Midwives say they can help women have better, more natural births, and in many cases, they encourage women to have their babies at home. The medical establishment is solidly against home births, but have begun to support nurse midwives attending births in hospitals. While some say this is a step in the right direction, others say that it just continues to perpetuate treating pregnant women like patients, and that leads to more invasive care than is necessary for most. Now, new legislation on Beacon Hill seeks to establish training guidelines and a registry of midwives. This week on Radio Boston, we’ll take a look at the midwife community in Massachusetts, and ask questions about whether our system of giving birth is really the right one for women and their babies. Comment here now, and join us this Friday at 1.
I have given birth twice in a hospital, without drugs, with a midwife present. Due to a long labor, my first birth would certainly have been a c section had I not had a midwife; my second was also an easy candidate for medical intervention since I was two weeks overdue. So from a pure costsaving perspective, I saved my insurer a great deal of money using this approach. But that’s not remotely why I did it. I wanted to experience birth as naturally as I could, but was not comfortable doing so at home for a number of reasons (risk, hygiene, fear). Having the option of delivering in a hospital with a midwife allowed me to have a compassionate partner there in the process advocating for me, with the backup of a full hospital. I can’t say enough about how positive each experience was. And I attribute my sons’ robust health and easy taking to breastfeeding partially to the fact that they did not have any drugs during the birthing process.
But this experience is not widely available – new mothers, with everything else they have to think about – must search for a supporting hospital and provider. I was dismayed to find out that many of the hospitals in Boston, including the one I was first scheduled to deliver it – support this approach in name only. So it’s a matter of finding not only a midwife, but a hospital that allows her to do her job.
Other cultures do not have the interventionist births that are commonplace here, and if I remember correctly, we have a pretty poor infant mortality rate for a first world country. I think it’s time we closely examined how we approach childbirth and open our minds to something other than the typical hospital birth.
It is critical for accurate media coverage on this topic to refrain from looking so myopically on US practice alone, when most other developed countries with superior maternal health outcomes effectively integrate nurse midwives AND homebirth midwives into their systems. What seems fringe in the US is normal in the countries with the best maternal and infant outcomes.
Sure, you can get Mass General’s Dr. Tracy, an outspoken opponent of out of hospital birth, to give a great “against” quote, but her views, as well as the those of the American College of Obstetricians and Gynecologists, are uniquely American. Our Canadian and British physician friends clearly support collaboration between birth practitioners for the sake of better birth outcomes for mothers and babies.
The hostility between midwives and physicians is particularly poignant in the US where childbirth is such a key business,
From the Childbirth Connections Website:
23% of those discharged from hospitals are childbearing women or newborns.
6 of the 15 most common hospital procedures in the entire population involve childbirth. Cesarean section is the most common operating room procedure.
Maternal and newborn hospital charges ($86 billion in 2006) far exceed those of any other condition.
Perhaps because other countries physician associations are not as focused on protecting the financial interests of its members are our American medical association counterparts?
The key issues here have to do with preserving safe, optimal choices in childbirth for women and their families. There is no question from the medical literature on midwifery that well-trained midwives (CNMs, CMs, and CPMs) all do a remarkable job of achieving safe and satisfying outcomes for birthing women in the home, hospital, and/or free-standing birth center setting. Many MDs and others committed to evidence-based medicine have long recognized the benefits of the midwifery model, and Our Bodies Ourselves now has a statement about Choices in Childbirth signed by hundreds of such experts in the maternity care field (these individuals support expansion of access to midwifery care in all settings):
http://www.ourbodiesourselves.org/book/companion.asp?id=21&compID=129
Our Bodies Ourselves is also collaborating with Mass Friends of Midwives and others in the production of an 11-minute DVD designed to educate Massachusetts legislators about the benefits of the midwifery legislation under consideration in this session. It will be available at our website by mid-January 2010.
After OBOS produced our latest book (“Our Bodies, Ourselves: Pregnancy and Birth”) in March 2008, I had the unique opportunity to speak with hundreds of doctors, midwives, and community members in more than 50 cities across the country. It is exciting to see greater community activism trying to expand access to midwives in all settings. This will reduce the obscenely high cesarean section rate in this country, improve outcomes for both mothers and babies, and could also save millions of dollars now spent on inappropriate obstetrical interventions that actually worsen rather than improve outcomes.
