Not about homebirth, except when it is.
Originally posted elsewhere April '09. Thought it was worth putting up here too.
Of late, I've heard several senior midwives in my community voice concern that media attention is being focused too closely on home birth, and too little on midwifery care, which indeed is probably the key factor to all the excellent outcomes which midwifery clients enjoy. I've sat and mulled over this for a couple of weeks now, about what place homebirth should take in campaigns to further access to midwifery care. Is it ALL about midwifery care? SHOULD we shift the focus away from homebirth?
It's true, we DO need more midwives providing midwifery care to improve this horribly broken system women are fed into routinely, and fed out of with more than their fair share of iatrogenic morbidity (unnecessary cesareans anyone?). But we also need to take a deep breath and look closely at where we're at and what it is we are really asking for.
When compared with the hundreds of thousands of babies born in hospitals annually in the US, homebirthed babies are rare and precious creatures. Homebirth is still considered 'fringe' in many quarters in this country, though homebirth advocates (usually those who've actually experienced the difference!) are vocal and impassioned. I think it's easier for all of us to focus on the stunning, life-altering shift of a baby born into a mother's or father's trembling hands than it is to dissect the much less awe-inspiring (and certainly less sexy, media-wise) impact of good, thorough, woman-centered care during the childbearing year.
Direct entry midwives/Licensed Midwives/Certified Professional Midwives provide midwifery care in out of hospital settings. We achieve excellent outcomes for both mothers and babies at HOME and in FREESTANDING BIRTH CENTERS. We do this in deceptively simple but extraordinarily cost effective ways. We spend TIME with our clients. Hospital OB practices are occasionally (dare we hope increasingly?) taking a leaf out of the midwives' playbook, making that same commitment and guess what? They're lowering their CS rates (and I'd bet their client satisfaction rates are climbing too). If it were possible for physicians broadly to set aside the focus on pathology of pregnancy and birth, and apply the very basic tenets of midwifery, I think we'd see a shift away from the 32% cesarean rates, probably see a shift away from the low birth weight and premature birth rates, increases in breastfeeding rates and associated life-long health benefits to both mother and babe, to say nothing of the profound impact a shift like that could have on women's lived experience of their care, and entry to motherhood. We need only look to physicians like Marsen Wagner, Sarah Buckley, Michel Odent and hundreds of other less well-known physicians worldwide who we laud as being revolutionary. They might be within their circles, but they're just talking about midwifery care, are they not?!
As I write this, independent (homebirth) midwifery in Australia is being sold down the river by none other than the Australian College of Midwives. In a schism which I find oddly reminiscent of the divisions which keep midwives in the US divided and effectively conquered: So called "independent" homebirth midwives will be de-registered and find themselves practicing illegally if they practice without professional indemnity (malpractice) insurance. Midwives working within hospital birthing units however will receive limited prescriptive authority, increased autonomy and the indemnity insurance. The College appears to be effectively trading independent midwives livelihoods, not to mention Australian women's birthing choices so that they can increase their hospital purchase. Their logic I'm sure is that this will increase women's access to midwifery care. Perhaps it will, but at what cost? My bet is that it will marginalize further those women who seek to birth at home, further limit access to VBAC (a whole other note), and force midwives to practice illegally - to no-ones benefit whatsoever.
Last year the American Medical Association at its annual meeting it adopted a policy written by the American College of Obstetricians and Gynecologists against "home deliveries" and in support of legislation "that helps ensure safe deliveries and healthy babies by acknowledging that the safest setting for labor, delivery, and the immediate post-partum period is in the hospital" or accredited birth center. When powerful physician trade union interests are threatened sufficiently that they call for legislation to restrict women's choices in birth, or intervene successfully to lobby to have pro-midwife legislation voted down in state houses (as happened this week in Michigan), midwives need to recognize that this is a basic threat to our livelihoods, to women's choices in maternity care, and her right to birth wherever she chooses. In this way it IS about homebirth.
And so, if it's the impassioned, satisfied home birth clients and the "ooh" factor of homebirth which keeps midwifery care at the forefront of the momentum to reform our broken mainstream system, then so be it. I've become a homebirth midwife because I didn't want to be a CNM, or an OB. I'm not ashamed or reluctant to talk about the fact that I will care for women inside their homes, and handle transports to higher level care when and if women need it. I feel that the midwifery care I provide to healthy, low risk women is far superior to medical or high-volume CNM midwifery care women and their babies experience in hospitals. Every opportunity I get to talk about homebirth is a springboard to larger, more important discussions about thorough informed consent, the wider benefits of midwifery care, about how mothers and babies DESERVE better than they're getting.
