Home Births

Mamas on Bedrest: ACOG’s New Recommendations on Planned Home Births

February 4th, 2011

ACOG just released its new recommendations on planned home births.

As many of you may recall, last summer, ACOG “leaked” data from a study done by Dr. John Wax and colleagues at the Maine Medical Center stating that women who elected home births had a 2-3 fold increase in neonatal mortality. The study was published in the fall, but the data was publicized in July, Just as New York and Massachusetts were voting on whether or not to grant practice privileges to midwives. The study data was immediately criticized by the American College of Nurse Midwives, Childbirth Connection and a multitude of birth advocates. As the dust has settled, ACOG has reviewed its stance and published their latest recommendations in the most recent issue of Obstetrics and Gynecology. (Obstet Gynecol. 2011;117:425-428)

MedScape Summary of ACOG Home Birth Recommendations.

Each year some 25,000 women elect to give birth at home. A meta-analysis done of observational studies by Wax and colleagues concluded that there is a 2- to 3-fold increased risk for death for planned home births. Previous studies have also shown a decrease in neonatal mortality in regions with readily available transport to hospitals. In the United States, studies show that the lowest mortality rates in the presence of a highly trained midwife who is well-connected to the health care system. To reduce the risks, women who choose at-home birth should be informed about appropriate candidates for home birth. According to the committee, these include women:

  • With absence of maternal disease previous to or during the pregnancy
  • Singleton fetus
  • Head down presentation
  • Gestational age between 36 and 41 completed weeks of pregnancy
  • Spontaneous labor or labor induced as an outpatient,
  • Women who have not been transferred from a referring hospital.
  • Women who have had previous cesarean deliveries should absolutely not undergo planned home birth
  • Have at hand a certified midwife, certified nurse-midwife, or physician
  • Have consultation access
  • Have access to timely transport to a nearby hospital if needed.

The analysis also found that planned home births were associated with:

  • Fewer maternal interventions, such as epidural analgesia, electronic fetal heart rate monitoring, episiotomy, operative vaginal delivery, and cesarean delivery.
  • There were also fewer third- and fourth-degree lacerations and maternal infections and similar rates of postpartum hemorrhage, perineal laceration, vaginal laceration, and umbilical cord prolapse.

The percentage of planned home births will likely continue to grow, and according to this MedScape Editorial and many experts in obstetrics and gynecology and public health, it is incumbent on the medical profession to adapt and integrate the practice, though many physicians remain resistant to working with midwives.  Said Eugene Declercq, PhD, professor of maternal and child health at the Boston University School of Public Health in Massachusetts, who takes issue with the numerous “flaws” noted in the Wax Study,

“I’d prefer to have people finding ways to work together, rather than this ceaseless interprofessional battle. The reality is that there are more and more women seeking planned home birth, and we need to make it safer for everybody.”

The complete MedScape News Editorial is located on the Medscape Website.

Where are you planning to give birth? Need help creating a birth plan? Let’s work up a plan together in your Complimentary 30 Minute Bedrest Breakthrough Session. Schedule your session by e-mailing info@mamasonbedrest.com.

Mamas of Color Rising: Advocating for Mother Friendly Births For Mamas of Color in Texas

January 11th, 2011

Prior to 1989, Midwives practiced freely in Texas. Many Texas children were born via midwife assisted births and many of these births took place outside of the hospital. In 1989, The Texas Midwifery Act was amended to include mandatory basic and continuing education requirements which took effect in September, 1993. The law was further amended in 1997 when new rules were written to assist the Midwifery Board in implementing the law through disciplinary actions which could include removal of documentation and administrative penalties.

In 2002,  midwives ceased to practice in hospitals in Austin.

Since that time, access to mother friendly childbirth practices has been essentially  non-existent for low income women and women of color in the Greater Austin Area. These women have been at the whim of whatever Medicaid would cover and whatever treatments the obstetricians who accept Medicaid reimbursement are willing to provide. To say the least, low cost, high quality, minimally invasive care has been scarce.