- Judy Norsigian, Executive Director, Our Bodies Ourselves
The paradigms of our lives are not without cultural context. This is true of the midwifery and birthing dialogue as well. Apart from the statistics that should be able to stand on their own (ie. high cost and unnecessarily exorbitant number of caesarians, the U.S. with the fourth highest infant mortality rate in the world, and a 30-40% post partum depression rate) is the emotional and psychological climate for the pregnant family. With 15-minute office visits and more recently, rotating staff within an office, there is little opportunity to establish an authentic and responsive relationship, trusting, and attune to the nuances and needs of the mother. Prenatal, birth and postpartum care lives beyond just the medical. With our mobile society, we no longer have the close and ongoing contact and benefit of multi-generational wisdom shared. A midwife provides that and more. It was my midwife who helped me establish comfort and security in my ‘self’ as a soon-to-be first time mom. My mid-wife and I discussed the prenatal care and birthing options clear of corporate and insurance company profits and demands. She worked in partnership with my ob-gyn. When it was time for the birth, I did eventually go to a hospital, accompanied by my husband and midwife, where I did eventually have a Caesarian. However, had I been in a different hospital in Boston, or with a different team of practitioners, where pitosin is given to move labor along, I would not have a son. His cord was wrapped around his neck twice, and he would have been strangled. Women for millenniums had been giving birth relatively on our own until the male medical practitioners and insurance companies took over. Women all over the world continue to have a high rate of successful births without medical interventions. Surely objective and beneficial solutions can be created with collaborations between the medical and midwifery communities to create the best advantages of both. I look forward to hearing the dialogue.
I am the mother of 2 young children and when I became pregnant with my first daughter I researched everything there is to know about natural birthing and outcomes of our current model. Both my husband and I were appaled at what we found. For those under the care of an ob-gyn the chances of birthing naturally were very low. The standard seemed to be to “medically manage” the labor and birth process. Something that for centuries and beyond the US borders occurs on it’s own time table and with much less intervention. The norm in the US seems to be medically induced labors, pitosin to speed up or begin labors and an an astronomically high C-section rate.
At the time of my first pregnancy I was in California and they allow nurse midwives to attend hospital and home births and the birthing community is far less medically oriented. I chose a hospital midwife group. They spent a lot of time (30+ mins at each visit) on education, nutrition and prenatal care. Something my friends who went to ob-gyns never experienced. They did not try scare tactics or urge induction when my due date came and went. They “trusted” the birthing process and on the 8th day postdate I gave birth easily to a healthy daughter. I had a phenomenal birthing experience with my husband and birth doula by my side. Had I been with an ob-gyn they would have insisted on induction. For my 2nd pregnancy it began in California and I was with a different practice. Unfortunately, the midwives in the practice were tightly governed by the ob-gyns and operated in the same manner- too many test, scare tactics and little patient education. I switched to a home birth midwife and never regretted it. At the end of pregnancy I moved to Massachusetts, where I grew up. I found a phenomenal home birth midwife with 20+ yrs experience and it was the best experience. I can’t even compare the level of care that she took. She never risked my health or the baby’s and would have no problem transferring care to a hospital. This is what I appreciate- the knowledge to know a woman and know when it is time to seek medical help. Our current model is without this.
The US is ranked 45th for infant mortality according to the CIA World Factbook yet we spend 20 times the amount on healthcare as the country ranked #1 (Singapore). Why? Why is it so hard for home birth midwives to be reimbursed by insurance companies?
This past Sunday, December 6th I gave birth to my first child- a healthy 8 lb, 1 oz baby girl at Anna Jacques Birthing Center. I didn’t see a doctor my entire pregnancy- I had a RN/ Certified Midwife. I chose the birth center option because I firmly believe doctors are great for atypical pregnancies that need interventions. When the pregnancy is healthy and normal, they don’t need to get involved. However, knowing a doctor was on call just in case made me feel better.
I had a great birth experience. I labored at home for 48 hours based on the recommendation from my midwife and when I went into the center, I gave birth 4 1/2 hours later with no pain or other interventions.
I don’t understand why more women don’t go this route. I think as a society we’ve been trained that birthing is too hard to do naturally. The fear of pain makes the situation that much worse and causes muscles to constrict, making birth harder. Women need more education and trust in their bodies!
With out first child we decided to use a midwife, though we chose to deliver at a hospital. Prenatal care seemed to be first rate. My wife appeared to be in labor just over a month early and just as they midwives said they would they tried to keep us at home as long as possible even though my wife’s pain was extreme. We held out for nearly 5 hours before informing the midwife that we were going to the hospital. Even while at the hospital the midwife continued to try to manage the situation, however when blood test results came back it became apparent that this was not a normal situation. My wife was in the advanced stages of HELP syndrome and the pain was caused by a severely swollen liver. Because we waited so long to go to the hospital, my wife’s platelet count was so low that an emergency c-section would soon become seriously life threatening for her so there was no time to even attempt to induce labor. So she was given an anti-seizure medication and taken to the OR. The medication caused nausea and dementia and short term amnesia so she has little memory of our son’s birth. Despite the challenges after a few days of special care both my wife and son recovered but this has forever changed my opinion of midwifery and it nearly cost my wife her life.
After the birth of my first child who was born at the hospital with and OB I felt wronged by all the interventions. At this point in my life I didnt know that natural birth still existed and thought my experience was normal but it didnt sit right with me. What have we done in our country that makes women think that labor/birth needs to be messed with instead of letting nature take its own route like it has since humankind began?
With my second child I sought out the services of a homebirth midwife. He was born gently at home. I would not trade that experience, and beleive that everyone should have the option to have a similar experience if they choose to do so.
Thank you, Radio Boston, for presenting this topic. It is puzzling to me that so many women of childbearing age in the U.S. are still unaware of (or misinformed about) the benefits of nurse-midwifery care. I hope your show will avoid the simple sensationalism of the two extremes in this argument and highlight the facts, since there is strong evidence that shifting to a more midwifery-centered model of care would improve the health of American women and babies.
