving enough that you *notice* -- enough that something is given up in return, that’s one ticket to true happiness. It combats depression, it motivates good self care, it just does all sorts of really good stuff. Giving sacrificially with a group creates a community, a bond, a purpose that nothing else will.

The other part of the AHA was basically the same realization about my job – I’m working more hours and giving more of myself but its so completely different from my last job – I’m part of a team that’s completely committed to providing the best Veterinary care possible, to making a real difference, better than anyone else. That feels good. I suppose the combination of my job and ICAN are why, right now, I feel happier than I have in a very long time, in spite of the other things in my life that do anything but create happiness.

So – want to be happier? Want that happiness to last? Want to be in community and make a difference? It really isn’t that hard…but it does require sacrifice….money, time, energy….but the payoff is SO worth it. I’d love for ICAN to be the recipient of your sacrifice but heck, at least give it somewhere – to the homeless, to working with at-risk kids, to environmental causes, Heifer Project, Katrina relief, Habitat for Humanity, HIV/AIDs. Give up something to get back something you can’t have any other way.

Cesareans and Private Insurance

I'd started to work on this project but then life happened and it got put on the back burner. But then it happened to a good friend. So its not on the back burner anymore.

Turns out, if you are looking to get private insurance (you know, the kind that isn't provided by your employer, or the govt., the kind that some politicos want to give you tax breaks or special savings plans to buy) you might well be denied coverage if you've had a cesarean within the past 5 years. Why? Well, because there are too many complications in that time, after that surgery. Interesting. But its just another way, a better way, to have a baby. Even better, if you do agree to surgical sterilization, they'll go ahead and cover you. (So basically, I think the complications they are worried about are future pregnancies and the repeat cesarean that they know you'll likely have, whether you need one or not). Because its so politically risky, insurance companies are not allowed to mandate a TOL (trial of labor) or VBAC, and understandably, they don't want to pay for a bunch of expensive repeat surgeries that aren't necessary most of the time. So, because this is a market economy at times, they just don't provide their service to women with previous cesareans. I don't blame them.

But I have to wonder if anyone is warning women about this unforseen longterm complication of having a cesarean? Oh, it doesn't really matter if you don't have to have private insurance. But depending on the outcome of the current bickering about health care, that might be just exactly what a lot of people have to get. Except a pretty good number of them won't qualify....unless they are willing to undergo surgical sterilization, of course. Is that offensive to anyone other than me?

The great part is, I'm not just ranting about this. I already have one very motivated woman who is really pissed off about this. I need a few more. Who would be willing to talk to the media. It is distinctly possible that this could become a national story...if we find at least 3 women, with good documentation of the insurance policies and the refusal, who are willing to talk about it. And if its spun well, it'll really highlight what a disaster the 30+% cesarean rate really is, in ways that most people haven't even contemplated. So, if you are one of these women, please contact me. Ask around, see if you know anyone who's had this happen, who'd talk to me. Email me, please!

VBAC ban

The VBAC ban project is finally up and running! What is this you ask? Well, simply put, we are going to call every hospital in the U.S. and find out what their policy is on VBAC. The International Cesarean Awareness Network did this a few years back and found out that over 300 hospitals officially "ban" VBAC (even though this is patently illegal). Needless to say, we are sure the situation is much worse now. But, the cool thing is that ICAN is about to launch a fantastic new website and included on that website is a map of the U.S. upon which every one of the hospitals we call will appear....with information about that hospital and its policies on VBAC. AND, there will be a way for anyone to leave feedback about that hospital, so you can see what other women experienced there. But, in order for this to happen, we need people to call! So if you are interested in helping out, please email me and I'll get you set up and going.

Help ICAN shine the light into the oppression that so many hospitals are inflicting on women.

I wish I'd written this!

This is one of the best bits of birth writing I've come across in a while. So check out Looking glass Alice examines birth and parenting in our culture. Her other stuff is good too -- I like the fact that she's not afraid to "offend" and seems to have a good handle on why we shouldn't be afraid of "offending".

After all, which one of us ever changes if we aren't offended to begin with?

Cesarean Rate Rises. Again.