Mams of Color rising, is a collective of mamas of color in the Greater Austin area fighting for birth rights for all mamas. Here is how they describe themselves:

“Mamas of Color Rising is a collective of working class and poor mothers of color based in and around Austin, TX. We are interested in organizing ourselves and other women/mamas of color around issues with accessing needs like food, housing, education and safety, finding out together what our larger ideal community looks like and building it together.”

Currently the  main objectives of Mamas of Color Rising is  to gain equal access to “Mother Friendly Birth Practices” for low income mothers of color. Their goals are:

  • To Create a volunteer doula project for low-income women of color in Austin. This project will begin with 20 women of color being trained as doulas March 2011.
  • To Work in collaboration with pro-midwifery lawyers and other organizations and to get Medicaid to cover Midwifery care in Texas
  • To Start free pre-natal midwifery care in Austin with volunteer midwives. This will serve as as a pilot for a Medicare Proposal.

To that end, Mamas of  Color Rising is working to train 20 women of color as doulas in the greater Austin TX area to serve the Austin Mamas of Color in need. These women will be trained this coming March, 2011. Mamas of Color Rising is raising funds to cover the cost of training for these women. This training will be the first step in launching a culturally based volunteer doula project for low-income women of color in Austin.

Currently, Mamas of Color Rising has raised $933 of the $2000 needed to train the doulas. If you are so moved, please consider donating to Mamas of Color Rising in support of the Doula Training Program. You can make a donation directly on their website mamasofcolorrising.wordpress.com via PayPal.

As Mamas of Color Rising has so aptly pointed out:

“Our vision of organizing around motherhood is not a biological one, it’s not just about biological moms, or even just moms, but about all of those members of a community who share in the often undervalued and invisible work of care-taking and parenting.  It’s not just symbolic either, because unfortunately right now its mothers and other women who do the vast majority of the work of taking care of children, elders, and sick folks who cannot take care of themselves.(all unpaid!)

As Mamas of Color Rising, we want to present these issues for public conversation and struggle. We see this work as a way to challenge the patriarchal and isolating model of nuclear family units AND as a way of creating social justice for everyone because a society is only as good/strong/just, as how it treats its (women) children and elders.

If you agree, please support Mamas of Color Rising.

References:

Association of Texas Midwives

American College of Nurse Midwives: Addendum to Federal Trade Commission Department of Justice Hearings on Healthcare Competition


Mamas on Bedrest: Some Things Just Stink!

November 10th, 2010

Some things just stink. I have wrestled with this blog post for over a week trying to find a tactful way to address the battle waging between obstetricians and midwives. I have looked at several articles and commentaries and have come to the conclusion that the tactics that the American Medical Association (AMA) and The American Congress of Obstetricians and Gynecologists (ACOG) are using to limit  in some cases, and frankly ban in others, midwives from attending home births and other births just plain stink.

As previously stated in the blog post A Plea From Mama to OB’s and Midwives, the primary focus should always be what is in the best interest of mothers and babies. Unfortunately, the AMA and ACOG both have not only adopted adversarial stances against midwifery practice, they have gone so far as to use faulty study data to support their claims and to push for legislation to limit or ban midwives from practice. And while midwives have offered their fair share of negative assaults on obstetrical practice one has to admit that midwives have never sought to limit, ban or outright erase obstetrical practice. This is the unfortunate tenor that the AMA and ACOG have taken and why this battle has turned so ugly.

But don’t believe me. Let’s look at what the major issues are. Maternity care in the United States is subpar at best. If you are insured, you fare quite a bit better, but women are still subject to far too many interventions and unnecessary procedures that have lead to a cesarean section rate of 32% nationally. According to Amnesty International’s Report Deadly Delivery: The Maternal Health Care Crisis in the USA, 2 women (or more) die each day from pregnancy related complications. A woman is 5 times more likely to die in childbirth in the US than in Greece, 4 times more likely than in Germany and 3 times  more likely than in Spain. Our maternal mortality rate has more than doubled from 6.6 maternal deaths per 100,000 in 1987 to 13.3 maternal deaths per 100,000 in 2006 and these rates are higher in women of color (Black women are 4 times more likely to die from pregnancy related causes than white women). Amnesty estimates that these rates may actually be low because there is no federal requirement to report these outcomes. Amnesty International also notes numerous barriers to maternity care, noting that poverty is a major factor, but even insured women have difficulty obtaining safe, effective, low intervention maternity care. The US’s own Healthy People 2010 has documented benchmarks to improve maternity care-none of which the current model of obstetrical care has been able to meet. And the World Health Organization reported that despite the large amount of money spent on health care in the United States, The US still ranks 37th out of 191 assessed countries in health care delivery and accessibility, far behind many other industrialized nations. What we are doing is not working and as they saying goes, “The definition of insanity is to continue doing what you are doing while expecting a different outcome.”

