Guest Post — Getting Over the Guilt: NCB is Not Easy to Shake

Please welcome guest blogger and raptor extraordinaire, Lisa Miller.

On different parenting sites we’ve all seen quotes like this:

“At the moment we decided on the transfer, however, was the moment I felt the most guilty and as though I had failed.”

“ [I] Was so ashamed and embarrassed to have gotten the epi[dural] after 26 hrs of horrible back labor, I somehow had myself convinced I did something wrong for it to hurt so bad…”

“Even though I KNOW that I want an epidural this time, I occasionally catch myself thinking that I should just tough it out again and see if it’s better”

“I was not strong enough to make it. I pussed out.”

“I remember feeling immense guilt and failure for several months after Anna was born.”

“I knew I wanted the epi[dural] with #6 but felt weird about it all at the same time.”

“I still feel guilt over not nursing Elijah as long as I did the others and feel that it’s my fault he has had so much to deal with health wise.”

“ I do remember – however – feeling worried about posting my birth story on Babycenter (haha, why Lord, why?) because it ended in a c-section and I felt like I failed at birth (siiiiiiigh) that first week or so after the surgery.”

A Confession to my Closest Friends:

Common as these types of conversations are, this is not a collection of quotes from Birth Without Fear or Baby Center. These are selections from a conversation the Raptors were having just this morning. Yes, all these women are the rational ladies who support a woman’s right to choose drugs for labor and to formula feed and see nothing wrong with either. Apparently we do not extend such courtesy to ourselves.

How deeply do those of us who were steeped in Natural Child Birth still feel guilt over making the choices we did in labor? I feel so guilty that I have been lying to you all for the past year. Yes, I’ve told this lie so many times that it just seemed natural to tell it to the hordes of new best friends I have made over the last year. You all know that I got an epidural with my second birth, but you didn’t know I also got one with my first.
Why would I do such a thing? I know that getting pain relief in labor is a fine, safe, and perfectly acceptable option. Why the lie?

The first thing I am going to do is to rationalize my lie to you, because I STILL feel the need to defend it. With both my kids I was pushing within 30 minutes of getting pain relief—thus I still feel like I earned the title of Natural Birther, because I did all the hard stuff without drugs. This does not matter one bit. But it still does to me. Why is that?

The Natural Child Birth Does Me Wrong:

I had not been able to unclench my jaw since my daughter had been born. The pain from the clenching had caused my teeth to ache. I went to the dentist where he filled my teeth and gave me Vicodin. The only time I felt OK was when I was taking it. Soon enough I could not get any more narcotics and the pain from my jaw had moved to my neck and was making its way down my back. I was frantically borrowing pain killers from friends and family, scared to ask for some from a doctor because I feared they’d think I was a drug addict. Something was wrong.

Nine months pass and I can no longer get out of bed without help. I ache like a 90-year old-woman. The Doctors test all come back fine. They occasionally see some inflammation but they test me for everything under the sun. It’s not Lupus, it’s not Lyme’s. In the mornings I load my kids up in the car. We buy lunch at fast food places and we drive until I can’t afford anymore gas. It is the only way I can take care of them. At least when they are strapped in I don’t have to walk or move much, which causes me too much pain. I have resorted to buying pain pills from a sketchy guy that comes into the place where I work for $5 a pill. And they don’t help much. This is not the mother I wanted to be.

When my legs start swelling and I get fevers of 101.1, I break down in a doctor’s office. I tell her about everything, the pain, the pills, being an awful mother. She places her hand on my knee and looks over my record. “Honey, you have Fibromyalgia” She says as she rubs my shoulder.

And finally I have a name. Fibromyalgia is a disorder of the central nervous system that screws up the bodies pain receptors. It tells your brain that you are in pain when you are not. In people with fibromyalgia, as many as 35% have also been diagnosed with PTSD, or Post Traumatic Stress Disorder. When my doctor asks me about what was happening around the time the disorder started, I wrack my brain.

“If it was some type of trauma” She began “It would be something that you’ve replayed over and over, almost obsessively. Perhaps something that causes you nightmares?” Well, now that you mention it…

I had been having the dream since the day of my labor–the first one starting in the hospital. I see my husband– his usually calm and collected face looking at me in terror—eyes wide, head slightly shaking, and this scares me. He is the strong one and here he is falling apart. It scares me to death. And the pain, I can feel it like it was actually happening. Most people forget the pain of childbirth almost as soon as it is over, but I wake myself up having another dreaded contraction, only to find that it’s not real. I am clutching a deflated belly with not so much as a cramp.

My son’s labor was just long. Twenty two hours, with back labor and Pitocin and I got just got tired. The epidural helped to relax me and he was born soon after.

