NY Times story on Indiana prosecution of home birth midwife

Comments below are in reply and cross talk to a blog by Ann Althouse, in which she comments on the NY Times article on the arrest and prosecution of Indiana midwife Jennifer Williams, CPM.

Background info on CEO web site.     Shortcut to Ann Althouse Blog, midwife topic

Reply       #1 faith     #2 Elfanie      #3 Cherrie      #4 faith      #5 Cherrie      #6 Ann Althouse

Ms Althouse's blog was dated for April 3, 2006 at 8:48 AM 58 comments

"It was the most cozy, lovely, lush experience."

That's a description of childbirth, accomplished at home, by candlelight, with the help of a midwife. It's pretty when it's pretty, but what if the baby dies, and it wouldn't have died in the hospital?

What a vaginal birth does to a baby's head -- if you did anything like that to your child after it was born -- with your hands, I mean, not your vagina -- it would be horrific child abuse. You can say it's "natural" -- but it's an extreme thing to do to a baby and it can cause permanent damage. To treat it as a spiritual experience for the adults is creepy.

Every birth is a potential disaster! So is every car trip. Lots of us assume we will be lucky, especially when the odds are in our favor. That's why when we lose we say "Why me?" We rarely think to say "Why not me?"

The question is whether the state ought to save us -- and our children -- from our relentless optimism.

==================================================================================

April 3, 2006 faith gibson said ... 

re: The question is whether the state ought to save us -- and our children -- from our relentless optimism.

I started my professional life relentlessly optimistic about the benefits of hospital-based medical care for normal childbirth.  I was an L&D nurse in a big busy hospital and it was a fact of everyday life that complications could and did suddenly occur. My opinion about planned home birth mirrored all the derogatory comments read here and elsewhere – mainly that it was “only for idiots”. However, working for two decades in the hospital-based obstetrical system relentlessly stripped me of optimism about ‘modern’ obstetrics. The public’s perception about medicalized childbirth in hospitals is wrong. It is TV obstetrics and not real life.

 After just a few years in a high-volume L&D I began to see the connection between obstetrical interventions routinely applied to healthy laboring woman (70% of all pregnancies) and a steep increase in the need for additional interventions, unexpected complications, operative deliveries and breathing difficulties for the baby. Immobilizing a laboring woman in bed in anti-gravitational positions, hooked up to IVs and electronic fetal monitors, is not a biologically-effective way to facilitate normal childbirth.

I remember only to well racing down the hall with a stretcher, frantically trying to get a patient with a ruptured uterus to the operating room before she died. Eventually an emergency hysterectomy was necessary to save her life. As a young and inexperienced nurse, I initially thought this disaster proved that the biology of normal childbirth was dangerously defective. Afterward the older nurses talked about this ‘accident’ of childbirth, privately admitting among themselves that the Pitocin electively used to speed up her labor is what caused her uterus to rupture. I saw similar situations in which it was the baby who suffered permanent disability. However, all the families would ever learn was that the mother or baby was the victim of a life-threatening obstetrical emergency and that the quick response of the medical team had saved their life. Even though these emergencies were a known side-effect of obstetrical intervention, no acknowledgment of that important fact was made to the family.

I began to wonder if other things that we all took for granted were also causing iatrogenic complications. By paying close attention I soon noticed a direct correlation between the use of drugs and anesthesia and the need for assisted delivery (episiotomy, forceps or Cesarean section). I saw a direct correlation between the use of Pitocin to speed up labor, fetal distress in the baby and excessive maternal bleeding or even hemorrhage after the birth. I also saw a big spike in babies who had trouble breathing when their moms had narcotics during labor or other interventions such prolonged pushing (due to anesthesia) and /or delivery by forceps or C-section. All of these personal observations were also acknowledged in the drug company inserts or confirmed in the scientific literature.

My efforts to change the hospital culture failed miserably so I eventually cross-trained into community-based direct-entry midwifery. Counting my experience in both home and hospital, I have been present at approximately 3,500 births over the 40 years of my professional life. I can testify to the improved safety for both mothers and babies of physiological (vs. medical) management. Physiological management refers to care “in accord with, or characteristic of the normal functioning of a living organism”. This non-medical, non-interventive form of care depends on continuous one-to-one social support, ‘patience with nature’, the right use of gravity and a commitment not to disturb the natural process. Presently, physiological management is only available in an out-of-hospital setting and midwives are the only caregivers a mother can turn to for non-interventive maternity care. Planned home birth (PHB) always includes a skilled birth attendant and appropriate access to medical services when indicated or requested by the mother. 