So I'm a bit behind in the blogging (what's new?). But I will add my voice to all the others expressing our outrage and grief (though not surprise) that the National cesarean rate for 2006 was reported by the CDC to be 31.1%, a 3% rise from 2005. Given what I see in the stories from just the women who join the ICAN email list, I'm not surprised at all. What with VBAC bans, early inductions and cesarean surgery becoming the "treatment of choice" for suspected macrosomia....I knew the numbers would be bad.

You want to know what's really bad? These numbers are very likely lower than the reality. Why? Well, because some states (Florida is one) exclude "high risk" cesareans from their data -- so if a woman has a cesarean and she was carrying muliples, or the baby was breech or the baby was premature....that doesn't "count". I'm trying to wrap my brain around why this would be a reasonable thing to do....and honestly, the only reason I can come up with is that it keeps the "official" number lower. The argument that these are "necessary and unavoidable" cesareans doesn't make sense to me (and isn't true anyway since all of those pregnancies can end with a vaginal birth)...and excluding breech alone has to raise the cesarean rate by at least 3%...what I am sure has not had any real effect on the numbers are the "patient choice cesareans"....because they really are very rare. You wouldn't know it from the popular press but anytime anyone has tried to get a handle on how many non-medically indicated cesareans are done by maternal request....a very small number is generated. Add to that the fact that most likely, some proportion of hospitals are just plain lying about their cesarean rates (we have a few cases where we know for sure it happens, I'd assume its not limited to those few hospitals) and you get a number that's higher than 31.1%.

So in my state, Michigan, the cesarean rate was 29.8%. About the only good thing I can say about that is that it isn't 37.4%, which is where New Jersey, the state that cuts more women than any other, falls. You know things are getting bad when you see a rate below 25% and want to celebrate (or move to that state). Look up your state -- and then look at the Press Release from ICAN...and then send it to all the media outlets in your area you can find, and to your state and national legislators. Let them know that you are tired of your healthcare and tax dollars being pocketed by the medical and insurance industries, while the U.S. suffers one of the worst maternal and infant mortality rates in the developed world. Let them know that you are tired of women's legal rights to informed consent and refusal being systematically trampled on.

And then, put your money where your mouth is. Join ICAN. If that doesn't appeal, join Lamaze Intl., or CIMS, or Citizens for Midwifery or birthNETWORK or ANY organization that's trying to make a difference.

If you want to get personally involved, email me -- I've got a big project just about ready to launch and I'll need people who are willing to donate time and phone minutes. The problem is huge....but you know what else? If even a quarter of the women who've been through the medical establishment while having a baby got involved....we could make a big difference. So how about it?

N*A*T*U*R*A*L* spells....

vaginal? boy, I thought new math was strange, this new spelling is WAY out there. I'm getting really old....

Seriously, though...it seems (I've noticed this myself, I'm not just hearing it from other women) that "natural birth" is the new way to say "vaginal birth". Well....ok? Yes, a baby coming out of your vagina is an integral part of a natural birth...and admittedly, having a baby come out of your vagina is a HUGE accomplishment in this day and age....but natural?

So how do we decide to define a word....strictly, as in by the dictionary or by traditional usage? By current cultural usage? What are the consequences of allowing (either actively or tacitly) definitions to shift? How important is a word, anyway....I'd say words are very important, even more so because most people don't recognize how important they are!

Let's use the word "choice" for example. I could very accurately be described as someone who is pro-choice when it comes to birth options (what did you immediately think of when you read that? My stance on the "other" choice issue? Now you are probably wondering). The minute I use the phrase "pro-choice", the minute an organization like ICAN uses the phrase "pro-choice", even if we are clearly using it in the context of birth options, not abortion...people assume that we are "PRO-CHOICE". That phrase has gained a certain specific cultural definition that then restricts how I can use it in a different context.

So, if a "natural birth" has come to mean a "vaginal birth" and has no relationship at all to the circumstances of the labor with regard to drugs and other interventions...so what? Why in the world do we care? Are we truly "natural birth nazis" out to make any woman who has any intervention feel guilty, forcing women to suffer needlessly in childbirth through the strength of our criticism, reveling in our obvious moral and physical superiority because we pushed a baby out our vaginas without drugs or assistance? Given the diversity of humans, I'm sure there are some women who feel like that, I've experienced my share of birth elitism when the fact that I've had a cesarean becomes known...but honestly, most women who plan a drug-free birth aren't like that at all. And certainly, the women I know who plan drug-free births don't do it to prove anything...they just want to maximize their chances for a safe vaginal birth and its clear that using as little technology as is safely possible is the way to do that.