My daughter’s labor was 6 hours start to finish and was frantic. I remember trying to walk in the parking lot outside the hospital but every step caused a contraction and each one was worse than the last. When I actually got into the room, I went from my hands and knees, to the tub, to the ball to the bed and could not get a break from the pain. It hurt so bad that I remember looking down at my knuckles, which were white and griping the bed sheet and wondering how I could kill myself quickly. I didn’t ask for the epidural so much as I demanded it, and then begged. I cried knowing that it would take an hour for them to get a bag of fluids in me and then to get the actual drugs. I don’t like remembering this. Some folks might say that it was the epidural that caused the fibro to flair. To them I say: I didn’t have nightmares for months about getting pain relief. But I still have guilt.

So I did it to myself. I have given myself a life-long disorder for a belief I would later come to realize was not even real. The medicine they have me on has allowed me to be the mother I have always wanted to be. I still have bad days but I have a life. Having this condition has taken so much from me and once it is released, no amount of getting over my birth will make it go away. I am currently pregnant with our third child, taking a risk to be on the medicine while I am pregnant. Fibro has taken so many things from us, I refuse to let it take the family that my husband and I always dreamed of.

This labor, I plan of trying to be induced so that I know I can have an epidural as soon as possible with no waiting time. I have not a bit of guilt in that, and yet I still have guilt and shame from the epidurals I got in my other labors. I still feel like I failed at some goal I had set for myself. My rational mind knows this is insane, yet the guilt is still there.

So to my Raptor friends: I apologize for lying to you. And I am also sorry that I still have the need to offer further explanations (I have a pelvis that turns my babies’ sunny side up and makes labor very painful). But knowing that many of you still carry around the guilt makes me see how powerful this business of NCB really is. I see how it can get into your head and make you crazy with thoughts and insecurities. So here is to getting over it, moving on and not forgiving ourselves…because we’ve done nothing wrong.

Nine Times Nothing is Still Nothing

Please welcome guest blogger Mrs. W! She is a a health economist, a mom and a modern feminist who lives in British Columbia and blogs at Quality Care for BC Mothers.

The Nine Statements of Consensus from the Home Birth Summit: Nine Times Nothing is Still Nothing

There are substantive and real issues confronting the home birth and obstetric communities in the United States.  Having a summit could have moved things forward, fairly substantially, if they actually took the 9 pre-determined agreed upon consensus statements and used them as starting points, instead of accomplishments – because nothing is accomplished as a result of the statements made.

  •  We uphold the autonomy of all childbearing women…
 Autonomy in the absence of complete and unbiased information is meaningless – there cannot be free informed choice when the information given to women on childbirth is incomplete or biased.  A woman must be informed of the risks and benefits of the choice she is making if she is to be empowered to make the choice that best meets her needs and the needs of her child.  If the autonomy of childbearing women is to be upheld, there must be a consensus on what the real facts of childbirth are, and a commitment to providing that information to women in an unbiased and accessible way.  
  • We believe that collaboration within an integrated maternity care system is essential for optimal mother-baby outcomes…

Again a really lovely idea, but, clearly there are substantial barriers to making this a reality in the current system.  In order to collaborate, midwives and OBGYNs need to speak the same language.  In order to collaborate, midwives and OBGYNs would need to hold each other in esteem and respect.  In order to collaborate, they need to facilitate the work of one another.  This means that when a woman who is at risk in labor is transferred to hospital for care, the hospital is prepared for her arrival before hand and the midwife is capable of giving full and appropriate information about the woman and her labor to the OBGYN upon arrival.

  • We are committed to an equitable maternity care system without disparities in access, delivery of care, or outcomes…

Homebirth as it exists in the US today does not ameliorate disparities in access, delivery of care, or outcomes – it accentuates them.

Women in the US are far more at risk accessing the homebirth system than the hospital birth system.  They are at risk of having a care provider who does not undertake standard and appropriate prenatal care (gestational diabetes testing, group B strep testing, weight and fundal height measurements, and pre-natal ultrasounds).  They are at risk of having a provider who does not have adequate and appropriate education and experience.  They and their babies are at greater risk of death or disability and they are at risk of having a provider who does not carry malpractice insurance and who would be held accountable to a lower standard of care in the event of death or disability.

There will continue to be disparities in access, delivery of care and outcomes seem unavoidable in the current context.

