Quoting from the press release issued today by the American College of Obstetricians and Gynecologists:

“…restrictive VBAC policies should not be used to force women to undergo a repeat cesarean delivery against their will if, for example, a woman in labor presents for care and declines a repeat cesarean delivery at a center that does not support TOLAC [”trial of labor after cesarean”]. On the other hand, if, during prenatal care, a physician is uncomfortable with a patient’s desire to undergo VBAC, it is appropriate to refer her to another physician or center.”

“‘…interpretation of The College’s earlier guidelines led many hospitals to refuse allowing VBACs altogether,’ said Dr. Richard Waldman, president. ‘Our primary goal is to promote the safest environment for labor and delivery, not to restrict women’s access to VBAC.’”

But the New York Times suggests the trend will be difficult to reverse: “Women’s health advocates praised the new guidelines because they expand the pool of women considered eligible for vaginal births, but they expressed doubts about whether the recommendations go far enough to change a decade of entrenched behavior by doctors, hospitals and insurers…Maureen Corry, executive director of Childbirth Connection, an advocacy group, said, ‘Overall, it’s dubious that these guidelines will in fact open up access for women.’” The Times goes on to name several hospitals that currently ban VBAC and have no intention of changing the policy.

Here’s how precarious women’s birthing rights are, even in New York City: when Bellevue hospital shut down its midwife-run birth center, women — particularly women with low incomes — lost one of the most supportive places in the city to give birth: the C-section rate there was less than 4%.

Then, in April, when St. Vincent’s hospital closed entirely, nearly all of the home birth midwives lost their legal right to practice. That’s because the state requires that every midwife have a written “practice agreement” with a physician or hospital, and St. Vincent’s was practically the only one willing to sign.

The agreement is a piece of paper that midwives and advocates argue doesn’t mean very much — their professional standards already require that they have “back up” in place to transfer clients who need advanced medical care. But without this piece of paper, the midwives are now effectively illegal. Advocates are trying to change the law, and the New York Times reports that “a week ago, a bill that would repeal that requirement breezed through Assembly and Senate committees, and its champions expected it to pass the full Legislature within days. Then it hit heavy opposition from the American Congress [formerly “College”] of Obstetricians and Gynecologists.” The professional group’s reasoning? It would allow the midwives to “expand their turf and directly compete with doctors.”

And that’s not all: “This legislation…has the ability to pave the way for midwives to open their own independent birthing centers,” said ACOG.

Where will it end?? If more midwives were able to practice, more women would have access to out-of-hospital birth, and there would be fewer cesareans, fewer related complications, and less cost to taxpayers. There should really be a law…

Circle of Health International works worldwide in areas of conflict and crisis to address women’s health needs, and the group announced yesterday that it is sending a team of midwives, trauma specialists, and obstetricians to Haiti. Says the group: “Women’s health needs — often a matter of life and death — do not cease to exist in crisis and post-crisis situations. In fact, the already dire condition of women’s health in these communities is often further threatened in times of emergency. Before the earthquake, Haiti suffered from the highest maternal mortality rate in the Western hemisphere, with 670 women per 100,000 dying in childbirth. Sadly, we know that during times of such tragedy and unrest, rates of sexual assault and domestic violence escalate, further endangering the lives of women in such settings. COHI pledges to do everything in its power to prevent further worsening of women’s health status and to ensure these vital needs are met.” You can donate funds, supplies, or inquire about volunteering at www.cohintl.org.

In part III of its global survey on childbirth, the World Health Organization reports that C-sections have reached “epidemic proportions” worldwide. In 2005 the WHO surveyed hospitals in Latin America and found that where the cesarean rate had risen above 10-15%, women and babies suffered more complications and deaths. This latest survey, conducted in Asia, confirms the previous findings with data from 110,000 births. Women who gave birth by cesarean were more at risk for blood transfusions, hysterectomy, and death, and babies had higher rates of death and poor outcomes that led to extended hospital stays. “Together these findings provide strong multiregional support for the recommendation of avoiding unnecessary caesarean sections,” the authors write. “To improve maternal and perinatal outcomes, caesarean section should be done only when there is a medical indication.”

