Tuesday, November 30, 2004

Are hospital midwives an endangered species?

Here’s a nice interview with Penny Simpkin. She talks about her own birth experiences, her reaction to the 2003 birth data (see yesterday’s Doulicia post) and the changing climate for caregivers and parents.

As evidence of this, look at recent headlines of nurse-midwife practice closings. Last week a Florida practice announced it was laying off its nurse midwives. This week a North Carolina practice made a similar announcement, this time in North Carolina.

The culprit, as always, is malpractice costs. In the North Carolina practice, even though the midwives were well received by their patients and their physician partners and despite the fact that their practice was growing in size, they were the expendable piece in an office facing $250,000 annual malpractice insurance premiums.

Interestingly, one of the financial problems was the hospital’s policy that a physician must accompany a nurse midwife in the delivery room. So for every CNM-attended birth, an OB had to be present (and paid). This seems extremely wasteful, not to mention insulting to the nurse midwives. But, once more, look to malpractice litigation as the driving force. A hospital that’s named as a defendant in a birth injury or death suit would rather show that a doctor was present supervising the birth than say it trusted the nurse midwives enough to let them deliver on their own. And, sadly, the hospital’s hunch is probably correct: juries are likely to think it more responsible (and therefore less blame-worthy (and therefore less financially liable)) to have doctors delivering babies than nurse midwives.

Something for a rainy day would be to look at jury awards against hospitals/care providers based on whether a CNM or an OB did the delivery. Would we see a bias toward doctors and against nurse midwives? I suspect we would.

Which means that it is very important for anyone who values alternatives in pregnancy and childbirth care to educate at every opportunity. Even though it might not seem worth your breath to explain to your uncle why you chose to have a home birth or to tell your skeptical girlfriends how skilled and trained certified nurse midwives are, please do. You never know who will be selected to a birth malpractice case. The fewer misconceptions they take into the courtroom with them, the better.

Monday, November 29, 2004

Birth in America: 2003 in Review

Doulicia has been wondering about the timing of launching a blog around the holidays. Not because the holidays are crazy and who has a chance to do anything. But because the holidays are when my family gets sick. So I spent last week on my back along with my toddler. Now my spouse is ill. But I’m back in the desk chair. So…

The CDC’s National Center for Health Statistics’ analysis of 2003 births [550 KB PDF] is getting its moment in the sun. What is getting most space is the record high 27.6% cesarean birth rate. It rose from 26.1% in 2002. Not surprisingly, the number of VBACs fell by 70,000 from 2002’s numbers. Page 4 of the report has a graph that shows the VBAC rate’s increase through the early 90s and sharp decline starting in 1997 (correlating to ACOG’s promotion of repeat elective cesareans).

Here’s a link to one of the many articles on the report. And, as a ray of hope, here’s the International Cesarean Awareness Network’s homepage. Doulas be sure to check out Pauline Scott’s book “Sit Up and Take Notice! Positioning Yourself for a Better Birth.”

The numbers also reveal a slight and as-yet-unexplained increase in low birthweight (less than 5 lb. 8 oz) and preterm babies. This despite the fact that teen birth and maternal smoking rates decreased, and the percentage of women seeking prenatal care in their first trimester rose. I wonder if there has been any look into iatrogenic prematurity? The analysis doesn’t include labor induction numbers. If they, too, have risen, then induction and cesarean deliveries could be bringing out babies whose gestational age has been misdiagnosed and who are really not yet ready to be born.

Saturday, November 27, 2004

Late List

Wednesday, November 24, 2004

We Are (not) the World

Anyone who does google birth searches like I do has to notice the impressive amount of international news on midwives, doulas, concern over Cesarean births, etc. It is a pleasant reminder that Birth as An American Rite of Passage is not a global norm.

Currently there is a lot brewing in Australia about midwives: a looming midwife shortage and government provision of indemnity insurance.

A recent report from the Welsh government is pleased at the rise in home births. “The Welsh Assembly Government has said it would like to see 10% of all straightforward births in Wales taking place at home.” Zoinks.

In developing countries, as you might expect, things aren’t so perky. Many poor countries are experiencing a shortage of skilled health care providers, including obstetricians and midwives.