One very important fact to share with the public is that nurse-midwives do NOT only provide care to women seeking unmedicated birth! Although I have heard of midwifery practices that screen their patients regarding these preferences, most midwives are focused on two things: helping women make informed decisions about childbirth interventions, and using those interventions appropriately based on scientific research. This leads to better outcomes and happier families.
Second, most nurse-midwives have never even seen a homebirth. The number of women who choose to give birth at home in the U.S. is extremely small, less than 1%. So, if midwives are delivering 10-20% of babies, obviously the vast majority of those births occur in hospitals. Homebirth and midwifery are NOT the same thing. I personally support the option of homebirth for appropriately screened patients who will be attended by skilled midwives, because research shows this option to be as safe as hospital birth, but since most women want to give birth in hospitals, that’s where most midwives will continue to work.
This leads to my third point: I hope you make a clear distinction between “professional” or “certified” midwives who are trained by accredited programs and licensed and regulated by state boards — the majority of midwives — and “lay” midwives who train by alternative methods and are not licensed or regulated by the state. While many lay midwives are extremely expert providers of safe care, the lack of regulation is concerning to those who know the risks involved in childbirth.
Last, I’d like to say congratulations to Meghan on the birth of her child, and best wishes for motherhood! To Chad, I am sorry for the frightening and dangerous experience you and your wife had, and glad she and your son are okay. HELLP syndrome can develop very quickly, as you saw, and midwives screen carefully for signs of problems but cannot always predict or prevent bad outcomes. I don’t know where your wife delivered, but at my most recent practice any woman in labor before 37 weeks would have been brought into the hospital early in labor for infection prophylaxis, and her blood pressure would have signaled to her providers that there was a serious problem. Of course it’s impossible to know if the outcome would have been different; the important thing is that your wife and son are well.
Sincerely,
Johanna Swift Hart CNM MSN
Thank you for doing this radio show!
Midwives and midwifery clients and advocates have been working for many years to achieve meaningful regulation for midwives in Massachusetts. The current bill this radio show refers to would create a Board of Registration of Midwifery, which will license and regulate the practice of Certified Nurse Midwives (CNMs), Certified Midwives (CMs), and Certified Professional Midwives (CPMs). The point of having such legislation is both to create a reasonable system of accountability AND to increase access to midwives in all settings.
There is no one type of provider or one birth setting that is best for all pregnant women, because we are all unique individuals. There are always some risks in childbirth, no matter where or with whom you give birth. For most women, pregnancy is a normal process that proceeds on its own unless interfered with, but this process can also be affected by the mother’s beliefs and feelings, and by how she is treated by the people who are with her and their beliefs about birth. Furthermore, a great deal of standard hospital and obstetric practices and interventions applied to women in labor are not based on any evidence at all. Therefore, it is only reasonable that women should have a range of proven options available to them. Passing legislation that enables credentialed midwives to practice legally and with accountability makes sense. No one is going to force any woman to have a home birth, or to have a midwife, but for those of us who would prefer to be attended by a midwife in hospital, birth center or home, such legislation would certainly increase our options.
ACOG is a professional organization accountable only to its members. It does not have evidence to support its anti-home birth stance, it is based purely on belief! See their statement at http://www.acog.org/from_home/publications/press_releases/nr02-06-08-2.cfm . It states: “ACOG believes that the safest setting for labor, delivery, and the immediate postpartum period is in the hospital, or a birthing center …” without citing a single reference to support this “belief”. So much for scientific medicine. In fact, a large collection of studies over many years and in a number of countries has consistently shown that for a woman having a normal pregnancy a planned homebirth with a trained midwife is as safe as the hospital, with far fewer interventions and less morbidity for mothers and babies. (for just one example, see http://www.cfmidwifery.org/pdf/CPM2000.pdf and see more fact sheets and resources on the CfM website).
Obstetricians and hospitals are not accountable for their outcomes. For example, while the cesarean rates have been increasing every year (now over 30%!!) in the absence of any medical justification for such high rates, no one in state or federal government offices has even been asking: Are we having better outcomes for mothers and babies with these rates of cesarean sections? In fact, research has shown that when cesarean rates rise above 10 to 15%, more babies and mothers die than are saved by the surgery. Similarly, no one has been asking about outcomes related to the huge increases in induction, use of drugs to intensify labor, and use of epidurals. In contrast, even the relatively rare instances of a midwife transferring a laboring woman to a hospital for medical care usually are scrutinized critically.
Informed consent in hospital-based maternity care in general is a joke – women are not adequately informed about the pros and cons (including the % risk) for specific interventions and for NOT doing the intervention. Hospitals and obstetricians rarely if ever inform women that there are economic incentives behind each and every “suggested” practice and intervention, ie, conflicts of interest. In contrast, most states that regulate out-of-hospital midwives require extensive disclosure documents that the client must read and sign.