“The relative safety of the operation leads people to think it’s as safe as vaginal birth,” Dr. A. Metin Gulmezoglu, an author of the study, told the Associated Press. “That’s unlikely to be the case.”

Joy Szabo of Page, Arizona, was told by her local hospital that she wouldn’t be allowed to give birth vaginally there. She even met with the hospital CEO to discuss their policy of forcing repeat C-sections — a policy she equated with physical assualt — and the hospital responded by threatening to get a court order for the surgery. When the local paper headlined Szabo’s plight, the hospital backed off, but it still told her “No VBAC.” Instead of agreeing to the major surgery, Szabo pushed back. She found a willing hospital and provider in Phoenix, a six hour journey by car from her home, and made the decision to move there and await labor. She and her husband Jeff had to live apart beginning in mid-November, with Jeff remaining in Page with their three children (one already born by VBAC at Page Hospital!).

Finally, this week, CNN reports a happy ending: Szabo gave birth to her fourth son, Marcus Anthony (7 lbs, 13 oz) on December 5th: “It was such an easy birth,” Szabo said. “I was in the pains of labor for about four or five hours, then I pushed once, and he popped out.”

Congratulations, Joy. You are a hero and an inspiration to the hundreds of thousands of U.S. women facing the same coercive policies each year.

This good news from The Rebecca Project:

“US Marshals agreed to end the routine use of restraints on incarcerated pregnant mothers during labor, delivery, and immediate post delivery.  The US Marshals have also reformed the type of restraints to be used on pregnant mothers during transports.  Any restraint that constricts the belly region of the pregnant offender will be prohibited.

In the US Senate Judiciary Committee report for the committee passage of the Juvenile Justice and Delinquency Prevention Act (JJDPA) reauthorization, language included the prohibition of restraints and shackles on pregnant girls in the juvenile detention centers.”

Cesarean deliveries, even planned ones, can be traumatic for mother and baby: the woman is unable to feel or see the delivery, the baby doesn’t emerge slowly with time and uterine contractions to prime the lungs for breathing air; the cord is cut immediately and mother and baby separated, often for hours. British doctors and midwives are testing a “natural” cesarean technique that allows the mother and her partner to view part of the delivery and slows the birth process so that the baby emerges with the help of the uterine contractions, just as it would vaginally. “The baby’s shoulders are eased out ‘and the baby then frequently delivers his/her own arms in an expansive gesture,’” Nicholas M. Fisk , an Australian researcher, told Reuters. The baby is then placed on the mother’s chest while the surgery is completed.  Not exactly “natural,” but a step forward.

First, read Madeline Holler’s great Babble essay, “My Illegal Home Birth,” about going underground to give birth in Missouri, where midwives are felons.

Or, rather, were felons. If today’s Missouri Supreme Court decision holds, underground births like Holler’s — in Missouri at least — will be a thing of the past. The state’s highest court ruled 5-2 in favor of upholding a state law licensing certified professional midwives (read about the decision here; for some background on the saga, click here). The state medical society had sued over the legislation and a lower court found in their favor.

If you’re happy and you want to show it, consider a donation to the Friends of Missouri Midwives — they owe lots in legal fees.

Below are two responses to the AMA/ACOG’s resolution to limit women’s autonomy in how, where, and with whom they give birth. The first is from Canadian physician and researcher Andrew Kotaska, the second is from the National Childbirth Trust in England, where the government is encouraging women to consider home birth! More bloglinks and repsonses to come. If you have one you’d like to see posted, send it here.

“ACOG should join the 21st century”

I would invite ACOG to join the rest of us in the 21st century.Modern ethics does not equivocate: maternal autonomy takes precedence over medical recommendations based on beneficience, whether such recommendations are founded on sound scientific evidence or the pre-historic musings of dinosaurs. In the modern age, the locus of control has, appropriately, shifted to the patient/client in all areas of medicine, it seems, except obstetrics. We do not force patients to have life-saving operations, to receive blood transfusions, or to undergo chemotherapy against their will, even to avoid potential risks a hundred fold higher than any associated with home birth. In obstetrics, however, we routinely coerce women into intervention against their will by not “offering” VBAC, vaginal breech birth, or homebirth. Informed choice is the gold standard in decision making, and it trumps even the largest, cleanest, RCT.(randomized controlled trials).

