Midwives or Doulas and Prosecuters, Oh My!

There's a family in the midwest that is in a terrible predicament...one that is grossly unfair, and my heart goes out to them. The information on their website is that, after giving birth to a healthy child at home, with the assistance of a midwife "they made the decision"...(a few hours later)..." to call 911 just to be safe" because they were "a bit concerned about the mom". In the jurisdiction in which they placed the call, since a child was involved, the police were required to respond as well. The EMS personnel insisted that the baby "needed immediate medical attention", so mother and baby were transferred to the local hospital, both were found to be well and healthy, and after a few hours were released. The police took statements from both the midwife, and the woman's husband.

Two months later however, the family was served with a summons to appear in court having had the charges of child endangerment levied against them. At their most recent hearing, they were offered a plea bargain for the charge of "disorderly conduct", which the family chose not to accept because they feel that they "are not guilty of anything", that "a guilty plea would validate the charges against" them, and that a "guilty plea would give the impression that homebirth is wrong, and possibly open the door for other families to be prosecuted". All noble arguments, but not exactly in their best interests. In fact, despite this family's earnest sincerity (and I do believe they are sincere), I'm not particularly certain that their arguments are even in the best interests of the homebirth community at large.

I agree that this family did nothing wrong. I support their right to give birth in the place of their choosing, with an appropriately trained, skilled, experienced attendant of their choosing; but despite my compassion for this family, and my desire to help them, and my fervent prayer that the charges will be dropped, I have concerns. There must be more important issues for the authorities to be addressing than a homebirth where the outcome was healthy and safe.

Or is there?

Whenever I see "calls for support" go out over the web for midwives or families that are being pursued by the legal system for whatever charges that can be trumped up regarding a homebirth (practicing medicine or nursing without a license, child endangerment, etc.), it is in my nature to question both the reasoning of the local authorities, and the actual story of those who are being charged. More than once I've heeded the call to a "persecuted" midwife only to find out that there may actually have been some questionable management of the situation. It's a sad reality in our culture that, due to the tenuous legal standing of midwives in general, and homebirth and Direct Entry midwives in particular, that the care the family received must be beyond reproach. That is difficult enough to prove, even in the best circumstances, when we've got the machinations of the AMA, ACOG, and sensationalist reporting such as the "Perils of Midwifery" piece recently aired by the Today show swirling around us. It becomes even more difficult to prove when those who are being prosecuted are not being forthright with every minute detail of the situation.

So, quick to my trusty Iphone I went, dialed my beloved friend C., childbirth educator and doula extraordinaire, who also happens to be in regular communication with our local CPMs. It seems that indeed, a small piece of information has been overlooked in the most recent reports of the incident. In initial media reports, the midwife, when giving her statement to the police, identified herself as the family's "doula".

Whaaaat? Now, when a midwife transfers her clients to a hospital, she certainly does cease to become the primary care giver, and steps instead into the role of doula. However, during the incident about which she was giving her statement, she was acting as the primary care provider. That role, as such, places her in a position of responsibility regarding the outcome of the situation. By identifying herself as a doula, this midwife exposed her client to suspicion that they were attempting to give birth unassisted, and I said as much when I questioned the family and their supporters on the informational website.

What I did not point out at the time was that I was not questioning the family's right to give birth any way they chose (I wasn't...although I won't mislead anyone here and say that I am in favor of giving birth without a skilled care provider in attendance, be that physician or midwife...but that is for another post). I was simply pointing out two things that could have a very important impact on the outcome of their case. 1). Those who were telling the story, be they supporters or the family themselves were not being forthcoming with all the pertinent information, and 2). A midwife who identifies herself as a doula, is going to be perceived as someone with something to hide...and so will her clients.

Well, immediately I was accosted by both supporters of (of whom I still consider myself to be among...I just want more information), and members of the family, including the much beleaguered mother. Was I actually insinuating that this family did not have the "right" to an unassisted birth if they chose?; that the charges were valid if there wasn't a midwife present? From there the arguments became not about how best to support and provide for the best possible legal outcome for the family, but a heated discussion, mostly directed at me, about the family's "right" to choose to birth in whatever manner they saw fit. Try as I might, until one post late in the day, I could not convince those who saw red the moment they read my words, that this was not about the family's "rights"...it was about getting all the information in their defense out on the table where it could be considered...and perhaps improve their legal standing. Ironically, that post was from a mother who chose to have several of her children unassisted. She simply pointed out the dominant cultural biases against homebirth, and how being seen as potentially giving birth unassisted were not going to work in the family's legal favor, despite their philosophical "right" to do so.