A woman can find out far more information about a used car than she can find out about her obstetrician. In most states, she may be able with some difficulty to find out rates for some interventions (cesarean section, induction) and outcomes (perinatal death, maternal death) for a local hospital, but not for individual obstetricians. For rates of episiotomies and cesarean sections, research has shown enormous variation among individual providers, even within the same hospital, demonstrating the lack of evidence for the high rates of these practices. A midwife is trained to observe and monitor, but not to intervene unless there is clear justification, because her focus is on supporting the normal birth, not getting in the way. For most women choosing a midwife, especially outside the hospital, she can be pretty sure she will not be subjected to any unnecessary interventions.
Nearly 25 years ago, when intervention rates were far lower than today, I was pregnant with my first baby. My husband (a scientist, and from a medical family) and I did extensive research regarding our options and birth practices. Even then, there was plenty of evidence that unless you had a real medical reason to be in a hospital to give birth, you would be better off at home with a midwife. As a result, at 7 ½ months we switched to a home birth midwife (who happened to be one of very few CNMs with a home birth practice at that time). It was one of the best decisions I’ve ever made. Not only did I get outstanding care and support, but my midwife competently, safely and non-intrusively addressed a minor “variation on normal”; had I been in the hospital, standard practice would almost certainly have caused a life-threatening hemorrhage. Glad I was at home with a midwife!
Susan Hodges
Disclosure: I am a founding member of and current president of Citizens for Midwifery, a national non-profit organization providing information about midwives and the Midwives Model of Care.
Thank you for discussing this subject. I delivered my first 2 children at home with lay midwives, with positive outcomes. These births were Wisconsin and Florida. When I moved back to MA, and became pregnant, I sought the services of a midwife that would help with the delivery at home. Living in Gloucester, I was unable to find a lay midwife from the Boston area who would travel to Cape Ann. There were lay midwives available in the Pioneer Valley, but again, the distance was too great. Reluctantly, I agreed to have my baby at the North Shore Birth Center at Beverly Hospital. The nurse-midwives provided excellent, professional care. My son was born in a small home-like room, and my 9 year old daughter and 2 year old son were both present, along with my husband. We drove home that evening and settled into our new home lives as a family of 5. It was strange to drive with a new baby: one of the reasons I believe in home birth is that the laboring woman should have people come to her, not travel to another place. It is strange that one of the first experiences a baby has is to be put into a carseat and driven home!
I do not think homebirth is for everyone, and I recognize that there are risks. However, for me and my family, having our children at home was the most normal, natural thing to do.
The documentary “The Business of Being Born” by Rikki Lake is an excellent documentary about this very topic. It does not pretend to be unbiased, but it does encourage women to believe in the power of their bodies, when pregnant and laboring, and it does illustrate the cycle of drugs/c-sections that many women undergo while delivering in a traditional hospital.
Thanks again!
One of the key questions to ask is, “Why are doctors allowed to regulate the practice of midwifery?” It is important to make the distinction that the practice of obstetrics is a surgical specialty whose training focuses mainly on pathology, while the practice of midwifery focuses on normal, healthy birth. They are two completely different training tracks. Do orthodontists regulate dentists? Do surgeons regulate internists? No. Each group regulates itself. Back in the late 1800’s, when doctors were mostly males, and midwives were almost all women, this construct of doctors regulating midwives grew from gender imbalances and sociological power structures. At the time, doctors were working to make inroads into the business of birth and painted midwives as backwards, dirty, uneducated women and virtually forced them completely out of practice. The practice of midwifery never completely died out, and as it had a resurgence in the mid-1900’s, again, doctors forced it under their umbrella. The structure that is used in other countries (which have much better maternal and infant mortality stats than the U.S.) is that midwives have groups that regulate their own practice, just as doctors have theirs. The groups work in partnership with each other, as colleagues of equal standing.
The evidence supports the practice of homebirth with trained, certified midwives. The evidence does not distinguish between certifications, showing that all certified midwifery groups have excellent outcomes, even when they practice outside of hospitals. The evidence supports both the practice of midwifery, and the practice of homebirth (which are separate practices as another comment wisely points out.)
American midwives, including Certified Nurse Midwives (CNM), Certified Midwives (CM), and Certified Professional Midwives (CPM), are perfectly capable of policing their own profession, just as doctors do for themselves. The arguing that goes on between the American College of Obstetricians and Gynecologists (ACOG), CNM’s, CM’s, and CPM’s has more to do with politics than with evidence and outcomes. There are around 100,000 obstetricians in the U.S., but only around 10,000 midwives. Take a guess as to who has more power, money, and influence when it comes to lobbying the legislature? The bottom line is that midwifery does not belong in a vertical power structure under obstetrics, it belongs separate and equal, with midwives and doctors working side by side for the health and well-being of women and children. That is what legislature should support.
Particularly in this era of healthcare reform, midwifery stands out as a model for reducing costs, to the tune of billions of dollars, and improving outcomes. Massachusetts would do well to untether midwifery and let it grow within the state.
People who study the way we assess risk make an important point here. Sometimes we think about risk in terms of probability (“It’s riskier to ride in a car than in a plane.”), but more often we think about risk in terms of possibility (“I would certainly die in a plane crash.”) While I think home birth sounds appealing, the “what ifs” and worst case possibilities–regardless of the probabilities–make me want a hospital birth.
