Articles and Publications Written by Heather Rische
AMA attack on home birth threatens women's privacy rights
Originally Published in Grass Roots Press Vol. 6 No. 4 December 2008 I drove to M's home at midnight after determining that labor was underway over the phone. I arrived to the sight of M relaxing in an inflatable birthing pool, dealing calmly with her intense contractions, accompanied by her husband and mother, daughters sound asleep in the next room. I washed up, checked her baby's heartbeat, her pulse and blood pressure, respected her wish to decline a dilation check, asked a few questions, and soon recognized the sounds of a mother bearing down to push out her baby (M has remarkably fast labors). I called her husband in, who had run to the kitchen for something, so he wouldn't miss the birth. M switched to a position she preferred: a hands and knees/squatting combination that allowed the warm water to soothe her lower back and receive her baby. Her baby emerged and I had the honor of passing the baby, still underwater, between the mother's legs so that M could be the first to hold her new daughter. M immediately picked up her baby, sat back in the water, smiled and spoke softly to the new little one. All of us surrounding her quietly remarked on the alertness and health of the baby, passing M towels to warm the baby while I silently observed to be certain that nothing unexpected was occurring. Eventually, M moved into the comfort of her bed, delivered the placenta effortlessly, changed into her favorite pajamas, enjoyed her baby with her husband, and cheerfully tolerated my occasional checks of her and her baby's vital signs. We all talked about what a wonderful birth had just transpired, and although the parents thanked me for coming, I said, as I knew, that I really didn't need to be there- everything happened as it should have. After the baby was weighed, measured and checked from head to toe, and we all shared some celebratory post-midnight snacks, everyone settled down to sleep, and I slept on the couch. I woke to the morning light and the sounds of the big sisters meeting the new baby. I allowed the family the privacy warranted at such a special moment, then packed up my birth supplies, looked over mom and baby one last time, arranged for a visit the next day to check on everyone, and left for home.
This past summer, at its annual meeting, The American Medical Association adopted a resolution (#205) to introduce legislation that could violate American womens' rights to privacy, and choices regarding their health care. (http://www.ama-assn.org/ama/pub/category/18587.html) The Association asserts that birth should always occur in a hospital or birth center, and an additional resolution (#204) calls for these births to be attended only by practitioners who are directly overseen by, or are, physicians. It is quite transparent that these resolutions are being introduced out of a fear of the threats that other practitioners pose to the profitable hospital birth industry.
'Whereas, There has been much attention in the media by celebrities having home deliveries, with recent Today Show headings such as "Ricki Lake takes on baby birthing industry: Actress and former talk show host shares her at-home delivery in new film" ' reads part of the resolution, revealing the threat that home birth entering main stream consciousness poses to doctors. Ricki Lake's film, "The Business of Being Born" not only normalizes home birth for the viewer, but exposes unsavory American rites of birth in hospitals. The film reveals statistics such as the peak times of Cesarean sections: just before Shift Change, Meal Times and Golf Time. These major surgeries which greatly increase the chance of death for mother and baby, the film reveals, are being performed out of convenience (and we can surmise, the increased profit a major surgery provides) for the doctor, unable or unwilling to wait patiently for birth to unfold naturally. The film examines American consumers' treatment of this important event: we spend more time deciding on a new stereo system or car than we do on choosing a birth practitioner- whom we trust implicitly and without question (can we say as much for a car salesperson?). The film also examines an insurance industry that makes it difficult for midwives to be paid for their consistently lower-cost services, and is undoubtedly part of the Cesarean epidemic (somehow, performing this complicated surgery reduces a doctor's risk of malpractice suits!). The rates of cesarean births are skyrocketing, despite the fact that mothers and babies die at markedly increased rates during these surgeries, and the fact that long term risks include, for mother, hemmorhage, hysterectomy, trauma to uterus and bladder, infection, pulmonary embolism, decreased fertility, anesthesia complications, long term severe back pain from epidural, and more. For baby the risks include being lacerated by surgical instruments (2-6%), accidental premature delivery and respiratory distress caused by cesareans being done too early based on inaccurate ultrasound dating, and other long term issues resulting from surviving these problems. While cesarean rates in some hospitals are over 60% currently, a more prudent rate to use this sometimes life-saving surgery for optimal survival and health of all involved rests between 1.4 and 5%. The exposure of these facts seems to weigh heavy on the minds of the AMA, a powerful political lobby with many dollars at stake, and many to spend on promoting their interests.
Obviously, the news of these resolutions threatens mothers and families for whom home birth is first choice, and the midwives who attend them. I happen to belong to both of these groups. I am a CPM, (Certified Professional Midwife) licensed by the North American Registry of Midwives (NARM) and licensed by the State of New Mexico Department of Health. (Not only do practitioners with the CPM and LM credentials perform home births, but many Certified Nurse-Midwives and Physicians support home birth and attend home births throughout the US, sharing with LM/CPMs the philosophy that birth is normal and can be trusted) I am also pregnant with my second child, whom I fervently hope to deliver at home, in privacy and peace, fueled by my belief that birth is normal and healthy. I hope to avoid the noise, lights, bacteria and loss of autonomy found in hospitals. I hope to avoid the iatrogenic complications ("doctor caused") that regularly occur in hospitals due to unnecessary interventions creating less than optimal birth outcomes, and a cascade of effects that often land mothers with surgical or drugged births they were not planning. At the very least, I hope to avoid the constant battle that informed parents wishing for a natural, non-interventive birth must often fight if choosing a hospital birth.