The mother says that she stands beside her midwife 100 percent.

But is her midwife standing beside her 100 percent, when she identifies herself, not as a midwife, but as a doula, whose role by definition, is anything but midwifery?

The mother goes on to say that "It shouldn't matter that the authorities see homebirthers as irresponsible. They are supposed to enforce laws, not their opinions".

She's right, it shouldn't matter.

But, unfortunately, it does matter. It matters very much in our as yet unenlightened medico/legal culture. Is this family willing to martyr themselves to a cause that their trusted midwife does not appear to be willing to herself? After all, if indeed she is a midwife, she placed herself in the role of "authority"; and now when another type of authority is attempting to insinuate itself (apparently, tragically, and unfairly) into the situation, she recoils from that role? That is abandonment of her client...and that is irresponsible. What would we do if a doctor in similar circumstances said something to the effect of "Hey, don't look at me...I'm just the gardener!". I know I oversimplify...but truly...are we holding midwives to the same standards that we hold other care providers? Or are we, because we are so passionate to advance the cause, allowing them to assume less responsibility for outcomes we would not choose?

If the local authorities believe that a family is behaving irresponsibly, they are going to try to find a law to, if for nothing else, make an example of the family, if for no other reason than to further discourage other families from making a similar decision. In the process, the family in question is placed under great stress, both emotional and financial, at what should be one of the happiest times of their lives.

As often happens, the support discussions concerning this family have evolved, for those who rally around them, more in support of the philosophy of birthing rights than the support of the family (although there is much to commend supporters on regarding the level of financial and other support being planned and given). Of course we have the "right" to give birth in any way we see fit; but legal "rights" are, unfortunately, variable, based on how a judge and/or jury interpret the law. How we present our argument to them is going to have a definite impact on their decision making process, and the outcome of the case.

The mother writes that a part of the charges say that she "gave birth in an unsanitary place and did not seek immediate medical treatment for the baby". Since they (the charges) did not address the presence (or absence of) an attendant, she does not feel that the midwife identifying herself would have changed anything.

But of course it would!

If, indeed, the woman who identified herself as a doula was actually a skilled, experienced midwife, and had identified herself as such, then the defense could point to the safety of midwife attended births in study after study, and it's acceptable practice in nearly half of the United States (let alone many other industrialized countries with much better maternal/infant, and dare I say it, economic outcomes than our own), thereby at least placing a chink in the prosecutions argument; but this would place the midwife in a precarious legal predicament, since the state in which the incident occurred is not one of the more "enlightened" states that provide a legal basis for the practice of midwifery for families giving birth at home.

So now the question becomes...on whose shoulders does the responsibility for the safe health care outcome of this situation rest?

On the Midwife's!...or at least as much as the family's!

Of course a birthing family is responsible for choosing the best possible care for their pregnant mother and unborn child. If they choose themselves as such, then they are responsible for the outcome...and liable should the outcome be not as expected. If they choose a midwife for that care, then the midwife, by the act of attending them, assuming the role of primary care provider prior to transport (if a transport is called for), and in accepting compensation for that role in whatever form deemed appropriate (money, barter, etc.), should accept responsibility for the outcome. Here it seems, only the family is being subject to prosecution, and I want to know,

Where is the Midwife?

Is the family protecting the midwife? Is the midwife going to publicly step up in the family's defense? Of course, if she does so, she assumes the risk that she will be prosecuted as well...but didn't she assume this risk when she chose to be a home birth attendant?