Midwifery as an organized body of knowledge preceded the modern discipline of medicine by more than 5,000 years. Midwifery principles recognized as effective and still valid in our own time were found among ancient Egyptian hieroglyphics dating back to 3,000 BC. Today, physiological management is the scientific backbone or evidence-based model of maternity care used world wide by midwives, except in the US where medicalized care eclipses all else. Physiological management is actually protective for both mothers and babies. Nationally certified direct-entry midwives (CPMs) using physiologic management in a domiciliary setting, reduced the episiotomy / operative delivery rate (and associated complications) from approximately 72% to approximately 5%, with an identical or even slightly improved perinatal mortality rate. It is efficacious -- that is, both safe and cost effective.

Nothing that modern allopathic medicine has to offer – no routine use of drugs or surgical procedures, no electronic devise such as continuous electronic fetal monitoring, no ‘preemptive strike’ such as universal hospitalization or the routine elective use of Cesarean section, has been able to create a system that is better or safer than the routine use physiological management for healthy childbearing women. However, these methods don’t belong to midwives per se. They belong to science and to society, to be used by anyone regardless of professional affiliation, including physicians.  

One must question how the ancient and honorable tradition of midwifery came to be obliterated almost to the vanishing point by the medical profession and then claimed by the medical profession to be an illegal practice of medicine? What brought about the wide-spread but uncritical acceptance of an unscientific method such as interventionist obstetrics for healthy women? In the last 30 years, despite all the new computer technologies and other ‘improvements’ in obstetrical medicine, the cerebral palsy rate has not dropped one itty-bitty, teeny-tiny little smidgen. Zip. Zilch. Nada. Even the American College of Obstetricians and Gynecologists (ACOG) had to admit that electronic fetal monitoring has made no difference in perinatal outcomes but its use does significantly increase the Cesarean section rate. The routine use of the medical model has produced a 31% cesarean rate without any improvement in perinatal outcome for normal pregnancies, while exponentially increasing the rate (3 to 10 times greater) and the severity of medical and surgical interventions visited on these same healthy women.

A survey conducted in 2002 on healthy childbearing women who had given birth in the previous 24 months revealed that 72% of these mothers had some kind of surgical procedure performed during delivery (35% episiotomy, 25% Cesarean section and 12% forceps/vacuum extraction). In spite of this, there is a gathering movement within the obstetrical profession to replace normal birth with a medically unnecessary or “patient choice” Cesarean section as the 21st century ‘standard’ of care. Under these circumstances, women who insisted on having a vaginal birth would be required to sign informed refusal documents, the equivalent of ‘normal birth against medical advice’.   

The medicalization of normal labor triggers a chain of inevitability that starts with the ‘domino-effect’, in which the unintended consequences of routine interventions make childbirth progressively more complex, eventually requiring the use of injurious interventions and sometimes progressing on to serious complications. When injury to mother or baby does occur, the biology of normal birth gets the blame. The complications of these obstetrical interventions are often cited as proof that “I would have died if I hadn’t given birth in the hospital”. This chain of inevitability, multiplied by forth years, has ended in an ever sky-rocking Cesarean section rate, which was a 30% for 2004 and is projected to be 34% by 2006. This is the disheartening background of most midwife/home birth prosecutions, which are inevitably based on medical politics instead of credible scientific evidence.

Like the midwife in the Indiana prosecution, I am a CPM, that is, a nationally certified professional midwife. CPMs are experienced direct-entry midwives who trained directly in midwifery instead of becoming a nurse first or becoming certified as a nurse-midwife. The statistics from the CPM study published in the British Medical Journal (June 2005), include those from my own home-based practice, as well as Indiana CPM Jennifer Williams and 500 other CPMs in the US and Canada . The BMJ study confirmed again the consensus of the scientific literature, which consistently identifies that planned home birth, when compared to hospital-based care for healthy women, is equally safe for the baby and reduces maternal interventions by as much as ten times.