I had a hospital birth with my first child 30 years ago. After reading Suzanne Arms “Immaculate Deception” I was concerned about giving birth in the hospital so I opted for a hospital midwife and a hospital birth. All was fine until I went into labor. It was a long labor and was interfered with, morphine, pitocin, etc. I eventually had an emergency C-Section after a 45 hour labor. I could not do that again.
Four years later I planned a home birth with a home birth midwife, who was also a nurse which was technically not legal. At that time there was one doctor left in Boston who would back up a midwife attending a home birth. I doubt there are any today but i don’t know. I went into labor at home with three midwives. We made a plan with a local ambulance company to be on call and knew which hospital we’d go to if there were complications. There was some excess bleeding during the later stages of my labor so we decided to go to the hospital. I was in transition in the ambulance but the transfer was successful. In the labor room i gave birth squatting on the floor, with my husband holding me up and the midwife on her back catching the perfect baby boy. The doctor was taking pictures. It was a beautiful birth and i went home that day. A far cry from the terrible experience with my first child where, I feel, being in the hospital made the process more dangerous. I experienced a postpartum depression after that birth and a 10 day stay in the hospital.
I fully support midwives being able to be licensed to attend homebirths in Massachusetts and their ability to connect with back up doctors and hospitals to provide the support if irregularities arise. I was asked to be in a radio program with midwives 27 years ago to discuss this whole issue. Seems we’ve made no progress. We used to say, our hairdresser can call herself a midwife and attend a homebirth, but a nurse or a nurse-midwife cannot. Something’s wrong here.
There is HUGE problems with maternity care in this country, and one of the biggest problems is the lack of VBAC access. VBAC rates in 1996 were the highest, and one of the LOWEST maternal mortality rates.
Why a Rado-Boston show about midwives without on-air representation by a midwife?
Great topic. If interested, here are the Massachusetts cesarean rates that are above the national rate of 31.8%.
South Shore Hospital – Weymouth 44.3
Melrose-Wakefield Hospital – Melrose 43.7
Caritas Holy Family Hospital & Medical Ctr-Methuen 42.9
Beth Israel Deaconess Medical Center – Boston 42.0
Metrowest Medical Center- FUC- Framingham 41.8
Caritas St. Elizabeth’s Medical Center of Boston 40.4
Brockton Hospital – Brockton 39.9
Caritas Good Samaritan Medical Center – Brockton 39.7
Caritas Norwood Hospital – Norwood 39.7
Milford Regional Medical Center – Milford 38.9
Tufts-New England Medical Center Hospital – Boston 37.7
Emerson Hospital – Concord 37.5
Newton Wellesley Hospital – Newton 37.2
Falmouth Hospital – Falmouth 36.3
Sturdy Memorial Hospital – Attleboro 35.9
Winchester Hospital – Winchester 35.3
Harrington Memorial Hospital – Southbridge 35.2
Saints Memorial Medical Ctr.-St. John’s Campus – Lowell 35.2
Brigham And Women’s Hospital – Boston 34.1
Charlton Memorial Hospital Fall River 33.7
Lawrence General Hospital – Lawrence 33.5
Morton Hospital – Taunton 33.5
Massachusetts General Hospital – Boston 32.7
Beverly Hospital – Beverly 32.4
Jordan Hospital – Plymouth 32.1
Lowell General Hospital – Lowell 32.0
I am hesitant to comment on this because I don’t want my case to be used as an argument against midwifery or homebirth…but decided that’s exactly why I need to share my story. I lost my baby recently during a midwife-assisted homebirth. It was the most painful, devastating thing my partner and I have either experienced. People are often shocked to hear that we both still fully support midwifery *and* the option of homebirth for women and families.
Ours was an extremely thoughtful, well-researched decision and we really believed we were making the healthiest, most nurturing choice for our baby. Though we don’t yet fully understand what happened during our birth, we are coming to believe that the death of our daughter could have been prevented by better training on the part of our midwife. We are fully supportive of legislation that regulates the certification and training of midwives. Bringing this consistency of care and accountability to the practice of homebirth midwifery would make the option of homebirth a safer option for families, hopefully preventing others from experiencing what we have been through (and will be living with for the rest of our lives).
For people who don’t understand our continued support of midwifery, I liken it to those who’ve lost a loved one to a drunk driving accident. When that happens, people don’t advocate for eliminating driving altogether. It’s the laws and education around drunk driving that need to be scrutinized in that case. It’s the same with midwifery and homebirth…I absolutely believe that with comprehensive regulations and training guidelines, midwifery and homebirth could be the best, healthiest option for many, if not most, women.
Well I’m glad the show happened but am saddened and offended that no one bothered to include even a single midwife in a supposed discussion about midwifery. Same ol same ol in Massachusetts I guess.
I missed the first part of the show…. was there really not a guest who is a midwife? I am shocked and disappointed. The more education around homebirth for the general public and regulation for those who are practicing, the healthier our mothers and babies will be.