The World Health Organization (WHO) has declared maternal and child health the topic of its 2005 World Health Day. As part of its efforts to raise awareness about childbirth around the world, we can now follow a group of six women (from India, Bolivia, Ethiopia, Laos Egypt and England) through their pregnancies. Kind of like “A Baby Story” meets PBS.

The WHO women are now in their seventh month. If you’re pregnant and feeling full of self pity at your swollen ankles or sore back (legitimate complaints), it might give you some perspective to read the accounts of the women in Laos, India and Ethiopia. I was surprised to see that ultrasounds were present in more than half the countries women had access to ultrasound or other means to determine the baby’s gender.

Saturday, November 20, 2004


When I describe what a doula is, I usually begin with “A doula is a woman trained to assist…” From time to time I’ve wondered whether that is completely accurate. Are there male doulas (or “dudelas” as one enthusiastic dad referred to himself)? Yes there are, though not many. And the one I found seems both bitter about his limited success in the area and a bit “off” besides. This could all have to do with his living in Columbus, which although not as conservative as Cincinnati, is still pretty much an “American values” type city.

I am pleased to report (in response to his complaints about male nurses being excluded from the delivery room) there are male nurses operating in the Washtenaw County (Michigan) delivery rooms. The male nurse who helped me through my older son’s birth is now a nurse-midwife in Toldeo. Last year I was at a birth where the labor nurse was a man. No one seemed to think anything of it. Hopefully this is the norm, not the exception

Thursday, November 18, 2004

Ounce of Prevention

This month’s issue of Obstetrics and Gynecology, the official publication of AGOC (American College of Gynecologists and Obstetricians), includes a study of non-hospital VBAC outcomes. The study concludes that VBACs should be performed in hospitals, not birth centers (nor, presumably, at home). It also recommends hospitals increase access to in-hospital care for “midwife/obstetrician teams” during VBACs.

These conclusions seem relatively mild compared to what I was prepared to see. After all, ACOG’s ethics committee was very hands-off in its examination of elective cesarean surgery. That the researchers didn’t cast aspersions on VBACs was encouraging, as was the mention of midwife/obstetrician teams. They did not say VBACs should be turned over to doctors, nor that they are unsafe no matter where they’re performed.

A few interesting numbers from the study:

1. Of 1,453 women to went to the birth center in labor, 24% (or 349 women) were transferred to a hospital during labor. Of those women, 87% (304 women) gave birth vaginally. Add those to the 1104 women who stayed at the birth centers and presumably birthed vaginally, and you get 1408 women of 1453 (or 97%) who birthed vaginally. Yay.

2. Six women in the study had uterine ruptures. Half of the uterine ruptures were in women who had had more than one previous cesarean or had reached 42 weeks’ gestational age.

This last point, as well as the overall outcome of the study, prompted the American College of Nurse Midwives (ACNM) to respond with its own statement that PREVENTING UNNECESSARY C-SECTIONS in the first place should be a top priority. A much stronger stand than that of ACOG’s ethics committee.

Wednesday, November 17, 2004

Keep an Open Mind and an Open Wallet

I am not a shopper. If I could afford a personal shopper, I would have one. It is just too irritating to wander store to store and haul several different sizes back to the dressing room with you (because if you only shop once every 2-3 years like I do, clothing manufacturers can change “size” dimensions on you and it is not reliable to just pick the same size number that you have in your closet). And that’s just clothes. Then there are the hundreds of other items you need: groceries, tools, jam jars, towels, a bike helmet, etc.

And THEN there are “personal” items. I mean men-strew-AY-shun (as our middle school nurse pronounced it) supplies. My personal favorite solution has been to order in bulk from Gaiam. Except that a few years ago they stopped carrying their unbleached pads. Between having a baby and having about 5 boxes already stocked up, it has taken until now for this type of shopping to become an issue.