I'll be brutally honest here. I would have loved to trained as a midwife and provided care to mothers giving birth at home; but at the time, I was a single mother with two young children to support. I needed a steady paycheck, and I couldn't afford to risk being arrested and convicted of practicing nursing or medicine without a license, lest I lose custody of my sons. Does this make me unwilling to "put my money where my mouth is"? I guess it does. I decided get a bachelor's degree in nursing instead, and attend mothers giving birth in hospital. That does not mean I think that the hospital is the best place for a healthy, low-risk mother carrying a healthy baby to give birth. I don't; and every shift I work, I struggle with the dichotomy of my belief system while trying to give the best, most compassionate, physiologically appropriate care to my patients that I can. It helps (sometimes), that I work on a unit that accepts many complicated transfers of care, and that the majority of my patients are those who a qualified midwife would risk out anyway; but when a healthy mother in normal labor comes under my care, I struggle. That is my lot in life. I chose it, I live with the spiritual and emotional consequences. I don't have to live with the potential legal consequences that a Direct Entry Midwife has to, but that was my choice. Does that make me a less-valid supporter of a woman's "right" to choose her birthing situation? I still place myself in the position of risking my license if I would harm a patient with a medication or practice error, or by not advocating for her properly should I feel that her medical care provider not be practicing appropriately; and ironically, for all my work to avoid loss of income by choosing a more culturally accepted way to provide care, I've found myself in situations occasionally when providing that advocacy did, in fact, jeopardize my employment. It's not easy being a pro-birth choice nurse in a culture that sees technology and the practice of medicine as the preferable way to give birth; and it's not easy being a homebirth and midwifery supporter who works in the dominant health care system!

This family's freedom, as well as, should she choose to come forward, their midwife's is of paramount importance in this situation; but we need to be careful about how we couch our arguments in the current culture. The reality is that if we're to advance a woman's right to give birth in an environment of her own choosing, we are, again, going to have to hold ourselves to the highest of standards, both of care, and of how we present the appearance of that care to the "authorities". I don't see that happening here.

Again, I have only compassion for this family. I deeply want to see the charges dropped. I'm furious at the waste of taxpayer money being used to harass and traumatize them, for no good legal reason; but I think there is a missing piece of information that someone, somewhere, is unwilling to, for whatever reason, address that could help them.

And I think that information has to come from the midwife.

Equal Time...

...for nurses, residents, and physicians who work in obstetrics. In my last post I used a lengthy and extreme (but for all intents and purposes...had to change some facts to remain HIPPA compliant...true) example to whine about families who come to the hospital with expectations that they did not educate themselves about beforehand.

Well, now for the other (at least an other side) of the issue. It frustrates me how few nurses and physicians are vehemently anti-homebirth, (or any other kind of "alternative" birth) based on non-existent (e.i., their opinion), or poor research.

For a long time, all homebirth advocates had to rely 0n in terms of published research to back up their point of view was the "Tew" study, ( British Journal Obstet Gynaecol 1986 Jul;93(7):659-74) which is now over 20 years old. In a world where research over five years old is considered outdated, regardless of how well designed and carried out it may be, this is no longer going to cut it; nor are subsequent studies performed in the ninties. Now we have the Johnson/Daviss study ( BMJ 2005;330:1416 (18 June), doi:10.1136/bmj.330.7505.14), obviously much more recent, which, even in it's criticism of it's own limitations, makes a very good case for the safety of homebirth.

So why do so many of the people I work with not know about this study, or any of the others? Why do they think that the "homebirthers" out there are uneducated women who place more value on their experience than on the safety of their baby? Why do they make fun of women who choose to give birth in any number of ways that does not jive with the "norm" of being limited in movement by I.V.s and fetal monitoring equipment, no eating or drinking in labor (not even clear liquids, heck, not even popsicles! Does someone want to tell me what the difference between one contraband popsicle and half a dozen cups of "allowed" ice chips is?), pushing in lithotomy position while holding breath, who question the need for Pitocin if they are otherwise healthy and not post-term, etc? (Yeah, I know, it's a run-on sentence, but make some allowances for passion, OK?).

In a discussion I once overheard between several of our residents and one of our attendings regarding the "trend" of waterbirth, I heard the attending exclaim "and what if you get a shoulder dystocia while you are in the water, then you are screwed!"...(uhmm, excuse me, ever heard of theGaskinManeuver???...aside from the fact that "shoulders" are more likely to occur in lithotomy position).