There was a time when "natural birth" absolutely meant drug-free and implied free of other interventions too. It was certainly something that many women strived for, and I don't think they wanted a natural birth in order to get their natural birth merit badge. I mean really, if the majority of women would like to have a natural birth, meaning no drugs, realistically it just doesn't mean that the majority of women think they are superior to other women. It means that there's an underlying cultural assumption that a drug-free birth is a good idea. But now we have this situation where its really hard to know what women truly want (and the benefits of a drug-free birth are no longer understood) -- there's the "epidural in the parking lot" crowd (who I think might say that as much because they think its trendy? funny? inevitable?), there's the "oh, nobody gets a badge for not using drugs" group (which I suspect is more about personal "failure issues" than anything) and of course, there's the "let me tell you how bad it really is" group (which I think is human nature -- we like to top each other's stories and talking a lot about something does take the mystery out of it....its just too bad we are replacing the mystery of "what's it going to be like" with false "facts" about what its going to be like). A pregnant woman surrounded by these statements is going to have a hard time believing she's capable of a drug-free birth and she's going to wonder why she should bother?

I don't know. I can't help but think about a study done in Brazil. Its been common belief that a big part of the reason the cesarean rate in Brazil is something like 80% is because women want to have cesareans (to save their vaginas I've been told). Well gee, someone actually went and ASKED...and guess what? The vast majority of pregnant women in Brazil say they want a vaginal birth, when asked at the beginning of their prenatal care. Look at that....we were wrong, it doesn't seem like its the women who are driving the cesarean rate after all! So, I have to wonder if we are wrong about women just not wanting a natural (drug-free) birth anymore....I think a lot of women do. Its just that by the time they get to the end of the pregnancy, they've been pounded with horror stories of how torturous labor is, they've been told (at least implicitly) that they are crazy or elitist to plan a drug-free birth, they've been told quite explicitly that they can't do it and they might as well not bother (you don't have to be a martyr, after all, you wouldn't get a filling without anesthesia. Actually, I would and have but that's neither here nor there since its an apples to oranges statement anyway) and they certainly haven't gotten a bit of support from their OB. If you set someone up to fail, well, most of the time they fail.

Ah, failure. A word that is very loaded in the context of labor and birth. But see, I don't have to tell a woman she's "failed". I really don't think of it in those terms anyway, to be honest. I know women are failed by those around them all the time when it comes to pregnancy and birth. That's where my criticism falls. Women tell themselves that they've failed, all the time about all sorts of things. I think that's where a lot of the stuff about not being a martyr comes from....because we DO judge ourselves based on what other women do (not just in pregnancy and birth). I don't think its a conscious effort to make another woman feel bad in order to feel better....but I do think that's some of it. Some of it is probably a (misplaced) desire to save your friend/sister/sister-in-law/cousin from the feelings of failure that you struggle with. It does make for a pretty damn touchy topic, especially when we are talking about "natural birth", a thing that most women "fail" at.

The question of whether one should "correct" the definition of "natural birth" when used to mean "vaginal birth" came up on the ICAN list. Boy oh boy, that was heated (though polite). It also showed up the limitations of email for discussing something that is going to be extremely nuanced and depend strongly on the context of the conversation that might need to be "corrected". For the record, I don't like the term "corrected" here -- birth is a tender topic...corrected implies "did it wrong" and honestly, there's a difference between the wrong use of a term and a "wrong birth". Do I believe that we need to fight against the trend making natural equivalent to vaginal? Yeah, I do. Its yet another erosion in safe birth....because it takes the very idea of a drug-free birth out of common language. If you don't hear it talked about, you don't think about it, you assume it doesn't happen. But for me, that doesn't mean stopping a woman in the midst of her telling her birth story for the first time and correcting her, when she says she had a natural birth with an epidural. It might mean asking some questions...if she's part of a group and everyone is swapping stories around, I might say something like "hey, that's so cool you had a vaginal birth, they are getting rarer and rarer, especially with all the stuff they do to you in the hospital these days" or depending, I might just ask "hey, did you say natural or did you say vaginal, I missed that part" or any number of more indirect ways to point out what I see as a disconnect. As long as they aren't threatened, for the most part, women LIKE to talk about their experiences. I like women to talk to me about birth because then I can share my experiences too. And then we can all think harder about pregnancy and birth and the state of things and what it should be like rather than what it is like. Because ultimately, that's what it is all about -- helping women fully understand what choices they have and what those choices mean -- giving women all the tools to make safe choices for their babies and themselves, something that most women just don't have the knowledge or confidence to do. And I believe that the vast majority of pregnant women will do whatever it takes to have the safest birth they can...they just don't know what a really safe birth looks like, and the only people telling them are us -- the crazy, hysterical natural birth nazis....