At Mt. Auburn Hospital’s Center for Women, I was told, since I had chosen to be cared for by a team of midwives, that I need not choose an OB/GYN to follow my pregnancy.
Although the CNMs consulted with whatever OB/GYN was on call for prenatal issues beyond their expertise – in my case these included vaginal prolapse and a pre-term labor scare – the final result was a disjointed care throughout the pregnancy an beyond. I was a week overdue, had a ten pound baby by emergency C-Section and was later re-hospitalized and underwent several surgeries for a life-threatening bacterial infection of my C-Section incision.
I don’t blame the CNMs for these complications. But it did seem that Mt. Auburn’s was relying on CNMs to pick up the OB/GYN slack for their overbooked Center for Women.
I can’t help feeling that because CNMs operate from the premise that all women possess the inner biological and emotional resources to give birth without intervention, they are more likely to approach childbirth ideologically – missing sometimes obvious signs of very real “pathology” of childbirth.
For example, days after I returned home with my baby, and I called to report that I had a fever and oozing pus from my C-Section incision, I was put in touch with the CNM on call – because I had no OB/GYN. She told me that “draining is good”, to wait and see. At my mother’s urging, I finally went to the ER the next day with acute infection. I almost died. It took me months to recover physically with visiting wound care nurses. And obviously emotionally, I’m still not over it.
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Lori said:
“People who study the way we assess risk make an important point here. Sometimes we think about risk in terms of probability (”It’s riskier to ride in a car than in a plane.”), but more often we think about risk in terms of possibility (”I would certainly die in a plane crash.”) While I think home birth sounds appealing, the “what ifs” and worst case possibilities–regardless of the probabilities–make me want a hospital birth.”
Yes, there are risks to all births, but there are problems with hospital births, too. Everyone should evaluate the risks and many will make different choices.
Are hospital births really safer? Is home birth just as safe? How much does the environment (location, support system, comfort, protocols) effect birth outcomes? How much does your provider shape your birth experience?
Hospital risk: lets just take one example, the risk of an unnecessary c-section. c-section rate should be 10-15% it is currently often 20-40% in hospitals… What’s your c-section rate is one very valid question to use to evaluate a doctor or midwife.
I know I didn’t feel safer with my first birth because I was in a hospital. I felt like I was a patient. I felt like I had to ask permission for everything. I felt like I put others in charge of me and it was hard to speak up and be heard. I felt pretty helpless because of the ‘hospital-like’ environment, something I had not anticipated and something my provider did not recognize.
Homebirth: The ideal situation is that a good midwife recognizes a problem early on and transfers before an emergency develops. Midwives are also trained and equipped to deal with emergencies if something unforeseen happens. Yes there is a transfer involved, but every hospital also has to assemble a team if there is an unexpected emergency. Some transport times are not going to change this much if the midwife, hospital and backup doctors are working as a team (perhaps this is one reason why the majority of countries using midwives as standard birth caregivers have better outcomes than the US- normal births are handled by midwives at home and in the hospital and doctors intervene only when there are problems)
For many that choose midwives and/or homebirth we look at the standard American hospital birth and look at the possibilities for there to be a cascade of intervention caused by hospital protocols. In addition it just is not the environment one is going to feel the most relaxed in. Some mothers will choose to be in a hospital just in case they need a c-section. Others will choose a midwife and/or homebirth to avoid being one of those unnecessary c-sections and to be in the environment that they feel supports them best.
As for cost, for what it is worth, take my case: A homebirth midwife is around $3-5,000 where I live. My first hospital birth (a vaginal birth with epidural and induction, and standard 3 day hospital stay) cost us $3,000 out of pocket because our insurance copay was 10%- so over $30,000 for a fairly standard birth, even though I had intended to go natural. It sickens me that the anesthesiologist got paid as much as my midwife did for his 15 minute ’service’ than for their care for 9 months and postpartum followups. I also had the standard problems that could have been caused by these interventions, sleepy baby, difficulty nursing, and slight ppd.
My 2nd birth was around $4,000 for a natural birth with midwife with a overnight hospital stay. I choose to pay and additional $800 for a doula, classes and other support. My midwife who provided prenatal can postpartum care still got paid less for all her service than the hospital charged for room rentals and 1 night. We ended up paying just over $1000 for this birth with our insurance company paying the rest.
There is no question that our maternity system needs to be changed. I believe that midwives have the ability both in hospitals and in homes to provide the best maternity care for the majority of mothers and babies.
Jessica
I had my first child in the hospital with a doula and my second and third children at home with midwives. I am sure I would have ended up with a c-section the first time around if it had not been for my doula (who is now a CPM). My homebirths were amazing empowering experiences with healthy babies and a happy mother. I would never go back to a hospital unless there was a medical emergency. Maternity care has become driven by fear and greed and it’s the women and children who pay the price.