Recently, a doula friend of mine told me about one of her clients who asked her physician (a woman who is an excellent diagnostician, and extremely skilled surgeon, and a favorite of many of the nurses where I work - including me - who chose her to deliver their own children) if she could push in a squatting position if she felt so inclined at the time. The physician said that she wouldn't be able to have clear access for catching the baby if mom chose to do so (hmmm...how so, when the mother would be several inches above the line of view if she pushed while squatting on the bed? I bet a lot of midwives would be surprised to hear that). This particular physician is part of a huge and popular practice, so I doubt that the loss of this one patient made much of a difference to her professionally, but I wonder if it made a difference to her personally? The mother subsequently gave birth to her baby at an outlying level-one hospital, in water, attended by a physician who is gaining in popularity because he seems willing to listen to his patients, and if nothing else, empathize with them. He managed to be able to have clear enough access to deliver this child, from the floor (I assume), and through water that, in all likelihood, became at least a little murky with the fluids of birth emerging with the baby. In the first situation, a woman denied a choice to another woman, seemingly for her own personal comfort. In the second, a physician who did not have the back up of countless residents and multiple ORs felt confident enough, and was willing to respect this mother's wishes. Professionally, this gentleman is very respected where I work. He doesn't transfer cases to us just because he would rather not deal with them, he doesn't take unnecessary risks with the cases he does transfer, and the attendings that I work with just seem to like him in general...he's a "buddy" to many of them; but there were more than a few raised eyebrows when I bragged that "hey, he's willing to do it, why aren't we?" I don't think it changed their opinion of him at all...but he's certainly not holding to the status quo, and I wonder how that is going over (unsuccessfully trying not to gloat here)?

As for waterbirth? Most of the nurses I work with think it's "gross"...I mean, you can get poop in the water (as if they don't see enough poop when the mother is up in stirrups); or, all that blood and goo in the water (what, they've never had to deal with blood and goo in this job?)! Can we get consistent here folks?

I once had a patient that didn't want pitocin routinely run in after she delivered her placenta. This was written on her (albeit, a little too long for my tastes) birthplan. When one of the nurses I work with, one who does a lot of training no less, asked "Why didn't she want Pit after she delivered?", the following conversation took place between the two of us:

"Because she didn't need it".

"She didn't need it?" (I knew I was being baited here, but I couldn't resist...)

"No. No one was yanking on her placenta, so she didn't need it".

"What do you mean?" (more baiting, my irritation and irrational need to win every
"argument" taking over),

"C'mon, C, you know better...left alone, a healthy one will come out on its own, you don't need traction, and there won't be any excess bleeding to worry about".

"I don't believe that"

"Of course you don't".

"Before we started using Pit after delivery, what was the main thing women died of
in childbirth?"

"If they were otherwise healthy? Infection"

"No it wasn't...it was hemorrhage!"

"You need to go back and reread your nursing school OB textbook".

Rolled eyes, sighs, shaking head, clucking tongue...tough having a "substandard" nurse like me on the unit.

And while I'm on a roll (am I ever not?)...about infection; we've recently been required to go to "handwashing" seminars, seeing as how insurance companies are planning to deny coverage should any of their insured's end up with hospital aquired infections (another lengthy post to come on this, I guaruntee). During the presentation, the well-known (I thought) story of Dr. Ignaz Semmelweis, the physician who originated the "germ theory of disease", based on his observations of the rate of puerpural infection when physicians treating pregnant women washed their hands between corpses and other patients and the laboring and postpartum patients. I assume we all know the outcome of this story? I assume we all know the story???? Evidently not...I was amazed at the number of nurses who had no familiarity with the story! Didn't this anecdote open most of our Med/Surge, Microbiology, Obsetrical, and Community Health texts, way back in nursing school? Sigh.

By the way...the aforementioned patient whose placenta so elegantly slid out without traction, and whose body (shockingly) required no Pitocin to keep its immedate postpartum blood loss under 300 mls, had been laboring most of the time on her hands and knees. True, it was a PITA to keep her baby on the monitor, but we managed. Just about when I thought my arm would fall off though, the same nurse I would soon have the previously mentioned conversation with came in to help with the delivery (so, we have our differences, but for the most part, we're always there for each other...just like any dysfunctional family). The doc was at the end of the bed, and baby began to crown. The mother was doing a fabulous job...her perineum was beautifully pink, stretching nicely with her short, slow, powerful non-valsalva grunts and pushes...no white, blanching, evidence of an impending tear. It would have been so easy just to guide baby out, and let the nurses help Mom while she lifted her leg over baby and turned over in bed...but no, the doc insisted, baby on the perineum, that the mother turn over in the bed immediately...and as she turned, baby's head ratcheted in the opposite direction, and you guessed it...a third degree tear ensued. Ask any other nurse on my unit and it occurred because the mother was on her hands and knees (grunting like a cavewoman I heard one nurse say...arghhhhh!)...and not because she was forced, at exactly the wrong time, to work against gravity and turn over! I could scream. I know the poor mother did...so unecessary!

