The Business of Being Born - #76297

[pillowy]

To me it makes sense that CNMs are limited in what they can do. My logic goes like this:

OBs: Most education, most training, most experience > regulated and overseen by whole systems of people > can do everything related to pregnancy/childbirth

Certified Nurse Midwives: Good (but less) education, good (but less) training, good (but less) experience > regulated and overseen by whole systems of people > can do many things related to pregnancy/childbirth, but are limited in some areas

Certified Professional Midwives (and any other type of unlicensed midwife): Least amount of education, least amount of training, least amount of experience > overseen by no one > can do whatever they want (including taking on high-risk patients) related to pregnancy/childbirth

Becoming licensed may "hurt" the midwife in that it keeps them from doing certain things they want to be able to do, but it keeps the mother and child safe from people with uneven and inadequate educations. Licensing limits the midwife and protects the mother and child (both physically and legally) at the same time. As a CNM explains in this article, "Should midwives carry malpractice insurance?" "Midwives are required to be licensed in the state they are practicing in order to obtain medical malpractice insurance, likely because holding a license establishes a minimum standard for education, scope of practice, and reporting of outcomes."

Breech and twin births are high-risk situations that really should be cared for by an obstetrician. The neonatal mortality rate for a normal, low-risk birth in a hospital is about 0.38/1000. For breech births in a hospital it's 0.8/1000. In the recently released MANA stats, breech births at home attended by a midwife (and I'm not saying all midwives operate at home births, but all these births were overseen by midwives) had a mortality rate of 22.5/1000. That's over 28 times higher than those delivered (possibly by midwives, but most likely by OBs) in a hospital. 28 times! And those were all overseen by midwives.

Twin birth is inherently even riskier. The perinatal mortality rate for twins is 5 times that of singletons, due to complications such as twin-to-twin transfusion syndrome, IUGR, premature labor, low birth weight, increased chances of placental abruption, increased chances of cord prolapse, and increased chances of premature detachment of the placenta. To me it makes sense to limit those pregnancies and labors to care by an obstetrician.

I had a really fast second labor too, though definitely not as fast as yours. At 9 pm my husband left for work and I started getting very, very mild contractions - I thought they were just Braxton Hicks, definitely not real contractions. I went to bed at 11:30. At 1:30 am I woke up with slightly more painful contractions. I called my husband and told him I thought I *might* be in labor. He told me to call my brother-in-law (who lives right next to us), and my brother-in-law came right when I called him and we left to go to the hospital (about 2:00 am). We got to the hospital and were in the room by 2:20, which is when my water broke and my contractions got insanely painful and everybody realized I was having the baby right then. She was born at 2:38. So, less than six hours total, and I didn't even realize I was in labor until the last hour. It freaked me out pretty badly, actually. I don't like the thought that I could've had that baby on the side of the road, with my brother-in-law to catch it. (I actually know someone who had their baby on the side of the road just last week.) And my husband wasn't there during the whole thing, because he had to find someone to come take his place at work. He walked in right as they were holding up the baby.

I've thought and thought about it and I think that next time (not pregnant right now, just in the future sometime) I'm going to be induced at 39 weeks. Neither of my babies made it to 40 weeks, so I doubt the next one will either. And my cervix was super favorable for induction this time - 3 cm and 60% effaced and soft for weeks beforehand. Also, if I'm induced I can get the epidural before they start any of the medicine, and so I will have to feel very little pain, if any at all. The more I've thought about it, the more the whole thing makes sense to me. So that's my plan for next time. I don't want to have to rush to the hospital in active labor either.

[pillowy]

Also, sorry all my posts are super long. I guess I don't know how to write concisely.

[pillowy]

And Whistler, are you pregnant right now? (I'm guessing from the "I'm planning to give birth in Provo" line that you probably are. )

[Whistler]

yes, DL and I are about the same amount of pregnant. I'm 24 weeks along (exciting because the fetus can hear now!).