(Incidentally, I believe it was the unbleached pads that led to my older son’s birth being treated as a “mec birth.” When I got to the hospital late in transition, the triage nurse asked what color the amniotic fluid was. I was, as I said, late in transition, and not in the mood to explain that “well it was hard to tell because I’d also urinated at the time it broke so the toilet paper didn’t reveal much and then I had on dark undies and by the time I thought to put a pad in I wasn’t in the mood to discern the color” so I grunted: “Check the pad.” Which was still attached to my undies lying in a corner of the triage room. She said “oh – it’s a little yellow.” And so Avery was born with a pediatric team in place and whisked off to the cart to have his breathing (despite his loud, lusty wails) assessed. When I got home I realized that even tap water will appear yellow when poured on unbleached fibers. But that’s water under the bridge, so to speak)

In my mind a suitable menstruation product should meet several criteria:

1. Avoid waste.
Think of all the time that goes into making and individually sealing a pad or tampon that gets used for a few hours and then thrown away. Reuse is always an important consideration.

2. Promote the body’s natural processes.
Toxic shock syndrome had largely faded from the spotlight by the time I was an adolescent. Nonetheless, something has always seemed wrong about stuffing a fibrous mass in the vagina to absorb (and in effect block) the flow of blood. I guess tampons have been around in one form or another since the beginning of civilization. And women seem to use them without ill effect. But, okay, they’re just not for me. That includes sea sponges.

3. Avoid chemical exposure. Manufacturers claim to have removed the elements of the bleaching process that produced dioxin. But I’m not enough of a chemist to know whether I should trust that and whether anything that uses a chlorine bleaching process is safe to put in or around one’s vagina.

4. All the usual concerns
Coverage. Portability. Discreetness (especially with two young boys in the house, one of whom equates any blood to serious injury and harm). Comfort.

So what am I left with? The best options seem to be reusable pads or a menstrual cup.

But, honestly, both put me slightly outside my comfort zone. In fact, my former neighbor and I had a discussion about this very topic four or five years ago. We agreed that it made sense and yet we were uneasy at the thought of the storage, cleaning and care of these products. And she had home births and I was a midwife wannabe.

Which is further evidence to me of how out of touch we women (Western Women? American Women? Middle-Class White American Women?) are with our bodies. What cultural messages have we received that make it perfectly acceptable – barely noticeable, really – to put bleached cotton in our vaginas starting at age 13 but leave us unwilling to use a little rubber cup? Or make the use of a disposable pad fine, but not so for a cloth one that we’d have to clean.

Is it the difference of having a white tube for tampon insertion and a pull string for removal versus possibly having to touch ourselves inside and out? Is it an issue of being able to minimize our bloodiness by throwing out the evidence instead of confronting it?

I’m guessing feminists have already written on this (something to dig around for another day), but an argument could easily be made that the mainstream menstruation products make it easy to ignore (that’s the generous description; a militant would say “are designed to rob us of ”) this amazing and significant symbol of our femininity.

Tuesday, November 16, 2004

Heritage Lost

Yesterday the world lost a legendary midwife when Margaret Charles Smith died in Eutaw, Alabama at the age of 99. In that wonderful midwife spirit, she delivered her own children, as well as 3500 others. She handled vaginal deliveries that many doctors today won’t touch -- breech, twin – and all in the comfort of women’s homes.

Not that home birth was her patients' first choice. A portrait of her in Mothering magazine said that her patients were often the poor of the county, African-American women who were prevented from getting professional health care because of race and economics. These women were malnourished. They were haggared. Safe to say they were not monitoring their urine for sugar or protein! Yet not one of them died under Ms. Smith’s care.

A biography of Ms. Smith, Listen to Me Good: The Story of an Alabama Midwife, won the 1995 Helen Hooven Santmyer Prize in Women’s Studies. This prize is awarded for the best manuscript on the contributions of women, their lives and experiences, and their roles in society.

To see what Ms. Smith looked like eight years ago, click here. And click here to see her at a Midwives’ conference in Oregon earlier this year.

Monday, November 15, 2004

False alarm...kind of

For all you women (and men) who’ve been bristling at the news that President Bush might appoint pro-lifer and author of As Jesus Cared for Women: Restoring Women Then and Now, Dr. David Hager, to the U.S. Food and Drug Administration's Reproductive Health Drugs Advisory Committee, you can relax. It has already happened. Two years ago. The e-mails of concern from that time have been resurrected in light of the recent election results. Analysis of the e-mail’s details shows a mixed bag of truth and invention.