In this same delivery, a young nurse, a nurse-midwifery graduate student, and an excellent new L&D nurse came in to help as well. She is a lovely young woman; confident; secure; patient; a breath of fresh air when things are getting intense and the primary nurse needs a hand or a new perspective. She soothed and comforted this mother with her lovely, calm voice and demeanor. In other deliveries I've seen her in, she just has a knack for gaining the absolute trust of the woman she is caring for. After the birth, I thanked her for her help, and complimented her on what a nice addition to the floor she has become. She, in an attempt to commiserate, I can only assume replied, "You're welcome...and thankyou; but it is all so much more pleasant and controlled when the mother has an epidural. I wish she had had an epidural...it would have been so much nicer!". I was so taken aback by her comment that I just let it slide by. I've always meant to gently revisit it with her, but have never been able to find the right time (or, I must admit, the nerve) to broach the topic with her again. This is a brand, new, "malleable" L&D nurse, a future midwife, an excellent clinician, with an excellent mastery of her craft, with so much potential to bring so much respect and compassion to her clients, and it turns out to be all an act???? How dissapointing. Why do we keep potentiating this?

And there are so many excuses why we don't change. I made no secret that I was reading Jennifer Block's book, Pushed during down time on the unit. I made certain to leave it conspicuously out on the table in the nurses station when I was with a patient. Did anyone ask me about it? No. Did anyone bother to turn it over, take a look at it? Not that I'm aware of. Instead, I overhead one nurse say "That's all well and good, I suppose, but it's different in the U.S. (excuse me, but the book was written by an American author, about American women, giving birth in the American medical system)...we've all intermarried with different cultures, and we have all different sizes of pelvises, and partners, and you just can't generalize about how easy it should be to give birth when you aren't a member of a more uniform culture". She never even looked beyond the cover of the book! She had no idea what the book was about; and, if her "theory" is so true, does she want then, to explain to me how so many of our not even five-feet tall Latina patients, giving birth to 8 and 9 pound-plus babies of big, tall, husky Caucasian and African-American fathers are able to do it so easily? I've seen plenty of tiny Asian women give birth to big babies as well, with very little, if any trauma or drama. Does this woman think that the pelvis of the American woman has evolved into something mostly inadequate for birthing, in the space of under 300 years? Please. It's not our pelvises that have become dysfunctional, it's our thought processes. To have read the book and had a rational discussion of it would have made it necessary to question the illusion of our own Golden Calf.

Finally, I get so frustrated hearing my coworkers referring to the midwives in town as "Lay" midwives!!!!! They don't know what a CPM is, they don't know what MANA is, they don't know what NARM is. Why????? The few times I've attempted to "educate" them about it, I got quizzical looks from them until I showed them printed materials from both groups, including the endorsements from physicians and state governments where they are recognized as collaborative members of the health care team...then I got little more than shrugged shoulders, and they still refer to these woman as "Lay" midwives...despite the fact that the founder of the most active group of midwives in this town is internationally known! She's a gem, she's a recognized expert in her field, she's drifting quickly into retirement, and we've never taken advantage of her opinion and expertise! What a loss.

For all my griping, I really do respect the nurses I work with. They can be nothing short of awesome in a situation that is going downhill fast. Most of them love what they do, and their patients love them. They know their stuff , particularly when it comes to high risk deliveries. I seriously believe that, in a city with too many L&D units, they are the best there are. They are the first person to be there if a nurse is in a situation that is getting hairy. If someone I loved or their baby were in trouble, these would be the nurses I would want to take care of them. Honestly, I would trust my very life with them. They are that good...I just wish that they had more respect for those who make different choices than they would. I wish they had more respect for the low risk side of things. I wish they would at least examine the other view before so staunchly defending their own.

I don't get it. I just don't. These are educated people. They know how to critically read research. The information is more readily available to them than it is to anyone else.

What Gives?????