I feel like I need to clarify some of what I said in the previous post about birth centers. But first I do want to apologize for the "sharpening their teeth" comment I made about the medical associations, because it wasn't fair and I shouldn't have let my frustration get the best of me. The comment was mostly a vent of frustration about last year. The AMA hires a full-time lobbyist in the Utah Legislature and last year one of her main jobs was to get a bill passed that would greatly limit midwifery care in Utah. I don't mind that so much-- she was just doing her job, but it was VERY frustrating when the medical community (physicians and the Utah Medical Association) wouldn't sit down and work out a compromise bill. Instead they kept pushing their own agenda (and creating new bills) without being willing to sit down and discuss the issues with the other side. If fact, the physicians and medical association representatives who were told by the legislature to meet with the midwives and work out a compromise failed to show up for the meetings-- twice. As a citizen, it was really frustrating to feel like just because I didn't have the money to hire a full-time lobbyist my opinions and rights were being pushed aside.
So that is where the comment came from, and I am VERY sorry if I offend any physicians or medical personnel because I didn't mean to. I realize that physicians and nurses always have their clients well-being and health as their first priority and just want to make sure everyone is receiving optimal care. I respect that and admire that. I realize that doctors and nurses have really hard jobs and I don't think they spend all those hours just to make money. All the medical personnel I know are wonderful, intelligent, kind and giving people and I appreciate what they do. Again I apologize if I was rude or ugly.
The frustration I feel about the conflict between the midwifery and medical communities mainly springs from the fact that it seems like some members of the medical community are not willing to give midwifery a chance or to look at it with open eyes. They are VERY passionate in their opposition to out of hospital births, especially home births, but I know of very few OB/GYNs or nurses who have ever attended a home birth or a birth center birth. All they ever see are the less than 10% of births that are transferred to the hospital because the birth was no longer going smoothly or normally, or they see women brought in by lay midwives who aren't certified and who don't have the credentials to be delivering babies. It isn't fair to base ones opinion of midwifery care on the exceptions rather than on the 90% of women who have successful out of hospital deliveries with qualified midwives. I just wish that there was more of open minded discussion going on in Utah--there are in some other parts of the country-- but in Utah it seems like it is hard to get the medical community to sit down and talk about midwifery as a viable option. Which is why I think it is so important for people, on both sides, to attend the meeting next week!
There were several comments on the last post that I wanted to address. It was mentioned that my logic was bad because I said that hospitals were opposed to birth centers because they were competition, but then said that Utah only had one licensed birth center-- therefore making that argument illogical. I guess I should have clarified better and said that I wasn't just talking about Utah. The birth center battle is a nation-wide battle and lots of birth centers around the country have been forced to close. I don't really think it is a matter of money or competition, but rather a matter of clashing birth philosophies-- I'll talk more about that further down.
Also it was asked if I had looked into the reasons the medical associations were challenging birth centers, which I have. Here is a link to the document outlining the birth center representatives proposed changes and here is the Utah Hospital Associations proposed changes. They are pretty much in agreement except over three things:
1) The hospitals want a hospital transfer agreement for every client, rather than a written transfer plan for the whole facility. Which doesn't seem like a big deal, but would greatly limit birth centers ability to operate normally and smoothly. There are 22 states where these agreements are requires and half of them no longer have operating birth centers.
2) The birth center wants to allow Certified Nurse Midwives (midwives who are nurses first and then have two years of midwifery training) and Licensed Direct-Entry Midwives (midwives who are not nurses but who are licensed by the state and have 3-4 years of midwifery training) to deliver at birth centers. The hospitals say that only Certified Nurse Midwives should be allowed to deliver at birth centers.