  • All health professionals who provide maternity care in home and birth center settings have a license that is based on national certification that includes defined competencies and standards for education and practice…
This begs the question what is the appropriate standard?  Furthermore, in the absence of legislation, what would be the consequence of failing to meet the standard?
  • We believe that increased participation by consumers … is essential to improving maternity care…
Is this the facilitation of informed joint decision making during the care delivery process?  If so, See number 1.  Or, perhaps more meaningfully, will this mean that consumers would have a way of voicing their concerns and having those concerns heard in much the same way that hospital patients can have a formal review of the care they received?
  • Effective communication and collaboration across all disciplines caring for mothers and babies are essential for optimal outcomes across all settings…
See #2.
  • We are committed to improving the current medical liability system …
Another starting point – what medical liability system currently applies to homebirth midwives?  Doesn’t a system need to be in place before it can be improved upon?  Is there an insurer that would take on the risk in the current environment?
  • We envision a compulsory process for the collection of patient … data on key … outcome measures in all birth settings….
So. Data is collected. MANA collects data. Does a $#!T load of good – unless you commit to releasing the data, it means nothing. Data existing does nothing without it being available to be analyzed, actually having it analyzed and releasing the results of that analysis.  Furthermore, there needs to consensus on what data elements are critical and the definitions of those elements – this is essential if the data across birth settings are to be comparable and the data is to be transformed into meaningful information.
  • We … affirm the value of physiologic birth … and the value of appropriate interventions based on the best available evidence to achieve optimal outcomes for mothers and babies… 

This seems at odds with valuing patient autonomy, particularly when not all pregnant women giving birth would choose physiologic birth if given complete information to make an informed choice.  Furthermore, valuing the particular process of birth (physiologic, a.k.a. “normal birth”) places form over function – shouldn’t the ultimate goal be healthy moms, healthy babies regardless of delivery method?

 

 

Why I Chose Hospital Birth

Please give a warm welcome to guest blogger Lauren Baden! Lauren is a SAHM and college student studying to be a microbiologist. She currently lives in northernish CA, while her husband serves in the Air Force. They move a lot, don’t get to  see each other as much as they’d like, and have amazing friends who get them through everything. She has one daughter, Aline, two cats, and a very large dog! She strives to promote safe birth, whether that is at home or in a hospital.

Let me start off by saying I am not against homebirth.  I am all for safe homebirth attended by an experienced medical professional, preferably a CNM.  I cannot in good conscience support unattended births or births attended by direct entry or lay midwives. However, I do believe that there should be state or federal guidelines as to what constitutes a medical professional, meaning there should be standardized schooling to allow more women the ability to birth at home if that is what they desire.

I delivered my daughter on July 16th, 2011 at the National Naval Medical Center in Bethesda, Maryland. I bring this up because I know there could be someone out there who says “Your doctor induced you to make more money!” This is untrue, as my doctor is a military member; therefore she got paid the same amount no matter what kind of birth I had.  Homebirth was never an option for me, because I have multiple medical problems that would have made it extremely dangerous.

The primary concern for my wellbeing, along with my daughter’s, of course, was my heart conditions. I have a mitral valve prolapse with regurgitation. This in itself is not enough to be seriously threatening to my life, but it’s certainly something that needs to be monitored. My symptoms got progressively worse as my pregnancy went on, and since I am fairly asymptomatic from that, it was a cause for concern. Additionally, I have atrial fibrillation, a type of arrhythmia or, put simply, a whacky heart rhythm. This can cause a myriad of problems, and to be perfectly honest, people with AFib really should consider the risks of pregnancy with the condition. On top of all that, I was born with a genetic condition called Neurofibromatosis type 1, and as with many genetic conditions there are varying degrees of severity. My family is very fortunate that, generally speaking, we have had no major problems linked to our NF1. However, one of the major concerns is that we grow benign tumors called neurofibromas on our bodies, and they can often grow on the spinal cord or even in the vaginal canal. One can see why this might cause issues during delivery. The final nail in the coffin, so to speak, was that I developed community acquired MRSA about 2 weeks before Aline’s due date. I had to be on some serious antibiotics, and they are known to cause severe jaundice in neonates. The doctors needed to be able to monitor Aline closely for that and for any signs of infection in her.

It’s tough to say what would have happened had we not had a hospital birth. I don’t know what would have happened if I went into labor naturally, as I was induced at 41 weeks. I’m aware that due dates aren’t an exact science, and normally I would have preferred to avoid an induction, but all of my doctors were strongly recommending scheduling an induction. My heart symptoms had reached an all-time high; I could barely walk up a single flight of stairs without my heart racing. After a 36 hour labor, including an MRI to check for tumors on my spine before placing an epidural, Aline’s heart rate dropping to the mid 50’s, my own heart rate skyrocketing to nearly 200, and my poor husband having his hand nearly broken.. Our precious daughter Aline arrived. Was her birth ideal? No, I didn’t really want to be induced and they had to use forceps as she was stuck behind my pelvic bone. Am I horribly traumatized and do I need lifelong therapy? Absolutely not.