I personally look forward to a day when I can attend my clients in the birth site of their choice: home, birth center or hospital, but that's a ways off for most LM/CPM's (though it IS happening people!!). I would note also though, that I wouldn't ever give up homebirth practice. CPM/LM's are, I think at heart, home birth midwives. Without birth at home as a legitimate, well-championed choice, we all lose. Not least of all the midwives.
Direct entry midwifery in the United States IS proudly, unashamedly, wonderfully ABOUT homebirth. I would suggest we forget that at our peril.
Of late, I've heard several senior midwives in my community voice concern that media attention is being focused too closely on home birth, and too little on midwifery care, which indeed is probably the key factor to all the excellent outcomes which midwifery clients enjoy. I've sat and mulled over this for a couple of weeks now, about what place homebirth should take in campaigns to further access to midwifery care. Is it ALL about midwifery care? SHOULD we shift the focus away from homebirth?
It's true, we DO need more midwives providing midwifery care to improve this horribly broken system women are fed into routinely, and fed out of with more than their fair share of iatrogenic morbidity (unnecessary cesareans anyone?). But we also need to take a deep breath and look closely at where we're at and what it is we are really asking for.
When compared with the hundreds of thousands of babies born in hospitals annually in the US, homebirthed babies are rare and precious creatures. Homebirth is still considered 'fringe' in many quarters in this country, though homebirth advocates (usually those who've actually experienced the difference!) are vocal and impassioned. I think it's easier for all of us to focus on the stunning, life-altering shift of a baby born into a mother's or father's trembling hands than it is to dissect the much less awe-inspiring (and certainly less sexy, media-wise) impact of good, thorough, woman-centered care during the childbearing year.
Direct entry midwives/Licensed Midwives/Certified Professional Midwives provide midwifery care in out of hospital settings. We achieve excellent outcomes for both mothers and babies at HOME and in FREESTANDING BIRTH CENTERS. We do this in deceptively simple but extraordinarily cost effective ways. We spend TIME with our clients. Hospital OB practices are occasionally (dare we hope increasingly?) taking a leaf out of the midwives' playbook, making that same commitment and guess what? They're lowering their CS rates (and I'd bet their client satisfaction rates are climbing too). If it were possible for physicians broadly to set aside the focus on pathology of pregnancy and birth, and apply the very basic tenets of midwifery, I think we'd see a shift away from the 32% cesarean rates, probably see a shift away from the low birth weight and premature birth rates, increases in breastfeeding rates and associated life-long health benefits to both mother and babe, to say nothing of the profound impact a shift like that could have on women's lived experience of their care, and entry to motherhood. We need only look to physicians like Marsen Wagner, Sarah Buckley, Michel Odent and hundreds of other less well-known physicians worldwide who we laud as being revolutionary. They might be within their circles, but they're just talking about midwifery care, are they not?!
As I write this, independent (homebirth) midwifery in Australia is being sold down the river by none other than the Australian College of Midwives. In a schism which I find oddly reminiscent of the divisions which keep midwives in the US divided and effectively conquered: So called "independent" homebirth midwives will be de-registered and find themselves practicing illegally if they practice without professional indemnity (malpractice) insurance. Midwives working within hospital birthing units however will receive limited prescriptive authority, increased autonomy and the indemnity insurance. The College appears to be effectively trading independent midwives livelihoods, not to mention Australian women's birthing choices so that they can increase their hospital purchase. Their logic I'm sure is that this will increase women's access to midwifery care. Perhaps it will, but at what cost? My bet is that it will marginalize further those women who seek to birth at home, further limit access to VBAC (a whole other note), and force midwives to practice illegally - to no-ones benefit whatsoever.
Last year the American Medical Association at its annual meeting it adopted a policy written by the American College of Obstetricians and Gynecologists against "home deliveries" and in support of legislation "that helps ensure safe deliveries and healthy babies by acknowledging that the safest setting for labor, delivery, and the immediate post-partum period is in the hospital" or accredited birth center. When powerful physician trade union interests are threatened sufficiently that they call for legislation to restrict women's choices in birth, or intervene successfully to lobby to have pro-midwife legislation voted down in state houses (as happened this week in Michigan), midwives need to recognize that this is a basic threat to our livelihoods, to women's choices in maternity care, and her right to birth wherever she chooses. In this way it IS about homebirth.