3) Birth centers want to be able to do vaginal births after cesarean (VBACs) under certain conditions, which are the same ones already in place by the Legislature for LDEMs delivering at home. These are the conditions:
2. Client has a documented low transverse incision
3. Ultrasound demonstrates placental location is not anterior and low lying (ie, not over an old scar)
4. Client has signed a VBAC-specific informed consent
5. Client has had one or more successful prior VBACs
6. Client meets all other risk criteria of the birth center
I don't think the argument really is about safety or money, because numerous research shows that out-of-hospital births, when attend to by a trained midwife, are just as safe for low-risk women as birthing in the hospital. And only about 2% of women in the US have their babies outside of hospitals, so they really aren't that much competition to hospitals. I think what the debate mostly comes down to is a difference in philosophies of birth. The midwifery philosophy is that birth is a natural, normal and non-medical event in a woman's life and the less you interfere with a natural process the smoother it will go. Unless of course it isn't going normally and then medical actions should be taken to help. The medical philosophy of birth is similar in that birth is a normal, natural thing but that it is a medical event and that a woman's care needs to be managed and handled with medical interventions-- even if everything is going normal. Both of these philosophies have their ups and their downs, and research supports both sides-- it is up to individuals to decide which one they believe in. It doesn't really matter to me which philosophy a person believes in, I just believe that women have the right to choose which type of care they receive. And with the current lack of cooperation between midwifery and medical communities in Utah, a woman's right to choose a midwifery model of care is being threatened, and that is what I am passionate about.
Thanks for giving me the chance to better explain myself-- next time I will watch myself better and not let my passions carry me away. It doesn't do either side any good to sling mud, it just makes the gap harder to bridge. I REALLY do appreciate all the opposing comments I got (even though it would be nice to hear from you who agree with me:) because I think it opens up an important conversation, and hopefully helps both sides understand each other better. So, I really do appreciate the opposing opinions and hope that we can all still be friends, even if we disagree! :)
9 comments:
Thanks for the clari fications. I do disagree quite strongly with the idea that VBACs should be done at birth centers. A VBAC is a very dangerous procedure in approximately 1% of the population (even given your criteria) with severe complications such as fetal anoxic encephalopathy, fetal death, and uterine rupture and maternal death. While 70-80% of VBACs go without a hitch, 20-30% morbidity with severe consequences is markedly high for an entirely elective procedure. Both the American society of Anesthesiology, and the American College of Obstetrics and Gynecology have issued a joint statement mandating that any facility that does VBAC should have surgery and anesthesiology services immediately available. We don't even do them at our hospital even though we have OB/Gyns in house and anesthesiologists in house just because we may be performing other procedures at the time.
Heather, I think you hear more from those who disagree because you know more about the issue than most and are one of the few who have seen the advantage of the non-majority way.
It's easy to agree with what the AMA or UMA might say because it's convenient for at least 98% of us, which is a comparable statistic to the amount of hospitals to birth centers. A lot of people who disagree with you have had good experiences with the hospitals and so don't see anything wrong with them.
Now that I've tried to be diplomatic, what I really want to say is:
Just because they offer it doesn't mean we need it. I compare hospitals and hospital births to the Home Depots and Lowes out there because they are big organizations that influence our activities and shut out the competition. For example, it's like planning to add a bathroom to your house. A simple functional design may become more and more complicated (and expensive) as you go to the mega-store and see all the options available to you. However, there are even more options than the ones you see. If you're lucky you can still go to another place like Standard Plumbing Supply where they specialize in plumbing and have even more options and better quality. Unfortunately, many Home Depots and Lowes have put the specialists out of business so you can't find what you want anymore. And that is what I see in the birth philosophy debate.
The AMA and UMA (cf. Home Depot and Lowes) are convenient but lack what everybody wants. For those that don't want to birth the way AMA and UMA dictate, it's a battle--and like we see elsewhere: a two-state solution doesn't last long. A better solution needs to be found.
I appreciate your ability to look into the other side of the story and share it's version with us. I think that if anybody needs to be open minded it's those of us who haven't invested the time into understanding both sides.
Jon;
I'd reckon that in spite of Jon's comments that insinuate that I haven't invested time or don't understand the issue, I've attended more births of women who at least started out at a birthing center or at home than either of you, read more peer-reviewed literature and studies on the subject and frankly spent more time with parturients that either of you put together. I've been a part of about 87 home births or birthing center births, and over 4800 other deliveries. Granted, I have the bias that they are usually home births that have gone bad and needed a physician. However, that the solution to a problem is to go to someone who can handle the situation that is beyond the scope of the nurse midwife implies that the person who handles the solution understands the scope of the problem and perhaps even a broader scope.