I know that every woman is different, and therefore her choices and her reactions to the outcomes will be completely different. In the end, as long as mom and baby are healthy and happy, that is what matters. One might argue that the trauma of birth will make mom and baby not healthy and happy, but, to me, the argument holds no merit. Childbirth does have inherent risks, there’s no denying that. There is a reason that childbirth was the number one killer of women for countless years. Sanitation, better medical techniques, and better nutrition have all added up to make childbirth less dangerous. Birth is not to be feared, but I’m not sure it should be trusted either. Birth is to be respected, whether it’s at home, in a birth center, in a hospital, or in the middle of the woods with you surrounded by your furry friends. Birth how you want, but please… do it safely.

Guest Post: On Bitterness and Babies

Please give a warm welcome to today’s guest blogger, Rachel Welch. Rachel is a former teacher turned SAHM. Her hobbies include composing soundtracks for epic nappy changes, scrubbing cupcakes out of the carpet with baby wipes and searching for lost socks. In the spare 30 seconds left after all that, she might sneak in an episode of Glee or a chapter of Love in the time of Cholera (And yes you read that right it is humanly possible to watch an hour long show in 30 seconds. She has a Tardis). She blogged her way through a long infertility journey, which although painful, did not break her spirit. The only thing which can dampen her mood is when she checks her cupboards and finds them bare of both chocolate and rum. Her lifelong dream was to become a mother of more than one child, now that’s out of the way she’ll settle for a cruise around the world with Gerard Butler. Or just 10 minutes to drink a cup of tea in peace and stare out the window.

“And we can’t use any lubricant, because the embryos don’t like it,” the nurse commented as I waited. I inhaled my breath sharply and gritted my teeth against the pain. Then two excellent embryos were transferred in my first and only IVF cycle. The embryologist looked extremely young-I felt panicky wondering if he was truly qualified for the job.  Regardless, two weeks later I had a positive blood test. “Knocked up and ecstatic,” was my new state of being.

I was one of the lucky ones.  Infertility treatments don’t work for every couple and for some; it takes several treatments to be successful. Despite the fact that 1 in 5 couples will experience some form of infertility (translation: someone you know) there is a perception in many parenting and birthing communities that all infertile women are crazy. Or not just crazy, but also bitter, angry, even consumed by utter jealousy. We’re jealous of women who conceive in a flash and have natural deliveries. Their bodies work but ours didn’t. Our bodies are traitors, theirs are comrades. This perception exists regardless of the fact that many of these women have gone on to become parents. The belief is that they will be this way forever.

As a woman who has been through infertility and out the other side, with many friends whose experiences are similar, I need to correct this assumption. You see, the belief that infertiles are coocoo for cocoa puffs equates to saying a pet owner who can’t stop grieving the loss of their elderly, ill dog is bananas. Personally, I’ve only ever owned one dog and I didn’t grieve that long over his death. Maybe that seems heartless, but I moved out 2 years before he died. So the bond just wasn’t there. My point is; I probably don’t understand the depth of emotion that losing a truly adored, furry companion can bring. And you out there, who points fingers but has never experienced infertility, can’t truly understand that either.

To begin to understand infertility you’d have to first dream up a goal. Any goal, anything your little heart desires. Then imagine how desperately you want it. Let’s say your goal is moving to Paris. Step one in achieving it is getting a job so you can save up. Tomorrow, you’re going out there to apply for jobs. But instead, you get hit by a car and spend months in painful, difficult rehabilitative therapy. Infertility is like that. You know  what you want and you desperately want it, but (due to pure chance) the goal posts keep getting moved further and further away. In my experience, before I fell pregnant successfully, I only endured secondary infertility, 1 ectopic pregnancy, 1 laparoscopy, 3 IUI’s, one IVF fresh cycle and 2 years of trying. A friend’s experience was different; “He showed me a scan and pointed to a dark line, that should have been bright. “You have a blocked fallopian tube.” My husband and I were so relieved. Finally, we had a mechanical reason for our three year long failure to conceive. A reason, a solution and an action plan; “We simply bypass the fallopian tube, place an embryo directly in the uterus, and your prognosis for a successful pregnancy is excellent”. And it was. Less than a year later, our funny, funky, sporty little girl was born.”

No two infertility experiences are identical, but I can safely say that mine was excruciating. I felt torn apart at the very core of me, like my identity had been stripped away. No amount of money, pleading with God or the universe, or developing healthier habits could bring me my baby. I’d go out for retail therapy to lift my spirits and end up seeing babies, pregnant women and families everywhere.

Yes, that was incredibly painful to go through. But I have let it go. I had to let it go because with the benefit of my infertility experience, I know I’d rather be enjoying life with my two beautiful children by my side, than dwelling on the past. I learned what I could from that time in my life and it’s over. There are no second chances, no limitless possibilities and that’s just reality. A different friend who has been through primary infertility agrees; “basically I think the reason I am not bitter is the emotional toll that facing the prospect of not being able to create a child took gave me the gift of perspective. I had to invest so, so much into the most important thing I would ever do, and that made me evaluate life differently. I’ve become so much less willing to invest in things that are trivial, or maybe now I just see things as more trivial than before, but either way I can’t be bitter when I look at my child and realize I was blessed with a miracle. The world is so much more amazing now.”