Unlike the recently arrested Indiana midwife, I am also licensed in my state of California but only because mothers and midwives in our state spent 30 years fighting an uphill battle against organized medicine to get midwifery decriminalized. Finally, in 1993, the California Legislature passed the Licensed Midwifery Practice Act. The LMPA officially recognized that the greatest safety for healthy mothers with normal pregnancies is to provide them with access to professionally-trained and licensed midwives. 

In my opinion, the relentless optimism that needs to be addressed in America is not false optimism about normal birth but the unfounded idea that the current obstetrical model is the most appropriate one for healthy childbearing women. Most important, everybody in society, even those who would never use a midwife or plan a home birth, benefits from preserving and promoting physiological management. In a perfect system, medical educators would learn and teach the principles of physiological management to medical students. Practicing physicians would utilize physiological management as the standard of care for healthy childbearing women. Hospital labor & delivery units would be primarily staffed by professional midwives, with incentives for current L&D nurses who wish to retrain as hospital-based midwives to do so at minimal expense to themselves.  This would dramatically reduce rate of injurious interventions and the cost of maternity care while increasing good outcomes and satisfaction of families served.

In a rehabilitated maternity care system, professional midwives, family practice physicians and obstetricians would all enjoy a mutually respectful, non-controversial relationship. Appropriate maternity care would be provided by all three categories of professionals in all three birth settings as appropriate – hospital, home and birth center – without prejudice, controversy or retaliation against the childbearing family or against other care providers. By making maternity care in all settings equally safe and equally satisfactory, families would not be forced to submit to forms of care that are not appropriate for their needs or that waste our economic resources. 

In the meantime, community-based midwifery needs to be legal for both mothers and midwives. If the problem is the law, then the law needs to be changed, as it must be kept in mind that the basic purpose of medical practice legislation is consumer safety, not as a political tool for promoting a medical monopoly. Enforcing medical practice laws in a manner contradictory to common sense and the well being of the public is not in the interest of childbearing families or a civil society.

#2 ~ 4:16 AM, April 06, 2006  elfanie said...

One reason I believe in hospital deliveries is that you never know. One kid I know went into distress during her delivery. It was, of course, picked up immediately on the fetal monitor, and was solved by giving her mother oxygen. If that had not worked, they were ready for a C-section. But in most home deliveries, it would have gone unnoticed, and the baby born with potentially some brain damage. Most likely not noticable, but there.

Ok...first off...you seem to think that homebirths are unmonitored. Homebirth midwives monitor the baby and DO catch the same "distress" that you are referring to.

secondly..you mention that it was "solved" by giving the mother oxygen. Bull. Homebirth midwives carry oxygen - but that in no way saved this baby, I assure you. If the mom's pulse ox was 98-100% (which it almost universally is), what benefit do you think putting oxygen on her did? nothing...just made the mother feel like they were doing something.

you said that if it didn't resolve they would have done a cesarean. Same thing with a homebirth. Something starts to look funky, you transport. Not a big deal.

You don't mention WHY the baby was in distress. Was mom being induced? (not happening at a homebirth) Was her water broken for her? (not happening routinely at a homebirth) Did she have anesthesia - an epidural? (not happening at a homebirth)

You say this baby was at risk...but how do you know that baby wasn't at risk BECAUSE of the hospital and the things we do to to them.
I see a lot of fear of homebirths based on the proverbial "what if"...but I also fear the "what if" of hospitals, since the #1 cause of complications is iatrogenic! We start messing with mom (inducing, strapping to monitors, restricting movement, restricting food/fluids, giving analgesics, giving anesthesia, breaking her water...) and then a complication occurs that wouldn't have otherwise.

THAT is what I think more people should find scary.

#3 ~ 1:46 PM, April 07, 2006 Cherrie said...

Thanks Faith, for a really well thought out post. I appreciate seeing all the accurate info you took the time to write down.

I think it's amazing how we all form such strong opinions on things we know so little about. We can't each be experts in everything, of course. And knowing this, we have to take somebody's word as the expert we choose to believe. Something like childbirth is so socialized, we tend to align our belief system with, say, our sister or neighbor, rather than take the time to educate ourselves. The evidence is out there, folks. But each of us has to choose to dig it up, read it, and then be able to critically examine what that means to us.