In fact, because of issues at our hospital regarding VBACs has come up within the past week, I have read 18 peer review articles on the subject with the past 48 hours. The largest study of VBACs (which I was quoting to Heather) studied 17898 women for vaginal delivery after c-section, and 15801 women with elective c-section. The VBAC women had a 0.7% complication rate including 4.6 symptomatic uterine ruptures and 12 instances of fetal anoxic encephalopathy. The c-section women had none.
Jon, your argument is flawed. It is comparing apples to oranges. Following your logic, Standard Plumbing (your analogy to the birthing center) offers more expanded services and is superior to Lowe's or Home Depot, which offer some of the plumbing services as well as other electrical services. The difference is that the hospital can handle very sick, emergency cases, and cases that turn into emergencies, while the birthing center cannot. None of the CNM can do an emergency caesarian section.
A better analogy may be the following: You are studying engineering. You likely need to study structures to be able to design a bridge that won't fall down. Now, many bridges are built that don't require an engineer. There may build very some very good bridges, and some that are very pretty. The Cougar ranch bridge is a good example. It has stood the test of time, and been pretty safe. However, we rely on engineers to build the Golden Gate bridge because it would be very dangerous if that bridge failed, and it would kill people. When we get to a bridge that may be iffy, we turn to an engineer. Certainly, the engineers are the people who understand bridges the best. They may not be the prettiest bridges, but in general, they last.
I believe there is a place for birthing centers. We work with CNM all the time, and have women who have wonderful experiences at birthing centers. However, I don't feel like it is safe for them to do VBACs; our hospital with available surgery teams doesn't even do VBACs. However, CNM's purview is and needs to be limited IN SOME SITUATIONS. It is a matter of safety. I know Heather had a wonderful experience during her birthing experience, and I'm delighted for her. However, for the safety of the infant, sometimes a birthing center isn't prudent.
Now that I've tried to be diplomatic, Jon, what I really want to say is this:
You have no idea what you are talking about, and it is infuriating for you to insinuate that either you or Heather understands the issues regarding safety of parturients more than those of us who have spent years of our lives, thousands of hours of schooling,that even those same certified nurse midwives who she works for need help to manage when the situation goes awry.
Where do you get off? I'd bet that in the past two months, I've been up at 2:00am performing life saving techniques on parturients more frequently than you've ever even been up at 2:00am in your life.
Thanks for all the research and thought you put into this, Heather. It certainly is a LOT to think about. I definitely agree with you that a woman should be able to choose where she will give birth and who her caregiver will be. I know that the more women are educated about these choices, the more they will be able to make wise decisions not based on tradition alone, but what is best for their family. Anything worth deciding about should indeed involve much research on ALL aspects of the issue, consultation with professionals as well as family and other respected individuals in the woman's life, and a whole lot of prayer. Definitely protecting a woman's right to choose how and where she'll give birth is an issue worth fighting for.
Whatever each individual care provider's reasons may be for using technology in birth, the fact is that many families simply wish to avoid any unnecessary procedures that they know they can't get away from in a hospital without a LOT of fuss. Many families are becoming educated about their options and are speaking out for evidence-based care. High-tech interventions are meant for high-risk patients, and don't need to be used for the majority of birthing women (normal, healthy, low-risk). Sometimes the optimal location for a family who wants to birth in a "clinical" environment, free from unnecessary interference, is a birth center. Oftentimes, the reason an otherwise healthy laboring woman is hooked up to a bunch of IVs and monitors, confined to her bed, denied food and water, induced or augmented with pitocin, numbed with pain meds and left to reap the consequences is because hospitals are busy places and L&D nurses can't keep a careful, patient and attentive watch for all the "what-ifs" the way a midwife can. The road to danger and dissatisfaction is actually created by the hospital's policy in this regard. Midwives are specially-trained, highly educated, and VERY competent at attending normal, healthy, low-risk births. They are able to take TIME with each family. They let things unfold naturally. They can see any potential problems coming from a mile away. If a transfer becomes necessary (i.e. if a pregnancy or labor becomes abnormal, unhealthy or high-risk), they quickly and easily identify the problem and transfer the mother to the pathologists and/or surgical specialists for her high-risk treatment. That's how it is in EVERY OTHER medical field. If an emergency arises, you go to the hospital. That's why they're there! Overprotecting, overmedicating, overtreating, overpowering care is not "care" at all for some families; it is overkill. It can even be harmful. Planned, natural birth under the supervision of a qualified midwife is a proven, safe and effective system and deserves the respect of the medical community. If you ask me, they could learn a thing or two. (Before a doctor condemns a birth center or homebirth, he should actually witness one. You'd be surprised by how willfully ignorant so many of these doctors confess to be about low-tech birth.)