[Dragon Lady]

Dragon Lady, I wonder if we had the same midwife. Thatonekid is nearly 5, but I went to those midwives too and I think she was still practicing with them for maybe a year or so after I had him. She also had me on cytotec (my water broke at 39 weeks and I didn't go into labor on my own. I went to the hospital 5 hours after it broke and I had no contractions and was at a 1. I think a different practitioner might have gone with a different method)

I went through 3 midwives. Abby is the one that made the decision I should be induced. I don't remember the name of the first one on call at the hospital, that put me on Cytotec and I think she also put me on Pitocin. She's the one midwife in the group I hadn't met yet. But she seemed nice enough. And Claudia is the one who finished me up and told me it was a ridiculous reason I was there and gave me the most input on what was happening.

[Dragon Lady]

pillowy, I think my biggest beef, the more I think about it, is the idea that someone else should get to make the decisions about how I labor. It's my body. It's my baby. Now, don't get me wrong. I am grateful for the massive amounts of education that medical professionals have. I am grateful for their availability. I am not trying to demean them in any way. At all. I'm not putting down modern medicine, OBs, midwives, anyone. I'm not trying to say that I (or any woman) am more educated or better qualified. (Except, perhaps, a female OB...) But I hate the idea that birth is a medical procedure. That women should be forced into any one stereotype. I think women should have the choice of how and where to birth (baby willing) and who to attend. And with that, I believe comes the *responsibility* to be educated in those decisions. She should always have a plan b, c, and even d, perhaps. Even if the choice is in the hospital, she should be aware of the risks of birth and be able to make decisions if something goes amiss. That's my biggest regret of DB's birth. Had I been more educated, I would have refused the induction in the first place. But I had no idea that I *could!* I wish I would have been better educated about the various induction methods, their side effects, etc. I wish I would have snuck more food into the hospital for me to eat. (Both the nurse and the midwife told me point blank, "If we don't see you eat it... you didn't eat it." Bless them. So I guess I had a little more than beef broth and popsicles, but one cheese stick and one yogurt do not give enough energy for 22 hours, either. I wish I had brought more easier-to-digest protein. Like hard boiled eggs or almonds.)

I had a neighbor who had twins a year and a half ago. She is a nurse, but she wanted a natural birth. She had a fantastic in-hospital, natural birth with her first and wanted that again. But then she had twins. She had to search all over Utah Valley to finally find one OB who would be willing to even let her try a vaginal birth, because they were twins. And she had to labor in the OR... just in case. Talk about a sterile, non-friendly, non-personal environment! But the thing is, she had no *choice*. That's what bugs me. (Well, that's not entirely true. There are midwives who will deliver twins. They're just not licensed.)

I guess I'm just very much a pro-parental-choice kind of person. I feel the same way about education, too.

And... perhaps I shouldn't have even posted this. Because I have a feeling it's going to be fodder for debate and such. And I've already said I don't want to debate. Ugh. Why do I do this? Ok. Here's my disclaimer: this is my opinion. Feel free to disagree. Just don't expect me to respond to those disagreements unless my lack-of-confrontational-energy levels change anytime soon.

[pillowy]

To both Whistler and Dragon Lady: congratulations! That's so exciting for both of you.

And Dragon Lady, I totally agree with everything you said. I think women should have choices, and it should be made clear to them that they have choices. They should be able to decide how they labor, where they labor, who's with them when they labor, etc. Care providers shouldn't just say, "I think we should do A." They should say, "I think we should do A. Here are the benefits and risks of A. We could also do B. Here's the benefits and risks of B. Or we could do C. Here are the benefits and risks of C. But I recommend A." (And they should tell them all of the risks objectively - not highlight the risks of one procedure and downplay the benefits, or vice versa.) And then with a full knowledge of the situation, the woman could make the choice that she wants to make. During the actual labor such conversations could be more difficult, due to time-dependent decisions and the physical state that the woman is in, but they can still take place.