The fear about the baby's head being a 'battering ram' originated long ago when mothers were out cold when giving birth. It has long since been proven over and over again that a vaginal birth has many benifits for the baby in prepairing it for those first breaths, and life outside the uterus.

Home or hospital isn't the question so much as what 'style' care your provider is going to give you. Expectant management? Agressive treatment? Defensive Decisions? There are so many decisions in the many months of pregnancy and childbirth, each practitioner has their own paradigm from which they make decisions for your care. And each decision has a big impact on the safety of both mother and child. Each birthing woman and her family should take the time to educate themselves just enough to at LEAST know which style of management they want, and find a provider who'll give it to them.

#4 ~ 3:10 PM, April 07, 2006  faith gibson said...

I am impressed by the thoughtful, informed and informing responses to my April 4th comments. Usually I am talking to myself when addressing any aspect of this unpopular topic. I have to admit that this is the first time I’ve ever posted anything to a blog, as my handlers usually keep me chained up in the basement, nose to the grindstone, and won’t let me ‘waste’ time with such foolishness. But the NYT article on the Indiana midwife had a link to Ann Althouse’s blog and I clicked just to see what it was all about. Imagine my surprise! Cherrie and Elfanie’s replies are so good and worthy of being quoted. So I’m officially asking – may I quote you both?

The actual hot issue of the day is not the prosecuted midwife in Indiana but the draft report by the National Institute of Health subsequent to their “State-of-the-Science Conference on Cesarean Delivery on Maternal Request” (which they kindly reduced to ‘CSMR’ for the keyboard challenged). The conference was held March 27-29 in Bethesda. One of the most interesting aspects is that a government agency officially released a report at 5pm on March 29th, the last day and last minute of a conference. [www.consensus.nih.gov] Obviously, the report had already been written, which means the input of the participants was just a feel good move and window dressing for a predetermined agenda.

The NIH draft report concluded that mothers are demanding C-sections in greater numbers (good data says not true!), which ‘explains’ the 29% percent C-section rate for 2004 (and the projected 33% C-section rate for 2005!). The report went on to infer that there isn’t really any good data to determine if C-sections are better or worse than vaginal birth, but if you’re only planning one or two children, the odds are about even.

The illogical conclusion was that if you want to, go ahead and have all your babies by scheduled C-section (something about consumer convenience and giving mothers ‘control’ over their birth), never mind that it doubles maternal mortality and costs twice as much. Rumor has it that one of the things fueling this conference was a push for a CPT code (Current Procedural Terminology) for patient choice CS. This would permit them to hide a lot of poor obstetrical practices under the banner of women’s reproductive freedom and a woman’s ‘right to choose’. How poetic.

The NIH’s official conclusions are a great way to distract the American public from the real issue, which is physician fear of normal birth, spurred on by lack of education or experience in physiological management of spontaneous labor and birth, hospital policies that make physiologic process hard or impossible for either mother or physician to use in an institution, run away litigation, pressure on doctors from malpractice insurance carriers not to ‘allow’ mothers with VBAC, breech and twin pregnancy to deliver vaginally (docs get a ‘good driver’ discount if they agree) and astronomical malpractice premiums. This is all wrapped up in the notion that Cesareans (referred to as ‘vaginal by-pass surgery') are safer and better than normal birth (referred to as “delivery from below” – uck!). All these spurious ideas come to us courtesy of a dis-information campaign by many spokespersons within the obstetrical profession, who go on the Today show and NRP and assure us that vaginal birth is very bad for the mother’s pelvic floor (under anti-gravitational obstetrical management I agree!) and the baby and that “Cesarean is safer for the baby”.

Mind you, I’m not anti-obstetrician or anti-hospital. I have several physician friends that are obstetricians, even ones that are politically active in ACOG. They are all honest dedicated people. I am however ‘anti’ the politics of organized medicine, which includes methods of mass deception and the ill-informed idea that the best way to prevent complications is the “pre-emptive strike” -- routine use of potentially injurious interventions on healthy women and a form of malpractice insurance referred to by OBs as “when in doubt, cut it out”.