 

I often hear it said that women prefer seeing a midwife because of the special relationship they develop with this individual, or group of carers. Infertiles develop a similar bond with their OB. These men and women are not heartless or money-hungry. Personally, my health insurer picked up the majority of my OB’s tab, including infertility services. The same beautiful friend quoted above says of her time under a male OB’s care; “My OB is the nicest, gentlest and genuinely caring guy. He has always made sure I understood everything that was happening before I left his office…I was never just rushed through, and if he ever was in a hurry he had his midwife who would walk me through it all. I had panic attacks at one stage, brought on by heart palpitations. I was on the phone to him and burst into tears during an attack, and he pulled strings to get me into a heart specialist (his friend, who was booked out for months) straight away. I had ovarian hyperstimulation during one cycle and ended up in Intensive Care, he was on holidays but visited every single day and called as well to check on me. Then even though it wasn’t his fault he covered my hospital bills, because I had been under his care. He cried with me during my first ultrasound, and again when he delivered Miss E, and got photos with us. He hugged me, and shook my husband’s hand congratulations, visited me again everyday till I went home. He is my hero, and made me feel like he genuinely cared about me.”

 

Couples who experience infertility need to know their provider cares and is invested just as much as those who choose midwives. That level of compassion for their patient means an OB may suggest the way to give birth which is safest for that particular mother and baby pair. They know what their patient really wants-the priceless experience of parenthood. The simple, loving relationship which exists between a parent and a child.

When it was time for me to give birth, I definitely considered the idea of a VBAC. Several of my infertile friends were also set on natural deliveries. Even though medical advancements allowed us to conceive, we didn’t necessarily believe that would be needed on the special day. In my case, I knew I would not be taking any risks. Not because I hate the idea of natural birth. Not because I don’t “trust birth” enough. It was just one simple reason: maturity. Another friend who has experienced primary infertility agrees, “From the moment I stuck the first needle in my belly, I knew I would do anything for my child, and that came to her birth as well. I suffered from unmanageable pregnancy induced hypertension. My blood pressure was such that a trial of labour carried high risk of stroke, for me and my girl. Looking at my options I made a choice and hopped on the surgical table without a backward glance.  My birth plan went out the window, anything for her.”

In my case, I removed my needs from the situation and reviewed the evidence based on my past experience. I’d learned that there are no guarantees in life, none at all. In addition to that, time is incredibly precious. Every agonizing second I’d lost waiting and hoping and wishing but not always really living for that day, was already gone. I was not about to invest another 2 years and 9 months trying to successfully conceive and gestate. That part of my life was done. Here are my thoughts from when I decided on an ERC: I can’t be angry with my body forever. The reality is, I am relieved that, as long as bub arrives safely, TTC is over. I just can’t imagine going through another loss, or 2 more years of this same hell. So I will make my peace with it. 2 children is amazing.”

Those who don’t understand can call me and my friends bitter. But we’re not. You can’t understand this hell and I wouldn’t wish it on you. So please, stop judging and assuming. We’ve moved on.  We are seizing the day. Perhaps it’s time you did.

 

The Game of Risk

Astraea blogs about midwifery in Oregon and shares her own homebirth horror story over at Oregon Homebirth Reality Check. We felt this recent post of hers was so important that we arranged for it to be be re-posted here as a guest post. You can read the original post here.

Any plan is arguably only as safe as its contingency plan is solid. Common and less common emergent and urgent situations must be studied and planned for; backup must be arranged. Staff should be drilled on what to do in case of the most dire situations, they can act quickly and calmly in the face of an actual emergency and the panic it brings. This is a well-accepted principle. It is why we have fire drills in schools and offices. It is why lifeguards must be people who have been trained, and not just any person who knows how to swim. Unfortunately, among many “alternative” healthcare providers, risk planning is looked down upon. It is seen as inviting “negativity.” Some even believe that you can “manifest” good or bad results simply by thinking about them a lot. This is a childish, irrational belief, but unfortunately a common one in the circles of direct entry midwifery. (Childish, literally–remember Mr. Rodgers comforting children that they cannot cause a person to die just by wishing they were dead? That’s magical thinking, a normal developmental stage. We’re supposed to grow out of it.)
But homebirth is truly only as safe as the process used to “risk out” of it (and into obstetrical care in the hospital) is complete, thoughtful, and conservative. The risk assessment protocols for Oregon DEMs have again been changed. You can see how they differ from the 2009 version of the same. The criteria have been tightened up slightly in a few ways, but overall loosened substantially from the original 1993 criteria (see table). The legislators who allowed direct entry midwives to be licensed through the state in the first place approved a far more conservative set of safety guidelines than what is currently in place. These changes–for instance, moving from no VBACs to almost any VBAC; no multiples to most kinds of twins; no malpositioning to any breech and back down to no footling breech–have been put in place by the DEM board, without any outside oversight. What is worth examining in some detail is not just how the Oregon absolute and non-absolute risk criteria have changed, but how they compare to the homebirth systems that are so often held up as examples of why homebirth is safe. We cannot expect to get the same results as the Netherlands, Canada, or New Zealand if we are failing to be as conservative in our safety standards as those nations.

