Midwives in Australia

Private Midwife Melissa Maimann explains the current legal situation in Australia in Homebirth is not illegal!

Is VBAC illegal? Is homebirth illegal?

The VBAC Facts blog has a great explanation of the legalities of VBACs and homebirth. To summarize, VBAC is legal everywhere in the US. Homebirth (whether VBAC or not) is legal everywhere in the US. The only legal restrictions are placed on providers, what they may do and where they may do it.

You may also be interested in my previous blog post, Is it legal for Florida midwives to do VBACs?

Oh, and if you haven't read it yet, don't miss Time magazine's article The Trouble With Repeat Cesarians in conjunction with ICAN's recently-released report on the organization's hospital survey. I especially liked this quote from the Time article:

But while many obstetricians say fewer patients are requesting VBACs, others counter that the medical profession has been too discouraging of them. Dr. Stuart Fischbein, an ob-gyn whose Camarillo, Calif., hospital won't allow the procedure, is concerned that women are getting "skewed" information about the risks of a VBAC "that leads them down the path that the doctor or hospital wants them to follow, as opposed to medical information that helps them make the best decision." According to a nationwide survey by Childbirth Connection, a 91-year-old maternal-care advocacy group based in New York City, 57% of C-section veterans who gave birth in 2005 were interested in a VBAC but were denied the option of having one.

Hm. Why give patients information about a "procedure" that is not offered by you or allowed by your hospital?

Baby, You're Home

The New York Times published a piece on homebirth this week ("Baby, You're Home") which is getting good reviews in my normal-birth circles, though it was inexplicably placed in the "Home & Garden" section of the paper. It seems that while homebirths are up all over the country, the biggest surge seems to be in New York, according to local midwives and sellers of birth tubs. according to the article, this may be due, in part, to the impact of last year's documentary The Business of Being Born, which was filmed in New York City. Actual statistics on this won't be available for several more years, though.

Doctors 'in denial' about safe home births

Australian doctors are "in denial"about safe home births, according to an article in the Australia and New Zealand Journal of Obstetrics and Gynaecology:

And in the absence of publicly funded homebirthing programs, women who cannot afford private midwives are increasingly opting for unassisted homebirths, says Lareen Newman, a researcher in the department of public health at Flinders in Adelaide... When obstetricians point out the real risks of this trend, women may believe they are ‘crying wolf’ because of their unfounded opposition to safe homebirths, she writes.

She calls on RANZCOG [the Royal Australian and New Zealand College of Obstetrics and Gynaecology] to acknowledge the evidence for homebirths and support public homebirth programs in its revised statement expected next month.

Good luck with that.

Some news, and a break

Hello, faithful readers.

I'm going to be taking an extended blogging break - probably 4-6 weeks - and then I will be back with an announcement and a renewed commitment to my blogs. Until then, here are a couple headlines that have popped up recently:

An Arkansas court of appeals says that shackling prisoners during labor is not unconstitutional.

After a six-year absence, nurse-midwives are returning to Austin hospitals.

Midwife-signed birth certificates along the Texas-Mexico border questioned.

If you haven't heard, the AMA has joined ACOG in opposing homebirths. For more on this flap, check out these responses from ICAN, MANA (pdf), Citizens for Midwifery, and Ricki Lake, Jennifer Block & Abby Epstein on the HuffintonPost. Feel free to leave a link to your favorite blog post in the comments.

The Latest from ACOG

The American College of Obstetricians and Gynecologists "reiterates its long-standing opposition to home births":

Childbirth decisions should not be dictated or influenced by what's fashionable, trendy, or the latest cause célèbre. Despite the rosy picture painted by home birth advocates, a seemingly normal labor and delivery can quickly become life-threatening for both the mother and baby.

Anyone besides me think that this statement is a response to The Business of Being Born?

Attempting a vaginal birth after cesarean (VBAC) at home is especially dangerous because if the uterus ruptures during labor, both the mother and baby face an emergency situation with potentially catastrophic consequences, including death.

Oh, that's nice. More and more doctors and hospitals won't "do" VBACs, but they're telling you not to do them at home either. I think most HBAC-ing women would rather have been in the hospital, if they thought they would actually have been successful there.

ACOG encourages all pregnant women to get prenatal care and to make a birth plan.

Really??? Then don't ignore our birth plans when we make them. And put pressure on the hospital staff to respect them, as well. How come the L&D nurses think that birth plan = cesarean section? What's up with that?

The main goal should be a healthy and safe outcome for both mother and baby. Choosing to deliver a baby at home, however, is to place the process of giving birth over the goal of having a healthy baby.