So yeah, let's make sure we are clear on terminology. But let's mix that with a healthy dose of empathy and compassion for the women who've never had a chance to hear about a really natural birth.

Again, not nearly enough time to write like I'd like but...I came across this and I really like it. I dunno...it seems SO obvious...why don't more women get this?

http://naturalmomstalkradio.com/blog/are-women-weak/

When you think about how much many women (at least educated women) WON'T put up with...the things that they find inexcusable...the things that they do allow (certainly educated women are even MORE likely to allow birth abuse) are mind-boggling.

So what does it take to open eyes?

Gretchen

My Video

Ok, I'm gonna try to do this...my video is embedded at the bottom of my blog (when I put it as a sidebar, it got cut off) but I doubt most people will go look for it there....of course, when this disappears, they won't look for it here either -- not quite sure how to get around that :-)

Anyway, I made this video. And when I have a bit more time, I'll explain why I did (or didn't do) some of the things in it.

Gretchen

Fox in the Hen House hunting Witches

I recently learned about something very disturbing...the American Medical Association formed a group called the Scope of Practice Partnership (SOPP), whose mission is to launch investigations of unlicensed “midlevel providers” and to support initiatives to fight legislation expanding the current scope of practice for licensed “midlevel providers”. If you search "Scope of Practice Partnership" you'll find some interesting and really scary stuff -- unlicensed "midlevel providers" would include non-Certified Nurse Midwives ("lay" or "direct entry" midwives) in states where licensure isn't available, even if those midwives were CPMs and thus, license "ready". If you read between the lines (and on top of them too) you can see that "investigations" is a nice way of saying prosecution and of course, they also oppose legislation introducing licensure to these sorts of health care providers. Licensed "midlevel providers" include the following: chiropractors, advanced practice nurses (aka nurse practitioners), nurse anesthetists, optometrists, podiatrists, physical therapists and psychologists. This whole thing is being sold as an attempt to "ensure quality health care" but my answer to that would be deal with your own lousy health care before you started trying to "fix" someone else's. We all know how well most physicians do with individualized care...Log in the eye anyone?


Alternatively, I've seen it described as a "clearinghouse of information about non physician providers' educational preparation, licensure requirements, and state legislation and regulation regarding scope of practice." The big question is, what do they plan on doing with the information? Oh, well, whenever there is a "scope of practice question" (that would be some non-physician profession encroaching on the income source of the physicians in that state or states) this information can be used to "address the issue" or even better "develop model legislation that can help resolve that concern." A specific example would be nurse practitioners -- currently, the education level to be a nurse practicioner is at the Master's level. There is a move in the nurse practitioner community to move to a Doctor of Nursing Practice degree, rather than a Master's degree. Why is this a bad idea? Why, it would allow nurses to call themselves doctors! And heaven knows, we can't have that...gosh, are they going to come after me too? After all, I call myself doctor....I'm sorry, but physicians don't have a lock on the generic term "doctor".

I think it is most baldly put in this direct quote from AMA resolution 902 : “that state medical boards shall have full authority to regulate the practice of medicine by all persons within a state, notwithstanding claims to the contrary by boards of nursing, mid-level practitioners or other entities.” Needless to say, they define "practice of medicine" very very broadly. Resolution 902 also asserts that “patients may be put at risk for injury or death . . . receiving care from persons
who are not physicians (MD [medical doctor] or DO [doctor of osteopathic medicine])” It is important to realize that there is NO evidence to support this statement and the AMA has been unable to substantiate it. But then again, we all know that patients are never "put at risk for injury or death" by the actions of physicians....who practice only the most scrupulously careful, up-to-date, gold standard medicine, of course.