Again with the twins, I think that's a difficult situation. I can see it from both sides. I definitely wouldn't want to labor in the OR, and I can see why someone else wouldn't want to either. But I can also see it from the doctor's perspective, what with twin labors being so risky and them wanting to be ready to jump into action if need be. I definitely think more doctors should be willing to do vaginal twin deliveries, and that women should have the choice of laboring in regular rooms rather than the OR. It's just a tough thing to figure out where the balance should be.

But yeah, woman should have the final word when it comes to all the decisions about their labor.

[Dragon Lady]

Yay! We've agreed on a major point of labor discussion! I feel like we should all eat ice cream now.

[thatonemom]

DL that's interesting. Roberta delivered my oldest. I always liked Claudia because I thought she was good at explaining things. I've recommended seeing her specifically to a lot of friends, although she didn't deliver either of my kids.

[pillowy]

A tragic example how the lack of education of homebirth midwives hurts families: Jan Tritten, the editor-in-chief of "Midwifery Today" (the "journal" of homebirth midwives) is responsible for the death of a baby at a homebirth today.

Yesterday she posted on Facebook (Facebook! Because that's where professionals go when they're out of their depth and they need good medical advice in a life-or-death situation) that she was taking care of a woman who was over 42 weeks pregnant who had no amniotic fluid. She hadn't had amniotic fluid for days.

Instead of transferring the woman to the hospital immediately, as she should have done, she asked the other midwives what they would do. Some of the "advice" they gave her included "Respect leaving things alone," "Try a very good acupuncturist," "Leave her be," "Try stevia to possibly increase the fluid" and "Trust mom’s instincts too & who made up the 42 week law? Midwives or OBs scared of litigious times & distrust of mom’s owning their births."

The baby died last night.

[Dragon Lady]

Things like this are why I specifically interviewed my midwife options to see what they would do in case of certain emergencies. (Including the "emergency" induction I had with DB.) I asked about what things she transfers to a hospital for. I asked about backup OBs.

Just as you should interview any OB to find out what their policies are and what their stats are (C-section, episiotomies, etc.), you should also interview midwives (assuming they're an option for you, of course) to find out what they do in emergency cases.

I feel awful for that mom, but I also put some of the blame on her (assuming she wasn't pressured into her choices by the midwife in a verbal abuse situation) because a midwife (or doctor) should not be the sole decision maker for labor. The mother should also be educated and making decisions. And that mother should have put her foot down and said, "I'm going to the hospital. This can't be safe for my baby." I am willing to walk out on any medical care professional if I do not believe they are making the right choice. And there is always the option of going to hospital. Women need to be educated! (Have I mentioned this?) If your OB or midwife is not making good choices or makes you uncomfortable, *get the heck out of there!*

[Yarjka]

And that mother should have put her foot down and said, "I'm going to the hospital. This can't be safe for my baby."

But it sounds like in this case it was the mother who said she didn't want to go to the hospital. The question becomes, at what point should a midwife put her foot down and say "You are going to the hospital, this can't be safe for the baby."

[pillowy]

I feel awful for that mom, but I also put some of the blame on her (assuming she wasn't pressured into her choices by the midwife in a verbal abuse situation) because a midwife (or doctor) should not be the sole decision maker for labor. The mother should also be educated and making decisions.

Woah woah woah, seriously? Every single pregnant woman should be expected to understand pregnancy and labor as well as a health care provider does? An obstetrician goes through at least 12 years of school - 4 of undergrad, 4 of medical school, 4 of residency. A CNM has at least 6 years of school - 4 of undergrad, 2 of grad school. And every single pregnant woman should understand pregnancy and labor as well as them? Well enough to understand every complication that could happen and the correct course of action to take if it does? Well enough to take the blame for making a decision that ends in death?