Thank you for putting on this radio discussion. I would like to make a few comments:
1) Why was a CPM not included in the discussion? Especially while Angela Aslani was allowed to negatively comment on CPMs clearly without a proper understanding of the CPM educational route. Her simplified interpretation of requirements was made to project an idea of incompetence. She should make herself more familiar with the North American Registry of Midwives’ CPM credentials for certification. Expecting CNMs (practicing in very different settings) to have identical training experience as midwives practicing at home is also unrealistic. The education for a hospital bound CNM is naturally different than that of a CPM due to the difference in setting and the tools at hand – in addition, it could be said that the CNM education does not necessarily prepare them for birth at home!
2) Her comment regarding the CPMs as having “limited” training when discussing the use of life saving needed medications (such as Pitocin in case of hemorrhage) is also incorrect. Midwives are trained to use these drugs competently and responsibly. I, for example, am a CPM and have a license in the State of Texas and have spent over 2 years of the past 12 years working in an El Paso Birthing Center where I was given ample training and experience with unexpected complications and the responsible use of the needed drugs to correct them.
3) Another example of Angela Aslami’s lack of understanding of homebirth was her comment implying the non use of fetal monitors at home to record fetal heart tones. The fetascope is not the only instrument for listening to heart tones at home! Although not the same machine printing out findings on paper to which the mother is continuously attached (as in a hospital setting), CPMs do use dopplers to listen to fetal heart tones which can also be heard by others assisting at the birth! Fetal heart tones are monitored frequently, heard by more than one attendant, and these findings are properly documented.
Also – thank you to Susan Hodges, Judy Norsigian, and Michal Klau-Stevens for your informative comments above!
Sybille Andersen, CPM
Nantucket, MA
Wow- glad this show was aired- some feedback? Hmmmm, Is anyone noticing that we are all supposed to drop down and worship the hospital birth experience in Massachusetts- why so much talk of CNMs what about the rest of practicing midwives? Why not talk about the fact that we need ALL midwives in Massachusetts to be regulated. Right now only one type is regulated- the CNM. There is but one place to birth with them- in the hospital- or at only one of three birth centers in Massachusetts.
Some things I noticed:
Eugene Declercq provided the most compelling reasons for a board of midwifery in Massachusetts to be created. I don’t know why we have to continually defend midwifery against medicine-his analysis of the data should compel people to work for this change. I am so glad he was featured in this show. I don’t know how after listening to his perfectly reasonable arguments people wouldn’t get behind this bill and push it along. We have everything to gain: regulation, autonomy, options for a better birth and money saved.
In the best words of the entire show by Eugene Declercq: if you don’t want a home birth, don’t have one; however we must protect all the mothers, and their partners who choose this option. A board of midwifery will do so and as Whitney the previous poster noted- a board of midwifery will prevent another tragedy like the one they experienced (and will for a lifetime). I know they have no recourse if they decide to seek it- every home birth parent gets a “better luck next time” clause from the State of Massachusetts and the doctors who are holding this bill back.
I have to say as well shame on every Massachusetts legislator that listens to doctor’s special interest rhetoric and does nothing to pass this bill session after session. What are we paying you for? Now that we have heard for ourselves the words “defensive medicine” and learned of what it looks like: it’s money and outcomes first, patient second, we may want to speed this bill to the finish line.
Boo-hiss for featuring Dr. Angela Anslami- she is now known in my family as the great exagerator. In her July 28th, 2009 testimony at the state house she apparently could not help herself and needed to say not once, but twice “adorable, dead, blue, baby” when exaggerating about a homebirth transport that she was privy to. I saw the baby picture of the child she referred to and her lack of decorum and blatant dishonesty needs to be brought to the public’s attention. If the family were there would she have stooped so low? I considered her “smoke and mirrors show for legislators” so low brow, sensationalized and desperate and now that I hear her views on childbirth… she’s even more frightening than I knew. I have come to know the mother who experienced the care of Dr. Anslami- in the above mentioned incident and well, let’s just say someone isn’t telling the truth here. We should be very cautious about accepting anything she claims without first checking it for its factual basis. (btw: her hospital has a 39% c-section rate, go in there for a baby come out with a new surgery.)
And lastly, why parade all the hero worship stories about docs saving the lives of babies- the caller from Alexandria (isn’t that Virginia) whose husband is a doctor, well good for you- the interventions were there. This does not mean that every birth has to be attended by an OB- midwives, CNMs and CPMs are all trained in neonatal resuscitation. To feature her and the other hospital loving mothers devalues what many mothers want, a birth free of unnecessary interventions that are foisted upon them by over anxious, lawsuit fearing doctors.
Georgina Parker
Massachusetts Resident
Supporter of Senate Bill 847, and House Bill 2080
Pass it in 2010!!!!!
For those who would like to read more on this subject for themselves, I recommend the following books, all relatively recently published:
Born in the USA: How a Broken Maternity System Must be Fixed to Put Women and Children First, by Marsen Wagner, MD, MS (He is an OB-GYN, scientist – which most doctors are not- public health expert and former Director of Women’s and Children’s Health at the World Health Organization.)
Ina May’s Guide to Childbirth, by Ina May Gaskin (Ina May Gaskin is perhaps the most celebrated, most expert midwife in this country, and has much better outcomes for mothers and babies than found for average hospital births.)