This is a bully stealing the lunch money from the smart kid, who also happens to be a really nice kid too.


If you'd like to read some analyses of this, I've collected links here:


Coalition for Patients' Rights
Dynamic ChiropracticJune 6, 2006, Volume 24, Issue 12
Dynamic ChiropracticDecember 31, 2006, Volume 25, Issue 02
National Alliance of Professional Psychology Providers
Clinical Journal of Oncology Nursing • Volume 11, Number 2
American Dietetic Association
The Integrator Blog
Maryland Optometric Association
American Association of Nurse Anesthetists



Interestingly enough, I had a chance to discuss the quality empathetic and humane care pregnant women get from "doctors" the other night. For those who don't already know, I'm a Veterinarian and I work at a Veterinary ER Center -- I'm the person you see when your dog gets hit by a car or your cat blocks in the middle of the night (or on the weekend or the holiday, of course). I really love my work and the hours allow me to be other things besides a Veterinarian as well. When I'm working a weeknight overnight shift, I usually have 1 LVT (Licensed Veterinary Technician -- basically the Veterinary equivalent of a Registered Nurse -- they have 4 year degrees and have to pass a written and practical exam to be licensed). Anyway, we were discussing the recent birth events of another employee and I was expressing my disgust at how predictable things are most of the time -- this woman ended up with a cesarean she really didn't want at all and the way she got there was distressingly familiar to me. And my LVT, who is single, childless and in her 50's said all the right things...she was absolutely horrified that over 1 in 3 babies is born surgically. She was amazed that anyone could possibly think its a better way to have a baby. She was shocked that more women are dying in childbirth now than they were a year earlier...she was disgusted at the way OBs manipulate women at the end of their pregnancies when they are tired and exceedingly hormonal.



Too bad I'm not surprised any longer.



Gretchen

VBAC bans and other nonsense

Well, look at that, here I am again. I should probably be sewing Hallowe'en costumes...gonna be a busy couple of weeks I think. Anyway, I'm going to ramble this time about VBAC (that's vaginal birth after cesarean if you don't know, and if you are google searching blogs for that particular term ;-) and how much harder it is to have one now.


There's a lot of research on VBAC out there. For the most part it can be pretty easily summed up as follows:


The one complication that's relatively unique to VBAC is uterine rupture. Uterine rupture can be catastrophic, so it isn't something to ignore but catastrophic ruptures are also rare unless you do some stupid things. The rate of uterine rupture in labors that are spontaneous (that means no induction) and in the hospital is roughly 0.5% (1 in 200), but not all of those are catastrophic. Other than uterine rupture, there's no difference between a VBAC labor and any other labor. If you use things like pitocin or prostaglandins, you will increase the rupture rate. If you've had more than one cesarean, the rupture rate will be higher but its looking like it isn't really much higher (in one recent and very large study, it wasn't higher at all). If successful, VBAC is much better for the mother (obviously -- surgery really isn't "good" for anyone, it can be necessary but not good) and probably better for the baby too. It certainly isn't worse for the baby. The rupture rate is higher with incisions in the upper part of the uterus but we really don't know what the rates are -- all the numbers are quite old and women with these sorts of incisions are rarely "allowed" to have VBACs, so we don't know what the uterine rupture rates would be in this population. Things that do not increase the uterine rupture rate include being past your due date, having a "big" baby, having twins, being old, being young, being fat, being skinny or being short. Unless of course you are being induced because of any of those things.

Back in the 90's, the medical community "supported" VBAC. I'm too cynical to believe that this support was because of some noble desire to see women avoid the knife -- well, ok, maybe that was part of it....but really, it was about managed health care and cost cutting. And that's not a good reason...the good reason would be because its better care for mothers and babies to encourage VBAC (which it is) not because it makes the profit margin look better to the share holders. The reason I say this is because the OBs just couldn't keep their hands off ... birth of any sort goes better if you just leave it alone...and they couldn't. So they started doing stupid things like inducing women willy nilly and getting very casual about the whole thing...and so, because bad behavior begets bad behavior, there were some spectacular lawsuits. Though, I've been told that this has been somewhat overblown by the obstetrical community....I don't doubt it but I can't confirm it either. Anyway, ACOG (American College of Obstetrics and Gynecology, functionally the trade union for OBGYNs) came out with a practice bulletin that made "suggestions" about how to manage a VBAC and basically VBAC became an endangered species...ACOG claims that the practice bulletins are just "suggestions" but realistically, if an OB does something counter to the bulletin, they have little to stand on if they are sued. Which leads to VBAC bans.