As both consumer and provider of these services, I am unnerved by the thought that the wealthy lobbies of these organizations could very well change the face of home birth, driving it underground and unregulated. The false sense of security I had initially when considering the constitutionality of potential legislation was dampened by my recognition of the realities of what we have seen in recent years regarding our weakening constitution, and the ongoing pattern of profit trumping justice. The repercussions have already been seen as the first insurance company who find the resolutions a tidy excuse to quit paying for homebirths has emerged. Aetna has issued a policy bulletin stating home births are not medically appropriate and will not be paid, citing the physician-based organizations' statements against them. I hope that the ill-founded motivations behind these measures are recognized by the lawmakers who will be asked to review them, and that the idea of prosecuting a mother for having a safe and beautiful home birth is as ridiculous and repugnant to them as it is to me.
Both resolutions state that the safest place for a baby to be born is in an American hospital. These statements are not supported by any evidence in the resolutions, because it doesn't exist. One resolution even warns of the sudden and unforewarned onset of eclampsia in labor, something that medically should not happen: eclampsia develops prenatally and can be detected or prevented by the thorough prenatal care that is a hallmark of the midwifery model of care (think 1 -2 hour appointments vs. 10 minutes with a typical OB). The evidence on the safety of planned homebirth is consistent worldwide: the countries with the lowest infant mortality and maternal mortality rates are those in which midwives provide care for the majority of women , and/or the majority of births occur at home with trained attendants. (Sweden, The Netherlands, Japan, etc.) The US has a higher Maternal and Infant Mortality and Morbidity rate than almost any industrialized nation, and it is higher even than many countries considered "2nd" or "3rd world". In an overall study done by Save The Children, the US ranked 27th in 2008 (down from 26th last year) for maternal and childhood mortality (including infant mortality). The studies reveal that our African-American women die at 3.7 times that of white women, and African-American babies die at 2.4 times the rate of white babies. (http://www.savethechildren.org/publications/mothers/2008/SOWM-2008-full-report.pdf) The statistics are similarly dismal for Native American and Latina- American moms and babies. The "greatest nation in the world" apparently still has problems serving all of her people equally. Friends and family who work in hospital labor and delivery units tell me that patients are regularly discriminated against on the basis of race and economics, receiving a completely different brand of care under the same roof as their white and/or wealthy counterparts. I have cared for more than one client whose first motivation for home birth was to avoid the racist or classist care she received in a previous hospital birth. In New Mexico, we enjoy a relatively progressive environment in which information regarding choices for birth care is more readily available than many areas of the US, with the combination of our diverse cultures, continuous traditions of home birth, the border creating a unique demand for traditional birth attendants like midwives, and being one of the first states to license midwives. Recently, NM Medicaid began paying midwives to do homebirths after 7 years of non-payment, which has made it easier for low-income families to choose birth at home. Other areas in the US, particularly large urban areas, see the most discrimination and the worst access to quality care for mothers, leading to the highest rates of death and less-than-optimal outcomes. Another contributing factor which can not be ignored is lack of prenatal care or quality prenatal care- while midwives are trained in nutrition and typically spend time in each appointment reviewing a mother's nutrition and giving suggestions for improvement, very few physicians even mention this obviously critical aspect of prenatal health.
The horrifying US maternal mortality rate is likely largely due to the epidemic of cesarean sections. I see this trend of casually deciding to perform cesarean surgeries on mothers who are not thoroughly informed of the risks therein compared to vaginal birth as nothing less than a vicious assault on womens' bodies and minds, especially with the knowledge of what a small percentage of these are actually medically necessary for mother and baby. Equally egregious are the witchhunts and media attacks that occur when an outcome at a home birth is unexpected or negative; while in nearby hospitals, women and babies die on a regular basis without being mentioned. In fact, the CDC reported in 1998 that the number of maternal deaths is closer to 1.3-3 times what is reported to vital statistics. We as a nation investigate about half of maternal deaths, whereas countries with a much lower maternal death rate (UK, Germany, Austria) require a report to be generated on every maternal death in order to provide prevention information. Studies of planned US home births have consistently shown equal or better outcomes for mothers and babies as in hospitals, but I will not be surprised if home birth statistics soon drastically exceed the success rates of hospital births as unnecessary cesareans and all they entail continue to occur. (http://www.bmj.com/cgi/content/abstract/330/7505/1416, http://www.ncbi.nlm.nih.gov/pubmed/15961814, http://www.cmaj.ca/cgi/content/full/166/3/315)
All consumers of health care in the US need to continue to be vigilant even as we enter a more progressive political climate. Whether you are bearing children with skilled and concerned practitioners in home or hospital settings, parents seeking care for children, an elder facing a different set of concerns, or anywhere in between, in the case of your body and your health, I urge you to remember that you are a consumer of a service, that your care-provider is someone who serves at your behest (regardless of whether you are indigent, on Medicaid, or paying privately your doctor or insurance), should be interviewed carefully, and most of all, chosen with care informed by research.
Other sources: Holistic Midwifery Volume II Care During Labor and Birth, Anne Frye, page 1056; Ina May's Guide to Childbirth, Ina May Gaskin, pages 275-278; Maternal Mortality, No Improvement since 1982. ACOG Today, August 1999