Pushed: The Painful Truth About Childbirth and Modern Maternity Care, by Jennifer Block (She is a journalist, former editor of Ms. and the revised Our Bodies, Ourselves.)
Immaculate Deception II: Myth, Magic & Birth, by Suzanne Arms (She is decades-long advocate for midwives and birth centers.)
After reading these books, and seeing the statistics within, you will question whether hospital births really are safest for the majority of women, or only for those with complications. Also, Dr. Wagner makes the excellent point that even if you are in a hospital and an emergency arises, it is not unusual for 20 minutes or even much more time to elapse before the necessary intervention occurs – people are mistaken by hollywood that as soon as an emergency happens in a hospital, there is an instance response. From Dr. Wagner’s book I took away that if you give birth at home or a birthing center with a competent midwife, and can transport to a hospital within 1/2 and hour in case of complications, it is unlikely that the outcome will be different than if you were in the hospital to begin with.
All in all, I thought this was a great show about an important topic, and I appreciated the range of perspectives you presented. I am a certified professional midwife, (CPM) and I wanted to make a comment about my training: It was much more comprehensive than Dr. Anslami suggested. Before I qualified to sit for my the certifying exam that made me a CPM, I had to document my training in IV therapy, suturing, pharmacology, prenatal care and other clinical skills. I had to show that I was educated and practiced at recognizing and responding to common complications, such as hemorrhage, and that I was competent at neonatal resucitation. I had attended over 150 births when I sat my exam, including 60 as primary midwife under supervision. I think there is a common stereotype of midwives as uneducated, and this is simply not true for the vast, vast majority of us. Though there are several different educational routes available to CPMs, all valid and important, in my opinion, all educational routes are required to enable a CPM to demonstrate the same competencies, including recognizing and responding to the complications that Dr. Anslami mentioned. The process of becoming a CPM is designed to make CPMs experts in normal birth. When something deviates from the norm during pregancy, labor or birth, I am very grateful that there are OBs like Dr. Anslami that I can transport my clients to. When a woman needs high-risk care for an abnormal condition, obstetrics and obstetricians have a lot to offer. But when birth is normal, and most are, well-trained midwives are the best option for many women, because we recognize the birth process for what it is, and support it, while constantly monitoring for deviations from the norm. My ideal vision for maternity care in the US is one where midwives and doctors work together, with midwives caring for low-risk women and acting as the gatekeepers, referring higher risk women to OB care. I also think that low interventative birth needs to become the norm, except when intervention is truly needed, and we need to work on making sure that one in three women does not need to give birth by major surgery.
Thank you for opening this discussion.
I appreciate the previous poster’s comments. The frustrating part of doctors quoting the training of CPMs is that they always minimize the training- claim that CPMs have no formal training yet refuse to accept the truth: that these are NOCA and MEAC accredited programs, that the Department of Education lends financial support to these programs and that some CPM training Programs are comparable to the didactic portion of nursing/CNM programs. This would be too much for them to admit- that they can’t quite get their grips on CPMs who have been historically independent practitioners, unlike the CNMs they supervise in their practices and in hospitals. The worst part is that it seems like legislatorsin Massachusetts believe them based only on their “dr.” and have turned a deaf ear to the possibility that a CPM is as well trained as an obstetrician in the care of low risk pregnant women and can deliver a baby in an uncomplicated birth just as easily as they can. and for 1/3 of the cost. Even more frightening to doctors is that a CPM is as trained if not better suited to deliver babies out of the hospital than a CNM. Who would they have their grips in if we had independent midwives in Massachusetts? Only midwives who have delivered babies and trained in and out of the hospital setting are qualified to deliver babies at a home birth.The CPM is uniquely qualified and capable.
In states where CPMs, CNMs and Doctors all practice in cooperation there is a better climate and stadard of care for pregnant women and birth options are by far safer. People do not “call” themselves midwives who are not qualified because there is a system in place that allows consumers to choose qualified providers,and one that keeps mothers and babies safe.
When I lived in Boston during and after undergrad, I knew nothing about natural birth. After seeking out a more intuitive and natural existance, I came to understand the great benefits of choosing a natural birth for my child. Now after a wonderful unassisted homebirth, I know the necessary worth, knowledge, and devotion of a midwife! I am grateful I could consult an expert when needed. I chose only the best people possible to show up for me and my newborn daughter. I believe how we come into this world totally shapes our existance. I encourage anyone considering a hospital birth to educate themselves on “what it might be like at home”. Then of course, each mom should choose the best possible path for them. I am sad to say homebirth midwives are acting illegally in the state of GA. I am sorry for all those mamas and babies who won’t get the chance for that level of connection with eachother and their community. Can’t we go back to the old way of referral is enough, and not have this profession be government regulated? What a blessing that would be!!!!!
[...] NPR news station, WBUR, recently featured a program on midwives, “Midwifery in Massachusetts” (archived [...]
Thank you for the topic and the discussion. We need to keep it in the forefront until attitudes change. As a HypnoBirthing instructor I find my area in particular (South Coast area) to be in need of a progressive boost. There is no reason why in healthy pregnancies midwives and alternative birthing methods cannot be utilized.