ICAN is in the process of updating our list but as of a few years ago, there were over 300 hospitals in the U.S. that officially banned VBAC - in other words, you can't have one at that hospital, even if you've had one or more already. At least, that's what they'd like you to believe. Many more hospitals have de facto bans in place because there aren't any attending physicians who'll accept a patient who wants one or the restrictions on having one are so outlandish that it just never happens. I don't know about you but I find it really offensive that anyone, much less a hospital administrator or Board of Directors can tell a women how she's allowed to have her baby. Plus, I'm pretty sure its illegal. Why, you ask?

I'm still figuring this out but I think there are two different laws/regulations that actually make it illegal for a hospital to refuse to allow VBACs. The first is EMTALA (Emergency Medical Treatment and Active Labor Act) which says that if a woman shows up at a hospital in active labor, that hospital may not turn her away, no matter what. The hospital is required by law to admit her and stabilize her (defined as both the baby and the placenta out) OR if they are not able to provide care, transfer her to a facility that can (if they can transfer her before the baby and placenta are delivered. A physician friend explained to me that if the baby and placenta are delivered in transport, the hospital that shipped the woman gets in big trouble because obviously, they could have handled it). What EMTALA does is get the woman in the door. THEN there are the Medicare Conditions of Participation (CoP)- these are the rules any hospital that accepts Medicare dollars (most of them) must follow. The CoP has some very specific things to say about a patient's right to refuse treatment in the section on patient's rights:

"The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient's rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate."

Now...the one thing that I see a potential problem with is that last sentence -- "medically unnecessary or inappropriate." If someone did request a judgment on whether or not VBAC bans were illegal under this clause, I have to wonder if the argument would be made that VBAC is under some circumstances "medically unnecessary or inappropriate". The notion that VBAC is a "treatment" or "service" makes me crazy -- might as well say pooping is a treatment or service, it would make as much sense but that's not how it is framed much of the time -- I see VBAC referred to as a "procedure" rather frequently, even though the best way to have a VBAC is to not do anything at all (that's an odd sort of procedure). I wonder if the powers that be in the CoP world would look to ACOG for an "expert" opinion -- calling ACOG an expert in VBAC is like calling the oil companies experts in alternative fuel sources so needless to say, I have no faith that they'd give an unbiased opinion when asked. Its an interesting dilemma...should we push for a ruling on this? Or would it possibly backfire badly. To me it seems SO obvious that it is against everything we say is important in this country with regard to individual rights to bodily integrity, etc...but we are talking about pregnant women (who in some states are not allowed to draft advance directives or living wills because they are considered incompetent by virtue of being pregnant), particularly their uteri and we all know uteri aren't all that important (50% of all women will die without theirs -- hysterectomy is the second most common surgical procedure after cesarean. Can't help but wonder if things would be different if babies came out of prostates or something...) So here I sit wondering....should we push this? Where oh where is a lawyer familiar with Heath and Human Services law when you need one?

If you know of a hospital in your area that does outright ban VBAC, keep an eye out for the online survey that will be on the ICAN website soon. I'd love to have your information.

Gretchen

I want Google to find me too!

So, though the chances that you're here reading this and don't already know me are probably pretty slim, just in case you don't, I'll tell you a little bit about me. And yes, I have ulterior motives, because I'm trying to "do my part" and get birth issues onto the radar screen of the mainstream (yeah, I know, set a reasonable goal there). On the advice of a friend, who also happens to be an ultra cool cyber-savvy person and the Publications Director for the International Cesarean Awareness Network (ICAN) I'm trying very hard. She told us to go out and blog blog blog. I get the Google alerts for various topics, including "International Cesarean Awareness Network" and I want my blog to show up one of these days!

Now, you ask, why is this something you care about? Surely with 3 of 4 kids in a charter school (that means LOTS of parent involvement and 120 miles of driving each school day), a preschooler still mostly at home, a full-time job (for the moment) and all that goes with that, having a blog and actually writing in it can't be such a good idea. And maybe you are right....I've yet to prove that I can keep up with this. But, since my job does include a lot of down time in the middle of the night, maybe I can pull this off (sleep? who needs sleep....I lost that biological imperative about 9 years ago. Ha!). But seriously, why do I care?