 

 

Even a quick scan of the risk criteria by a careful eye shows many problems. For one thing, the list is very brief; many potential serious and common risks are not even weighed or considered. Compare it with the far more comprehensive and methodical list from the British Columbia College of Midwives and the sloppiness and shortcomings of the Oregon list are readily apparent. In almost 20 years, how is it that the board has not managed to come up with something as thorough as the Canadian risk criteria? For another thing, some of the determinations rely upon diagnostic tools or skills that DEMs are unlikely to have on hand–for instance, AIDS in an infant is an absolute risk factor according to the 2009 standards, but HIV is a non-absolute risk factor. How is a midwife to determine the difference on site, without being able to determine viral load, T cell count, or the presence or absence of AIDS-related complications?

“Absolute risk” is a condition that rules out homebirth as a possibility. The patient(s) must be referred out to hospital care immediately. “Non-absolute risk” is much blurrier in meaning. Oregon law only requires that the midwife consult with another professional about the situation and obtain “informed consent” from the patient. Another disturbing contrast with the BC system is that while for many conditions, Canadian midwives must consult with a physician and proceed as advised. Oregon midwives must consult with “another licensed professional” but it need not be a medical doctor. It could be a naturopath, in fact, or even just another midwife. Considering the extreme seriousness of many of the conditions on the non-absolute risk list (ie platelet count below 75,000; persistent unexplained fever over 101; labor at 35 weeks gestation; isoimmunization to blood factors) this is extremely alarming. Other direct entry midwives are no more trained in these high risk situations than the direct entry midwife calling the consult. Naturopaths are often not trained in them either, as they lack the inpatient experience that a licensed MD or DO must have. And the looseness of the law makes this a judgment call where the safety depends entirely on whether your midwife is cautious or reckless. A cautious midwife may choose to take an infant weighing less than 5 lbs or with a “suspected major congenital malformation” to the hospital. A reckless one may call a naturopath who in turn suggests breastfeeding and homeopathy…while a premature or growth-restricted baby slowly dies a preventable death, or major malformations begin to claim an infant’s life even though in a hospital, treatment would be available and effective.

And under current Oregon law? The reckless midwife would be absolutely justified, protected, and in the right. This is sick and wrong.

A number of the conditions Canadian midwives must refer for transfer are on the Oregon non-absolute list, or are not named on the Oregon lists at all. If we are looking to Canada’s outcomes to justify licensed direct entry midwifery in Oregon, why this discrepancy? But the difference is far more jarring and obvious when you compare the Oregon list of standards with that of the Netherlands, the country whose high rate of homebirths and relatively favorable outcome statistics are so often held up as an argument in favor of American direct entry midwife-attended homebirths. Nevermind that Dutch midwives are more like American nurse-midwives than our poorly trained and unregulated “CPMs.” Looking at the very strict, conservative, and comprehensive standards Dutch midwives work under, it is clear that we cannot expect to see Dutch results with our sloppy Oregon risk criteria.