American mothers don’t have a “C-section deficiency”. The most important issue is not maternal choice Cesarean, it is how and why the mismanagement of normal birth has been systemized by the entire obstetrical profession to become the 20th century ‘standard of care’. Abandonment by the medical profession of physiological management in 1910 has brought us, in 2006, to the brink of the “tipping point”. For the lay public, post 9-11 political & economic overload, normal human inertia and the blind spot and prejudiced reporting that the media treats this topicwith, combined with the relentless lobbying pressure of ‘special interests’ groups and especially the loss of ‘institutional memory’ within the medical profession for normal birth management, has us tittering on the brink of a precipice. In some ways, the NIH document represents that exact point of the “tip-over” into no man’s land.

The NIH’s went off track because they started with the idea that the ‘normal’ CS rate is and should be one out of three or higher. Since no one can tell which one of the three patients will have a C-section and since the other two mothers will be subjected to so many injurious interventions that the rate of sequelae will be as high as it is for scheduled C-sections, then why shouldn’t we retool the behemoth of obstetrical care into a 9-5 M-F walk in C-section assembly line, which is already how its done in Mexico City (95% CS rate, with surgery scheduled at 15 minute intervals).

Throughout the entire 20th century, organized medicine has been free to build a relentlessly ambitious system to replace normal childbearing with a new and improved version, orchestrated by institutional medicine but never exposed to scientific methods. This unofficial medical experiment required that the principles of physiologic process be ridiculed and discredited and that infrastructure for physiological management dismantled. In the obstetrical model the integrity of childbirth is broken up into two separate sub-systems. Normal labor is conducted as a medical condition managed by nurses (no directly billable units, just routine hospital charges). Normal birth is renamed as the ‘delivery’ and given its own special professional status and economic base. Delivery is considered to be a surgical procedure that can only be ‘performed’ by a physician-surgeon in an institutional setting and which generates an itemized professional fee to be billed on top of normal hospital charges.

After 96 years of this new world order, physiological management has become invisible, a total non-entity (aside from the practice of community midwives) and was of course, missing-in-action in the 2006 NIH scheme of things. The federal government’s rubber stamp for maternal choice cesarean simply gives the obstetrical profession the green light to continue on with business as usual. That business is the death of normal birth via the total replacement of spontaneous vaginal birth with various forms of Pitocin accelerated labors and assisted vaginal delivery under epidural anesthesia and what they'd like us to think of as the Rolls Royce of OB care -- Cesarean surgery. The ultimate goal is the obstetrical dream machine – 9 to 5, Monday thru Friday walk-in assembly line C-section as the 21century standard of care.

The NIH panel did not report anything that is technically in conflict with "the literature" at the most base level of interpretation. Its faults, of which there are many, are subtle instead of simple and easily apparent. What that means is the scientific facts must be explained one by one; those explanations requires several sequential steps, which of course, means the listener has to care enough to pay attention long enough to get the point. The bottom line seems to be that nobody cares enough about this topic to find out the facts and/or knows enough about the issues to hold the obstetrical profession accountable. Like the popular perceptions of Enron and Arthur Anderson, we all just assume that ‘they’ know what they’re doing and of course, ‘they’ have our best interest at heart. I wish it were true.

#5 ~ 6:59 PM, April 07, 2006 Cherrie said...

What that means is the scientific facts must be explained one by one; those explanations requires several sequential steps, which of course, means the listener has to care enough to pay attention long enough to get the point. The bottom line seems to be that nobody cares enough about this topic to find out the facts and/or knows enough about the issues to hold the obstetrical profession accountable. Like the popular perceptions of Enron and Arthur Anderson, we all just assume that ‘they’ know what they’re doing and of course, ‘they’ have our best interest at heart.

E.X.A.C.T.L.Y!!!!

#6 ~ 7:25 PM, April 07, 2006 Ann Althouse said...

Faith: We discussed the NIH study here.

Thanks to all who are bringing the pro-midwife perspective.

Personally, I'm skeptical of everyone, not just midwives. Being pregnant is quite a predicament, and you need someone to help you out of that jam. I didn't like anyone I had to deal with. But the reality was, with modern nutrition, the babies' heads were completely out of proportion to the pelvis. I had no real choice.

Good luck to all. I don't have the answer myself, other than to say I'm glad I lived through the supposedly "natural" phenomenon of childbirth. Millions of my sisters did not.

For more info on CEO web site.