I've heard it all before about "emergencies can happen at any moment with no warning." Should I hire a pediatrician to babysit my child? (He could fall! He could get into the medicine cabinet! He might get a tummy ache!) How about calling for a police escort every time I drive to the grocery store? (There could be a drunk driver! A child could run in front of my car! I might get distracted and run a red light! I could get hit by a train!) The truth is, accidents do happen, but life has risks. We take driver's ed (childbirth classes), we get a license (trained provider), we buckle our seat belts (back-up plan) and we take responsibility for our safety by being mindful, careful and respectful of the power (vehicle, life) in our hands, and more often than not, we make it through just fine.
p.s. to your friend Nate who likes to read about VBAC, I wonder if he has read this:
http://www.ican-online.org/vbac/critique-acog-bulletin-5-july-1999-vaginal-birth-after-previous-cesarean-section
or this:
http://www.ican-online.org/vbac/fighting-vbac-lash-critiquing-current-research
and I take issue with the implication that just because his hospital has attended "87" birth center and homebirth transfers that it equals a failure on the part of the birth center or homebirth midwives. It's a screwed-up chain of causality. Is he calling midwives irresponsible for identifying a problem and getting those mothers to someone who could attend to the problem, or is he blaming midwives for not being surgeons? Or is he claiming these problems are the direct result of the geographical location of labor? (Because emergencies never happen in L&D wards?) If all you ever see are transfers in labor (which are very rare in Utah), it does not have to follow that all homebirths and birth center births are catastrophes-in-waiting. Again, how many normal, healthy, complication-free homebirths or birth center births has Nate attended?
p.p.s. 4800 community-hospital, assembly-line, in-and-out in 15 minutes, stitch-and-ditch "deliveries" does not make one an expert on normal labor and birth. I would trust an ACOG Fellow to my low-risk maternity care any farther than I could throw him.
*wouldn't trust, that is.
This one goes out to your friend Nate.
To preface this clip: It is intended to lighten one’s mood. It is not meant to be mean-spirited, but it does bring up some issues.
http://www.youtube.com/watch?v=lxOu1DyVQV8
Doctor: “Don’t you worry, we’ll soon have you CURED!”
Woman:“What do I do?”
Doctor:“Yes?”
Woman: “What do I do?”
Doctor:“Nothing dear, you’re not QUALIFIED!”
2nd Doctor: “Leave it to us.”
I for one am truly grateful for competent and caring doctors. I am grateful for the time they dedicate to being educated and experienced. However, to ignore the fact that we in the United States function on a fee-for-service system is ridiculous. It's a system that accompanies our capitalistic society. The bottom line is, the more specialized a particular field of health is, and the more services that are offered, the more money the organization makes. This is only one reason that contributes to the fact that in 1970 about 1 of 19 babies were delivered Caesarean section. Now the total is 1 of every 4, if not more.
Heather, I loved that you point out that mothers, and I would add fathers, need to be EDUCATED. Some people, it seems, think that this means you need a degree and many hours in a hospital to prove it. Again, I'm grateful for the people with degrees, but I still think a mother can know all she needs to know about her pregnancy and birth. Today with the resources we have, like the internet, there is no excuse for a mother to be uneducated.
Birth, like you said, IS and NATURAL PROCESS. I’m quite glad that my wife’s body is more complex than an inanimate object like a bridge. It has this amazing ability to compensate when something does go wrong. The baby’s body has this ability as well, and quite often helps out in the process of birth. Thankfully, when something does go so badly that intervention is necessary, we have specialists who deal with those abnormalities. The problem is where everything is treated as if it needs to be “cured.”
I’m glad your friend is in the medical field and not a writer. I don’t claim to be one myself, but feel educated enough to recognize when an argument has been logically challenged. Saying “you’re wrong” and then going off touting one’s own horn about credentials and experience is not the most persuasive argument, nor is it very flattering. In fact, it’s ugly. :P
Post a Comment