For instance, the first three sections of the Dutch criteria, dealing with medical history and prior pregnancies, has no equivalent in Oregon statutes. The Oregon risk criteria deal almost exclusively with the present pregnancy and conditions that may arise within it. This is a huge oversight, considering the impact that medical history and pre-existing conditions can have upon a pregnancy. I think, because DEMs are trained narrowly in “normal birth”–they are more “birth assisting techs” than true midwives in the sense that Dutch midwife or a nurse-midwife is a midwife–they simply were too ignorant of all the possibilities to think of them for their risk criteria list! For instance, while the Dutch standards address alcohol abuse (common!) and chronic conditions like MS or rheumatoid arthritis, the Oregon standards only tangentially address the latter under the umbrella of “conditions that may need medication,” a non-absolute factor. The Dutch standards require twins and breech babies to be born in a hospital, while the Oregon standards do not. Yet the 1993 Oregon standards were in line with the Dutch standards! Why the change? There have been no scientific breakthroughs validating looser protocols. It seems a clear case of letting the people with a financial interest in increasing their reach (DEMs) have too much oversight over their practice protocols, and not enough legislative moderation imposed to slow them down. The Dutch require hospital transfer after 24 hours of ruptured membranes. The Oregon standards don’t even list that as a non-absolute risk factor–only after 72 hours AND the deadly infection chorioamnionitis has set in must Oregon DEMs transfer under penalty of law. Yet in 1993, the standard was just 72 hours…choreoamnionitis was clearly added in later not to protect patients, but to sweeten the deal for DEMs who feared transferring care and perhaps losing out financially or legally when they did so. Failure to progress in labor–a warning and risk factor for many potential problems such as shoulder dystocia, postpartum hemorrhage, and maternal exhaustion–are risk-out criteria after a set time in Dutch regulations. It was also an absolute risk factor in 1993 Oregon law. Now it is not even a non-absolute risk factor; women in Oregon can continue in labor indefinitely at the hands of a negligent midwife, as poor Margarita Sheikh did and the midwives are accountable to no one for this poor treatment of their patient.

The creeping risk factors in Oregon are in opposition to the findings of scientific evidence. For instance, take late prematurity. Recently, much has been made of the evidence that babies born prior to 39 weeks aren’t really ready. While 34-37 week babies were once thought to be mostly ok, we are now learning that they may face long-term effects in brain development and other aspects of their health. This has been the driving force to reduce elective c-sections that take place too early, inductions before 39 weeks, and other such potentially risky interventions. The Dutch criteria require transfer to hospital care in the case of rupture of membranes prior to 37 weeks. The 1993 Oregon criteria require transfer with rupture of membranes prior to 36 weeks. But the 2009 Oregon criteria don’t require the baby to go to the hospital unless it is THIRTY FOUR weeks. Incredible. Unprecedented. Where are they getting these numbers? After all, a baby of 35 weeks gestation still has a 12%  risk of respiratory distress syndrome–compared to the 3.5% risk at 37 weeks or virtually nonexistent risk in a 40 week baby with no other predisposing conditions. (See calculator here.)

What justifies these reckless Oregon protocols? And where will the creeping upwards in high risk stop? Will 33 weeks at home be argued for next time the criteria are reviewed? After all, stunt “midwife” Lisa Barrett in Australia is all for it–don’t let the fact that she’s being investigated by the coroner disturb you too much. (Warning, link contains nudity and graphic birth scene, not to mention appalling and nauseating stupidity and disregard for human life and limb.)

In fact while I find the Oregon protocols ignorant and lacking when it comes to the health of the mother, it is in regards to the well-being of the infant that I find them the most alarming and disgusting. To get perspective on what other homebirth-friendly areas allow in this regard, I compared the protocols to NICU or Level II admission standards in New Zealand. It seems a safe assumption that if New Zealand professionals, who are used to midwifery care and homebirth being integrated into their maternal care system, think a baby should be in the NICU or SCBU as I think they call the step-down units over there, a baby with the same condition in an Oregon home should be headed for the hospital.

On admission to level 3 in NZ, I found two questionable equivalents on the Oregon list. Since OR does not require transport for a Coombs positive (it’s non-absolute–so call your favorite naturopath to see what kind of sage to burn) Oregon DEMs cannot know if a baby needs an exchange transfusion or not. They cannot diagnose polycythemia or anemia, either, two other indications for exchange, and are likely to dismiss jaundice as “physiologic.” Also, since DEMs are not required to transport a baby who needed PPV at birth so long as eventually he perks up to an APGAR of 7 by 10 minutes of age, that baby will not be monitored in Oregon as he would be in New Zealand. Dangerous, since respiration isn’t a given and can decline without warning in neonates if it was shaky to start with (as too many homebirth loss parents know).

For admission to level II (“feeder grower” as some may know such units here) NZ guidelines require it for infants under 5 lbs 8 oz. Oregon midwives must only consult that friendly naturopath or her buddy midwife even if an infant is under 5 lbs. 36 weekers go to level II to get checked out in NZ; in Oregon, you call your naturopath if you’ve got a 34 weeker. Respiratory distress for an hour sends you to get a look over in level II by NZ standards; in OR you can be grunting and tachypnic and in distress for more than 2 hours before your midwife is required to take you in. Signs of bowel obstruction are considered by NZ guidelines, but not by OR. Metabolic problems get you a doctor’s exam in New Zealand, in Oregon your midwife must only call a friend to validate her less-than-informed opinion of your condition. A NICU doc must look over New Zealand babies with major malformations; Oregon babies suffering the same pain merit only a quick chat over the phone with another professional.