Several organizations including The World Health Organization and Amnesty International are advocating for increased use of  “more woman-centered, physiologic care provided by family-practice physicians and midwives”. Yet ACOG and the AMA have balked and have launched aggressive anti-midwife campaigns. Amy Tuteur, MD, in her blog post Midwives and the Assault on Scientific Evidence, repeatedly states that midwifery practice is not based on science and that many practices are based more on ideology. She cites numerous articles and books published by midwives, yet never names specific practices used by midwives that are harmful to mothers or babies. In contrast, there is well established evidence that restricting a woman to bed while laboring, labor induction and cesarean sections increase labor and delivery complications and all are common practices in obstetrics. Dr. Tuteur’s claims are well refuted by the 107 comments to her post, many with reputable citations.

Joseph Wax, MD was the next physician to attack midwifery and home birth in his article, Maternal and Newborn Outcomes in Planned Home Births vs. Planned Hospital Births:  A Meta analysis. His meta analysis concluded that home births attended by midwives resulted in a three fold increase of neonatal death versus birth in a hospital or birthing center housed within a hospital. While Dr. Wax’s analysis was praised by the main physician medical societies, using minimal scrutiny his conclusions were found to be flawed and based on study data known to be insufficient, inconclusive or just plain wrong. Yet, even before the study was officially published in the September issue of the American Journal of Obstetrics and Gynecology, it was “leaked” to the media during the summer-just in time to be read as legal decisions were being deliberated in New York and Massachusetts regarding midwifery practice and home births.

Both of these publications and others like them have the full backing of the AMA, which has been waging its own battle against midwives. In resolutions drafted in April of 2008, The AMA has voted to back legislation that will prohibit home births, AMA Resolution 205-1 and severely limit the scope of midwifery practice, AMA Resolution 204 Midwifery. While the legalese of these documents is sound, the resolutions themselves ignore the scientific evidence, stated by Amnesty International, The World Health Organization, The Cochrane Review and others that all state that midwife assisted homebirths, in uncomplicated pregnancies, are as safe as hospital deliveries.  Additionally, midwife attended births result in lower rates of interventions, lower cesarean section rates, lower rates of complications, lower rates of infants being admitted to the NICU and lower rates of maternal and neonatal death. (See Transforming Maternity Care, in the supplement to the January 2010 issue of Women’s Health Issues, the official publication of the Jacob’s Institute of Women’s Health, George Washington University.)

It’s okay for physicians to oppose midwifery care, in fact it’s somewhat understandable. In their eyes they have a lot to lose; revenue, patients and their status as “top” health care providers. Many obstetricians resent having to “clean up the messes” that occur when a home birth goes bad. But in the face of the evidence in support of midwifery care and the dire maternity statistics that arise out of the current US hospital based, physician driven maternity health care system it’s hard to believe that they are not willing to do more to bring affordable, effective, safe, low intervention care to all women of America. Holding onto this notion that the only providers able to provide quality maternity care is obstetricians in the hospital setting is not only bull-headed but unethical and is completely contrary to the line in the Hippocratic oath that states, “First do no harm.” (Yes, withholding care does as much harm as rendering poor care.) But to go so far as to bar others, who are trained and qualified to provide maternity care from doing so -especially to low income women who so desperately need quality, compassionate maternity care-while at the same time disparaging the work that they do is not only unethical, it just plain stinks.