And so, if it's the impassioned, satisfied home birth clients and the "ooh" factor of homebirth which keeps midwifery care at the forefront of the momentum to reform our broken mainstream system, then so be it. I've become a homebirth midwife because I didn't want to be a CNM, or an OB. I'm not ashamed or reluctant to talk about the fact that I will care for women inside their homes, and handle transports to higher level care when and if women need it. I feel that the midwifery care I provide to healthy, low risk women is far superior to medical or high-volume CNM midwifery care women and their babies experience in hospitals. Every opportunity I get to talk about homebirth is a springboard to larger, more important discussions about thorough informed consent, the wider benefits of midwifery care, about how mothers and babies DESERVE better than they're getting.
I personally look forward to a day when I can attend my clients in the birth site of their choice: home, birth center or hospital, but that's a ways off for most LM/CPM's (though it IS happening people!!). I would note also though, that I wouldn't ever give up homebirth practice. CPM/LM's are, I think at heart, home birth midwives. Without birth at home as a legitimate, well-championed choice, we all lose. Not least of all the midwives.
Direct entry midwifery in the United States IS proudly, unashamedly, wonderfully ABOUT homebirth. I would suggest we forget that at our peril.
posted by Louisa at 8:40 AM
4 Comments:
Very true. And I think letting the home factor slide to the backburner is doing a further disservice to continuing to paint homebirth as something wacky that only the Amish do, "birthing babies in a barn" and all that. Even if they would not choose it for themselves, I think if more people knew that homebirth is not some hippie who likes babies standing in a corner waving herbs and singing Kumbayah, but REAL, EFFECTIVE, SAFE care for mom and baby, it would not only promote homebirth itself but all births that CPMs attend, and promote the midwifery model of care as well. We have been chanting the creed of midwifery care for a while but we can't leave out the fact that this is what you get AT HOME. If we think that might turn people off from our cause, then we are betraying the entire thing. Even if we don't reach a 30% homebirth rate like the Netherlands, it's still important to teach people what homebirth and homebirth midwifery care really is, and why our country so desperately needs it!
I agree wholeheartedly. There is no homebirth for most women without midwives, for one, and it is time to break the stranglehold hospitals have over birth, for two. I like the idea of birth centers, but some seem to act as mini-hospitals in many cases. And as our system is currently structured, hospitals are just not set up in a way that optimizes normal, relaxed, birth--or, consequently, a midwifery model of care that restricts interventions and refuses to rush the process. They are set up to handle emergencies and treat the sick, which they do well. But that's not what a normal birth is. But few women in the US have the opportunity to have a normal birth, or even know it exists.
How would we set up birth care, if we were starting from scratch? It would be at home or in a homelike setting unless interventions were necessary, and only then be transferred to a hospital. It would be much less stressful for most women. It would save lives and it would prioritize good practice.
I think the time has to come when we stop trying to make birth "fit" into the hospital model and structure it to fit women's bodies and needs instead of assumptions based on the treatment of illness. I don't think that's radical or fringe, I think it's medically and ethically correct.
The concern I have is that in order for midwifery in the United States to be universally respected there need be universal standards. Right now midwifery in America is as unique as the midwife herself. There are not clear transport regulations and although the generals of the midwifery model of care extend to all midwives (yes even in the hospital so long as the CNM's don't have an OB practice breathing down their necks).
In Holland homebirth works so tremendously effectively and is so widely respected because they have clear care and transfer protocols. Until we have those in the US a few unregulated rogue midwives will continue to damage the reputation of midwives at large. By fighting standardization and regulation we as midwives damn ourselves and our clients.
I am a member of the Nebraska Friends of Midwives, and I can tell you this is a debate we go over all the time amongst ourselves. However, our case is extreme, as there are ZERO CPMs practicing in the state and our last DEM just got a cease and desist order. That's it. Any homebirth that happens here is UC or a midwife has crossed stare lines (which I can promise you is a very rare occurrence).
Legislatively we are just fighting to remove practice agreements for CNMs, force hospitals to keep the category open (several hospitals have simply closed the category of CNM); and to make it legal for CNMs to practice out-of-hospital (Which frankly and heart-breakingly might be sacrificed to gain the first to.)
We are singing the praises of the Midwifery Model of Care from the roof-tops, but barely uttering a word about homebirth. I wonder if it would be different if we actually had any homebirth midwives to champion?
Wanna move to Nebraska? The corn is delicious.
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