The first reason I care is because I had a cesarean over 9 years ago and I hated it. I knew I would (it was "scheduled" so I had lots of time to anticipate just how fun it wasn't going to be, given what I'd actually planned for) but I didn't anticipate how having it would completely shatter me. I mean, really, it shouldn't have, right? -- my husband and I had a lot of trouble conceiving and maintaining a pregnancy so we ended up in treatment (somehow I guess because I didn't just fall pregnant, I was supposed to really not care how the babies "got here"), the surgery was scheduled so I was able to request (demand) certain things to make it a better (less worse?) experience, my recovery was "good" (aka not medically complicated by anything)...and it shattered me. Pain that didn't just magically go away in 8 weeks (that's when they tell cesarean moms that they'll be back to normal), delightful depression that morphed into an impressive rage, a profound disconnect with my babies (fraternal twin boys), an even bigger disconnect with my husband (you can resume "relations" in 6 weeks. yeah, right. try 7 1/2 months and then not because you actually want to, you just feel that the likely damage done to your marriage is worth prostituting yourself to prevent), doubts and regrets that never ever stop and keep you awake night after night, the inability to take a shower without sobbing (because that's the only place you can do it and not be heard). The incessant fear that you are not a good mother that in fact you are a terrible mother because if you were a good mother, the overwhelming love you instantaneously feel for your babies (that I didn't feel at all) would make all the cesarean stuff just go away....yeah, I hated my cesarean.

When I found ICAN and joined the email support group, I found other women who had very similar experiences, very similar reactions, women who really didn't like their cesareans. And, they weren't afraid to talk about it! That was a sanity saver. THEN I started to realize how many women there were....that was many years ago, and the host for the list at that time was a program that was really difficult to use -- it was complicated and somewhat arcane to join, so I'm sure there were lots of women who never made it there (took me 3 tries and I'm pretty computer literate). Imagine how many there would be if it was easy and everyone had an Internet connection? As I started to move through my journey, I developed a passion for giving other women the help I'd gotten. Eventually, I took over ownership of the list, we moved to Yahoo and the number of women who joined each day was and still is staggering. Clearly, there is a problem with cesareans....and I can't turn my back on those women who are grasping at any hope that they aren't crazy and there was a way out of the place where they find themselves.

And things just get worse....the cesarean rate keeps going up and up (in 2005 it was 30.2% of all births, kinda -- turns out they don't even count things like multiples or breech or preterm in that number! Hey, I didn't really have a cesarean then...cool. No seriously, the real rate in 2005 was probably more like 36% or so...) The infant mortality rate is going up....and guess what? The maternal mortality rate is going up too! And the interpretation of this bit of news didn't even have to be spun by ICAN -- the government stated quite clearly that the increase was most likely due to the increasing cesarean rate (and obesity, though that is likely not independent of the cesarean rate, since over-weight and obese women have cesareans at a much higher rate than other women, often for no apparent reason other than being heavy), along with better reporting. That last bit is interesting...we've suspected for a long time that childbirth related maternal mortality is woefully under-reported (as much as 4-16x by some estimates) so actually, things have been a lot worse than anyone could prove for a long time.

If you have any awareness at all that our health care system is way screwed up, you'll love this factoid: the U.S. spends more (total and per capita) on maternity care than any other country on this planet. And our measures of outcome, those good ole mortality rates, suck. We rank somewhere (depending on the list) between 21 and 25 in the list of developed nations. There are lots of developing nations that have better numbers than we do. We are throwing money away, while women and babies die. How come I never hear any of the presidential candidates talking about that? Oh, I forgot, the American Medical Association uses a lot of those health care dollars to pay really good lobbyists and to make contributions. Wait, wouldn't that be illegal? Uh huh, and nothing illegal EVER happens in health care OR politics. Your insurance premiums at work there. And you thought they were going to buy you good medical care, silly you.

Needless to say, I could go on and on and on. And I suppose that's the point of a blog...but...maybe we'll just save the rest for another time. If you are desperate to read more, you can go to my website. Start with You Should Be Grateful, the first thing I ever wrote and then go from there.

Gretchen