And if you don't expect every single woman to understand every complication of pregnancy and labor, how can you blame them when their health care provider fails to explain (or even understand) what is going wrong and what the best course of action would be? Do you honestly think that woman fully understood the situation? The midwife posted "Mom feels everything is fine and want to leave things alone." She didn't post on Facebook asking for help with how to persuade a reluctant client to go to the hospital. She posted on Facebook asking for ways to reassure her it would be okay to wait. Unless this midwife told her client, "Your baby is in serious trouble. A homebirth is no longer safe and I will not attend you. If you don't go to the hospital immediately, there is a very real chance your baby will die," she is directly responsible for that baby's death.

Making the decisions in labor is the mother's call, but it's not her responsibility to know everything about every complication that could ever arise, and the correct course of action to take if it does.

[Owlet]

That's one thing I've been wondering about. When I'm interviewing people and educating myself, how do I know what the right answers are? I haven't even finished BIO 100 yet.

Oh and hi. I'm listening to this conversation and I find it quite fascinating. This is going to be really useful to me someday.

[Eirene]

I feel awful for that mom, but I also put some of the blame on her (assuming she wasn't pressured into her choices by the midwife in a verbal abuse situation) because a midwife (or doctor) should not be the sole decision maker for labor. The mother should also be educated and making decisions.

Woah woah woah, seriously? Every single pregnant woman should be expected to understand pregnancy and labor as well as a health care provider does? An obstetrician goes through at least 12 years of school - 4 of undergrad, 4 of medical school, 4 of residency. A CNM has at least 6 years of school - 4 of undergrad, 2 of grad school. And every single pregnant woman should understand pregnancy and labor as well as them? Well enough to understand every complication that could happen and the correct course of action to take if it does? Well enough to take the blame for making a decision that ends in death?

And if you don't expect every single woman to understand every complication of pregnancy and labor, how can you blame them when their health care provider fails to explain (or even understand) what is going wrong and what the best course of action would be? Do you honestly think that woman fully understood the situation? The midwife posted "Mom feels everything is fine and want to leave things alone." She didn't post on Facebook asking for help with how to persuade a reluctant client to go to the hospital. She posted on Facebook asking for ways to reassure her it would be okay to wait. Unless this midwife told her client, "Your baby is in serious trouble. A homebirth is no longer safe and I will not attend you. If you don't go to the hospital immediately, there is a very real chance your baby will die," she is directly responsible for that baby's death.

Making the decisions in labor is the mother's call, but it's not her responsibility to know everything about every complication that could ever arise, and the correct course of action to take if it does.

TOTALLY agree here. The whole point of having licensed professionals, whether they're healthcare professionals, lawyers, electricians, builders, or what have you, is that you can trust them to know things that ordinary people are simply not able to know. No one who has not delivered thousands of babies can hope to know what an OB knows (no matter how many books and blogs they read). No one who has not wired hundreds of houses can hope to know what a professional electrician knows. The whole point of having professionals is that they are guaranteed by a professional society to know what they are talking about, to give sound advice, to have safety standards, and to suffer appropriate professional repercussions when they screw up. That's the problem I have with CPMs: unlike nurse midwives, they have no set safety standards. They make no attempts to limit their scope of practice to what is appropriate for their extremely limited education. Worst of all, they have no professional repercussions when they screw up--their national organization is far more likely to stand up and lobby in defense of midwives who have killed babies than to promise a formal investigation, and most CPMs do not have malpractice insurance, giving families no way of suing when there has been malpractice. To have the word "professional" in their title is just a joke.

I really have nothing against midwifery or home birth in the appropriate circumstances, but I absolutely do have a problem with people misrepresenting themselves as knowledgeable healthcare professionals and charging money for their services when they utterly lack the education and professional oversight to do so. Any midwife who truly cares about her patients should go through the additional training to become a nurse midwife and practice under those stricter regulations, period.