Science supports homebirth as a reasonably safe option. Even if it didn’t, it still would be a woman’s choice. ACOG and the AMA are, by nature, conservative organizations; and they are entitled to their opinion about the safety of birth at home. As scientific evidence supporting its safety mounts, however, (to which BC’s prospective data is a compelling addition) they will be forced to accede or get left behind. The concerning part of this proposed AMA resolution is the “model legislation. ”

If ACOG and the AMA are passive-aggressively trying to coerce women into having hospital births by trying to legally prevent the option of homebirth, then their actions are a frontal assault on women’s autonomy and patient-centered care. Hopefully the public and lawmakers realize the primacy of informed choice enough to justify Deborah Simone’s words: “We don’t need to be angry or even react to these overtly hostile actions from the medical community. We just need to keep doing what we do best; the proof is always in the pudding.”

It is sad to see the obstetrical community still trying to earn itself a wooden club as well as the wooden spoon; if the resolution passes, it is sad to see the politico-medical community helping them.

Andrew Kotaska
Yellowknife

NCT and the Independent Midwives’ Association (IMA) voice concern over actions of ACOG on home birth

NCT and the Independent Midwives’ Association (IMA) today voiced concern at the recent actions of the American College of Obstetricians and Gynaecologists (ACOG), that seek to undermine and threaten American women’s opportunities to give birth at home.

The NCT and IMA call on the ACOG to reconsider their position as a matter of urgency. Following the example of its international counterparts it should consider all available evidence on the benefits and risks of home birth. Women in America should have access to home birth rather than being limited simply to the medicalised model of birth available in US hospitals.

In February this year the ACOG reiterated its long-standing opposition to home births. More recently, the ACOG, introduced a resolution to the American Medical Association (AMA) at their annual meeting. The resolution commits the AMA to “develop model legislation in support of the concept that the safest setting for labor, delivery, and the immediate post-partum period is in the hospital…”.

NCT and IMA are members of the Maternity Care Working Party (MCWP), which advises members of the United Kingdom Parliament on maternity care and services.

Counted among the membership of the MCWP, are the Royal College of Obstetricians and Gynaecologists (RCOG), the UK equivalent of the ACOG, as well as the Royal College of Midwives. These two organisations issued a joint statement in April 2007 on home births which states:

“There is no reason why home birth should not be offered to women at low risk of complications and it may confer considerable benefits for them and their families. There is ample evidence showing that labouring at home increases a woman’s likelihood of a birth that is both satisfying and safe, with implications for her health and that of her baby.” (Royal College of Obstetricians and Gynaecologists/Royal College of Midwives Joint statement No.2, April 2007)

NCT and IMA also believe that all women should have access to a home birth and up-to-date evidence-based information that addresses their questions, so they can make the right choice for them.

Home birth should be considered a mainstream option and offered as a regular choice for pregnant women using the health service, whichever country they reside in. For a healthy woman with a straightforward, low-risk pregnancy, home birth is a safe option. It is important that midwives provide care for women at home and that they have experience in home birth, receive active support and supervision, and that their training needs are met. Women’s individual needs must be assessed and the back up of a modern hospital system, with good communication and transport links, are important, should transfer be needed.

The views of the NCT and IMA are supported by UK Government policy which seeks to reduce unnecessary interventions in childbirth and increase the numbers of women who experience a normal birth.

Pushed and its author debuted on national TV this morning during a Good Morning America segment about unassisted childbirth! The piece features a woman, pregnant with her fourth child, who, unable to find midwifery care, chose to go it alone. The segment nicely illustrates why unnecessary and harmful hospital interventions are leading women to abandon maternity care entirely. Watch DIY Deliveries: More Women Go It Alone.