And of course I’m joking when I say relax. It is always worth keeping an eye on the committees and individuals who make decisions about our bodies.

Friday, November 12, 2004

This is news?

“Mothers should wait for baby, new study finds.” This was the headline of an article last week. Apparently Utah’s Intermountain Health Care studied 85,000 births and decided it was not a good idea to induce labor, except when medically necessary, before 39 weeks’ gestation. Inducing labor early, it found, produced a higher complication rate, especially for infant respiration.

On the one hand, it’s nice to see an HMO asking its physicians to wait until 39 weeks to induce labor. On the other hand, is anyone surprised that bringing babies out before 40 weeks gestation, especially when the mother’s body has not started labor on its own, can be detrimental?

Of course, what gets the HMO’s attention is cost. And because it is cheaper to keep babies out of the NICU and off ventilators, they decided to adopt a policy that facilitates that. It is worth noting that Intermountain Health Care (IHC)was awarded the top rank in a national survey of nearly 500 integrated health care systems (I wanted to link to the actual survey results, but they were only available for a fee at Modern Healthcare). In the assessment of Verispan, a Chicago consulting firm, IHC’s doctors, hospitals and health plans do the best job of providing for patients’ health.

So think about that. It has taken the best health care provider in the country this long to decide that postponing elective inductions until week 39 is advantageous. What does that mean for the 400+ other HMOs? Will they soon follow suit? Or will it take them a long time to see that, yet again, nature usually knows best?

Thursday, November 11, 2004

Need a Needle?

If you feel like I do about needles, you may want to check out the new J-Tip, which delivers medication without a needle. The article is a little vague about how the medicine gets from the syringe to the subcutaneous (i.e. below-skin) tissue. It reminds me of Philippine psychic surgery in reverse. And with a syringe instead of bare hands. But, hey, if you can give me medicine with out “a little poke and a burn,” please do.

The relevance here is its possible use in numbing up the skin before administering an epidural. I’ve had clients who wanted to avoid an epidural at all costs because there was no way they were going to let someone stick a needle into their back. It might be easier for them to contemplate (not that I’m pushing epidurals here) if they could be assured they wouldn’t feel the big, HUGE epidural needle go in.

And for any woman who’s ever had a misplaced epidural, it looks like help is around the corner. Well, not for the women who’ve already had a misplaced epidural. We can’t rewrite history and provide better pain relief or restore sensation or movement where they’re now numb or paralyzed. But in the future, perhaps, computer aided assessment of when the needle has in fact reached the epidural space will prevent these inconveniences and injuries. According to this press release (from the device’s manufacturer, so let’s acknowledge the bias), epidural placement is presently assessed by the anesthesiologist’s using her thumb to sense a change in pressure. And therein lies the art of anesthesia.

Wednesday, November 10, 2004

In and out of Mainstream

It was refreshing to see “doula” used without a definition – and in a New York Daily News story of all places. It was not refreshing to see the story was about a 56-year-old woman giving birth to twins. I am all for women having babies at later ages than used to be the norm. However, it seems irresponsible to have a baby when you know you’ll be 75 (or dead) when your child graduates from high school.

Still, does the News’ mentioning a doula in passing mean “doula” is making the next step toward mainstream? Instead of each city running its own story explaining what doulas are, they’re now returning to stories with birth at the center, and doulas merely mentioned as part of the birth team.

If doulas are gaining acceptance in the popular culture, it could be that VBACs (vaginal birth after cesarian) are not. A hospital in Frederick, Maryland has stopped performing VBACs, effective September 2004. Not one or two doctors, mind you, but the entire staff. It’s hospital policy. In 2002 the same hospital banned video-cameras in the delivery room. The lawyer in me wonders what’s happened at that hospital lately in the way of medical malpractice suits. If the doctors don’t want their work videotaped and they aren’t comfortable managing VBAC births, perhaps their skills aren’t up to snuff.

In fairness, it may just be that Frederick Memorial Hospital is our VBAC canary. With payoffs for medical malpractice, and birth injury in particular, increasing, who can blame physicians and hospitals for covering their rears? And those are the doctors who choose to stay in the business despite spiraling insurance rates.