All I can say is, it really seems better to be a newborn in New Zealand than to be born at home in Oregon. It sounds a lot safer to be a NZ baby, and it sounds like the adults in charge of their midwifery boards and government are thinking a lot more of their needs and comfort and right to not be left suffering at the whims of a midwife who either doesn’t know any better or is too arrogant to throw in the towel and ask for help.

All this shows one thing with incredible clarity: Oregon direct entry midwives are not doing a good or responsible job regulating themselves. They are taking advantage of the relative autonomy granted them by the state to put in place an ever-upward-creeping standard of allowed high risk pregnancies and births that they can attend and profit from. Like a game of “Risk,” DEMs have claimed one continent of risky births and are on their way to claiming more–until they win, and Oregon citizens lose. This is done without any heed to scientific evidence or global homebirth standards. And it is done with callous and cruel disregard to the safety of Oregon newborns and their mothers and families. The Oregon legislature must act immediately to put this game of risk to a halt. As a stop-gap, the original 1993 standards, approved by Gov. Barbara Roberts, should be put back into place. And then, a panel of experts should review the standards of care in nations like the Netherlands, the UK, Canada, New Zealand, and Japan; the scientific literature; and the track records of Oregon DEMs and come up with a comprehensive safety plan that serves mothers and babies and NOT simply the needs or wants of direct entry midwives and their high-paid Oregon Midwifery Council lobbyist, or “birth activists.” The panel of experts may contain DEMs, but it must also include MDs and/or DOs, nurse midwives, OB nurses, and public health statistics experts. The safety of Oregon families is worth a REAL effort, not this shoddy, incomplete, ever-loosening current “risk criteria” in place today.

Guest Post: How to Choose a Safer Homebirth Midwife — A CNM’s Perspective

Please welcome today’s guest blogger, Deb O’Connell CNM, MS. Deb has a private homebirth and well-woman gynecology practice in Carrboro, NC. She has been a midwife for 11 years and has attended over 800 births. Deb has experience teaching at the university level while managing low and high risk pregnancies, community hospital midwifery, gynecological clinics and homebirth.

While writing this for 10Centimeters, I am reminded of the intense debate that surrounds midwifery care for homebirth here in our country. While this is not an exhaustive list by any means, it is meant to give families an idea of some of the important questions to ask while interviewing a midwife for their homebirth.

I am a Certified Nurse Midwife and I personally feel that CNMs with experience managing high and low risk pregnancies are best equipped to attend a laboring woman who plans a homebirth. Why? CNMs are the only credentialed midwife legal in all 50 states. CNMs have been trained and have worked within the hospital setting – exposing them to both high/low risk pregnancies. Most hospital trained CNMs in practice will “catch” anywhere between 50-150 babies a year depending on the size/volume of their practice. CNMs have a master’s level education. CNMs have the lowest neonatal mortality rate of any other provider documented by the Center for Disease Control. Most CNMs are registered nurses that have then decided to move forward with their midwifery education. RNs have a vast knowledge of assessment skills, clinical skills and documented excellence of care. RNs are also licensed in all 50 states and a consumer can go to their state board of nursing to view complaints/grievances filed against their licensed CNM/RN. Finally, CNMs are credentialed to provide full scope midwifery which includes well woman care beyond pregnancy as well as contraception management and menopausal management.

However women will choose whom they want to attend them at birth – regardless of the midwives’ education level, training, experience, credential (or lack thereof) or even licensure.

Let the buyer beware.

Homebirth is not safe for every woman and any midwife who tells you that is grossly misinformed. Birth is not to be trusted – it is to be RESPECTED.

Homebirth is not as safe for baby as being born in a hospital – the NCB community can state it is (and in the past I have stated it as well) – however research has proven differently and parents need to be made aware that if the midwife they choose does not know how to recognize / anticipate when normal is turning into abnormal during the labor or birth, the results can be disasterous for mother and baby. A mother’s birth experience does not trump the safety of her fetus/newborn .

Parents who choose to have their birth at home should be sure their midwife has the following:

  1. Has experience in managing both low and high risk pregnancies.
  2. Licensed and credentialed to practice in your state.
  3. Carries malpractice insurance.
  4. Has a professional relationship with an OB/GYN or Maternal Fetal Medicine team for collaboration, consultation, referral, transfer and transport if needed.
  5. Has a well- organized transport system for her clients and reviews this with you during the pregnancy.
  6. Is willing to share her risk- out criteria, her practice guidelines, her stats and her professional license numbers with you (This should actually be a printed disclosure statement that accompanies the informed consent she has you sign).
  7. Asks you about the distance your home is from the hospital that has an OB Unit – ideally you should live no further than 30 minutes from your nearest hospital.
  8. Has another midwife or RN that attends each and every birth with her and they are both current in their BCLS and NRP certifications and have also had experience managing both low and high risk pregnancies.
  9. Follows you through your pregnancy to six weeks after birth.