Yo Mama! You is BIRTHIN'! Part 1

The internet is an obsession of mine, no, it's an addiction. I belong to groups discussing various aspects of living in Israel and making aliyah, literary groups which discuss Dorothy Dunnett's novels, Dorothy L. Sayers mysteries, Laurie R. King's Mary Russell books, the Outlander series by Diana Gabaldon.

And I read a lot of blogs. Most of these are medical, and quite a few are written by nurses, several by midwives. The one which is taking up most of my time currently is Homebirth Debate, hosted by Dr. Amy Tuteur. There are times when the comments quite frighten me.

Dr. Tuteur herself is a retired obstetrician/gynecologist. Her contention, and it is quite accurate, is that home birth is more dangerous than hospital birth. The women (and occasional man) who enter the forum and leave comments, cover the full spectrum of reactions. Some of the women have had home births, without incident; some have had extremely high risk pregnancies--including a few bad outcomes; some commenters are direct entry midwives. I think I'm correct in saying that currently I'm the only certified nurse-midwife contributing to the discussions.

There are a number of recurring themes. One is that birth is a normal physiologic process; logically it there follows that no special expertise is needed by birth attendants. Indeed, attitude rather than specialist knowledge is adequate, if not preferred. Over and over again the view is expressed that women don't get sufficient "respect" from doctors and nurses, whereas midwives (usually direct entry midwives are meant in this context) do "respect" their clients more.

"Respect" usually means two things: allowing the woman to conduct her own labor and birth as she sees fit, regardless of medical necessities, and improved communication between care provider and patient. There is a certain degree of just complaint. Communication--what used to be called "bedside manner" is often pretty bad. Doctors don't have courses in "how to be nice to patients"; they're too busy coping with the medical side. Nurses can be better at communicating with patients, but just as there are all kinds of patients, there are all kinds of nurses. "How are we this morning?" one of my co-workers used to ask every patient, and was rather shocked one day when the patient so addressed snapped back, "I don't know how you are, but I'm f**king terrible!" Outside the room the nurse asked me, quite upset, "Should I ask for a psych consult? She's so aggressive!"

Women may be experts in being women, but they're not experts in obstetrics. Another recurring theme is that a basic nursing education is superfluous in being a birth attendant, because nursing implies illness and birth isn't. Why, after all, should a midwife have to know such things as the names of the 12 spinal nerves or the symptoms and treatment of subacute bacterial endocarditis? Especially a midwife who is never going to take care of a woman who is having a high-risk pregnancy?

Unfortunately, even the lowest-risk pregnancy can become a massively high-risk one literally in a matter of hours. Then, direct-entry midwives argue, in that extremely rare possibility, expert help should be summoned. But how will they identify the situation, if they've never learned it exists? It should be noted that some conditions are less common than others, but many are more common than this type of midwife is willing to admit. But a certified nurse-midwife not only can identify them and instigate initial measures, she has experience with all sorts of conditions not directly related to the obstetrical situation. A pregnant woman can have appendicitis. A pregnant woman can have an aneurysm, or a perforated ulcer, or be at risk of a detached retina.

One of the commenters, on Homebirth Debate, has written:

The question we are left with is the wisdom of assigning
the
primary care of normal birth (admittedly a time-consuming,
patience-requiring
physiologically-based management skill) to a surgical
specialty?

Aren’t we
working against ourselves by not being more
realistic about these issues? Could
it be that we are barking up the wrong
tree by confusing the topic of midwives
and planned home birth with the
general problem of a maternity care system that
in general needs to be
reevaluated?

Americans have a few odd quirks. Individualism is
carried to absurd lengths. In spite of medical advances, quite a few women
jealously maintain they have a right to endanger themselves and their babies in
the name of personal freedom. Inadequately educated persons labelling
themselves as obstetric professionals jealously guard their right to be
allowed to endanger others in the practice of their entirely unregulated
"profession". As I write this, those Americans who think the Constitution
gives them the right to own guns are claiming that the students gunned down in
various campus shootings only died because they didn't have guns to protect
themselves against their assailants, rather than trying to remove guns from easy
access by the assailants.

We wouldn't allow doctors to practice medicine without being licensed, by a responsible authority, to do so, because lives are in the balance. Why do we allow "midwives" to do so? The first step to making reforms in our maternity care system is to make the practitioners of midwifery uniformly worthy of the respect of the medical community, as a unique branch of it. This would require, however, legislation on a Federal level, both of educational requirements, of the curricula of schools of midwifery, and of standards of practice. It would be necessary to create a governmental department responsible for the training, certification, and oversight of practicing midwives. Midwives would have to be, just as nurses and doctors are, graduates of accredited institutions meeting certain standards, be legally obligated to keep records, hold malpractice insurance, and do continuing education in order to maintain their licensure.

It ain't gonna happen. That would restrict "freedom". At present the demand for midwives is so small, and by such a fringe group that they don't exert any real pressure. Despite all their propaganda, DEMs account for less than one-half of one percent of births in the US.

The US is a very big and diverse country. European countries, on the other hand, are much smaller, more urbanized and centralized, and don't fear central government the way Americans do. European countries can, and do, regulate midwifery much more than will ever be feasible in the US. Also, the European homebirth model would be resisted vigorously in the US. Not all women are eligible for home birth in Europe (indeed, the majority deliver in hospital even in those countries held as models by homebirth advocates). One of the "rights" demanded by the homebirth lobby is that just about anyone who chooses a home birth must be allowed to have one, as a matter of personal choice, no matter how irresponsible that choice is. There is currently one DEM blogger who supports homebirth in a number of instances which are, by any criterion, not low risk (she even claims to have delivered a woman whose baby was in a position which is impossible to deliver vaginally). There is another DEM whose opinions have appeared on the internet which are completely refuted by all reputable statistics. Some women will be convinced by these women because they want to be .

"Empowered" is another term often bandied about. My guess is that it means that one is attempting to control an essentially uncontrollable process. The very unpredictability of birth is frightening. But whereas, if we were indicted on a capital charge, or if we needed to take an airplane to another city, we'd not hesitate to retain the very best criminal lawyer or put our lives in the hand of an experienced pilot, women who need this feeling of control over birth do the exact opposite. They choose not to trust medical professionals but deliberately want an amateur, who can't or won't contradict them, to be their birth attendants. Fear of hospitals is combined with fear of doctors, who are accused of being virtual sadists, bent on forcibly restraining women and subjecting them to gratuituous, painful procedures deliberately to wreck the "birth experience" (another phrase in the lexicon of those who want to reject modern science).

Oh, I could go on and on. Dr. Tuteur has written extensively about all of this. It is, to my mind, very odd.