[Dragon Lady]

You misunderstood. Sorry I wasn't more clear. I don't think that every woman should know as much as a trained professional. But something as big as, "Hey, my water broke days ago, there's no more amniotic fluid for the baby to be in" should be a red flag to any mother. Any woman who has done any amount of research on pregnancy or labor should have a semblance of an inkling at least that going that long without any amniotic fluid could pose a problem.

The problem I see with discussing this here is that we don't know exactly how it went down. Did she express concern and did the midwife assure her that babies live all the time without amniotic fluid? Did the midwife express concern about labor not progressing after that long, but the mother assured her that this is what she wanted to do, no matter the cost? We can't judge based on a Facebook discussion.

But yes, I do think that ideally every pregnant woman should have a basic understanding of what labor is and what some major red flags are. No, I don't expect them to know everything, but I do expect that women should know the basics and be willing to stand up to the professionals if something doesn't feel right. Yes, you should trust the professional you hired. But no, they are not omniscient and a mother's instinct should be considered. And if the instinct disagrees with the professional, she (or more likely her husband or someone trusted) should call another professional for another opinion.

Also, to be clear, I'm not standing up for the midwife here. What she did was stupid and unethical, so far as I can see.

[thatonemom]

But yes, I do think that ideally every pregnant woman should have a basic understanding of what labor is and what some major red flags are. No, I don't expect them to know everything, but I do expect that women should know the basics and be willing to stand up to the professionals if something doesn't feel right. Yes, you should trust the professional you hired. But no, they are not omniscient and a mother's instinct should be considered. And if the instinct disagrees with the professional, she (or more likely her husband or someone trusted) should call another professional for another opinion.

I like a lot of this (in theory) but I'll just toss out my experience as a bit of a counter example. I've tried not to share too much about my particular birth experiences because I know they're atypical. But they're the way my body does things.

I think that all pregnant women should have a basic understanding of labor. But also an understanding that their labor may be different from the norm. With both of my kids my water broke and I had no contractions. I was dilated to a 1 with the first and a 2 with the second (progress!) Both in advance of my due date, which is not typical (especially for first time moms). I'd heard all about early labor and walking around and doing other things to relax your body and help move labor along. That was my plan, but that's not how it happened. My water breaking put me on a clock to deliver (because of higher risks of infection. I didn't know that. My midwives told me. Most moms don't know much about what to do if their water breaks on its own because it doesn't happen outside of active labor very often. To the point that when I took the labor & delivery prep class from the hospital the nurse told me I'd never have to worry about it)

So instead of walking and doing whatever at home like I originally wanted, I was at the hospital with antibiotics (for group B strep) and medication to get my labor going. And that's ok. As as first time mom it could have been disastrous to trust my instincts or go with my original plan. I didn't have enough knowledge to have reliable instincts at that point. (Again, because my experience was outside the norm. I hadn't learned about all the different exceptions, but there I was living one) I needed competent medical advice.

I also think we don't really have a culture of challenging doctors, at least not to their face. Any time I've gotten a second opinion, I never told the first doctor I was going to get one. I think it would be really hard to do in the middle of labor, especially if it was someone's first time laboring.

[Dragon Lady]

Your story actually backs me up. Your plan was to be at home. But when your water broke early, your instinct was to ask questions and found yourself at the hospital because of it.

As for asking during labor... yeah. That's not gonna happen. But that's what husbands are for. I also believe husbands should be educated and have a basic understanding.

[Portia]

Your story actually backs me up. Your plan was to be at home. But when your water broke early, your instinct was to ask questions and found yourself at the hospital because of it.

As for asking during labor... yeah. That's not gonna happen. But that's what husbands are for. I also believe husbands should be educated and have a basic understanding. :)

I know I've said this before, but it bears repeating.

Percent of all births to unmarried women: 40.7%

CDC.gov

When 4 in 10 women don't have a husband, your solution is not widely applicable.

[Dragon Lady]

I also highly recommend a doula, whether your married or not. I would also think many women that aren't married have friends or parents or siblings that are invested in their health and well being.