But the two aren't mutually exclusive, the "process" and the "goal"! Don't you get it? A healthy process creates a healthy mom and a healthy baby. Disturbing the process adversely affects the outcome.

And I'm sorry, women who are so traumatized by their birth "experiences" that they will not set foot in a hospital again unless they are dying, are not "healthy". Women whose bodies are cut and then stitched back together are not "healthy". Babies who leave the hospital formula-fed when their mother had planned to breastfeed them are not "healthy". Healthy is not the absence of disease or medical condition. Healthy is body, mind, and spirit.

So ACOG, if you don't like out-of-hospital birth, start practicing evidenced-based medicine. Start trusting women's bodies to birth. Stop pretending that you know everything (anything?) about natural (normal, physiological) childbirth. Stop lying to women. Try listening to them instead.

Midwives & Malpractice Insurance

The Citizens for Midwifery blog discusses malpractice insurance for midwives:

When looking through this lens, it becomes clear that lawyers and insurance companies have more to gain from legislation mandating insurance policies for midwives than do birthing women and their families.

The impetus for CfM's post was an article by Judy Slome Cohain in the Winter 2007 issue of Midwifery Today entitled, "Mandatory Malpractice Insurance—Increases CS Rate & Profitability of Litigation, Decreases Planned Homebirths". I don't subscribe to MT, and the article isn't online yet, but the description in the table of contents is intriguing:

This frequent contributor argues convincingly that making malpractice insurance mandatory for midwives will lead to more profitable lawsuits and decrease the number of homebirth midwives to deliver babies, rather than improving birth outcomes or public health.

Unassisted Childbirth

The Washington Post has an article today on Do-It-Yourself Delivery. Though I am not a supporter of unassisted childbirth, I do have an interest in the positive - or at least fair and unbiased - portrayal of normal birth in the media. The article contained this gem:

To [Mairi Breen] Rothman, [a nurse-midwife and spokeswoman for the American College of Nurse-Midwives, which does not support unassisted childbirth], Shanley's beliefs underscore a more fundamental problem with maternity care. "To me the really interesting question is, Why would someone go outside the system?" Rothman said. "What is so broken that they don't want to use it?"

[Heather] Jones, the Navy wife, has an answer. Her first delivery in a hospital four years ago was marred by "interventions and interferences based on someone's outside judgment" of how well her labor was progressing, she said. She said she felt pressured to have epidural anesthesia, was not allowed to move around as she wished and was denied access to her baby until he was two hours old because he was being observed by the hospital staff.

Jones said she decided to give birth to her third child unattended after her second was born five minutes after the midwife arrived at her home."

She was like, 'See, you didn't need me,' and I thought, 'You know, maybe I don't,' " she said, as baby Gideon, now 5 months old, cooed in the background.

Homebirth Coloring Book

While looking up the legal status of midwifery in North Carolina, I discovered that the state's homebirth association has an online homebirth coloring book. Cool!

Unassisted Childbirth

Thanks to Hathor the Cow Goddess for this one. CPS in Spokane, Washington, removed a baby from his parents after an unassisted homebirth (a sucessful footling breech, if the facts are correct). This hasn't hit the mainstream media (yet), so I hesitate to publish facts that are unconfirmed, but here you go:

Midwifery Today Forums

Baby Davies

The baby was returned to the parents after a hearing. Apparently, mom is on some anti-depressants considered incompatable with breastfeeding, so she has agreed to wait until the drugs have cleared her system before resuming breastfeeding. The medical facts may be incorrect (there are very, very few drugs which can't be taken by a breastfeeding mother), but not an entirely unreasonable stipulation.

I hear this question a lot: Is homebirth legal? And I can't emphasize this enough - There is no state in which homebirth (attended or otherwise) is illegal. I heard someone say recently (thanks, Steve!) that "homebirth" is a noun, and nouns cannot be illegal, only verbs can be illegal; that is to say, only acts are illegal. There are many States in which a person (such as a midwife) performing certain acts at a birth (such as catching a baby, checking dilation, or administering pitocin for postpartum hemorage) are performing acts which are illegal (i.e. they constitute the unlicened practice of medicine or nurse-midwifery); therefore we say that "midwifery is illegal" in this State or that State.

When CPS investigates a family for homebirth or UC, what is really of legal concern is medical neglect. If the baby is not sick or injured, or is under the care of a doctor or other professional (such as a midwife in States where the scope of their license includes newborn care), there's not really any issue. Really.

Doula Liability

This legal question popped up on several of my newsgroups last week: Should doulas carry emergency childbirth kits when providing home labor support?

Factual background: A labor doula is a woman who supports a woman in childbirth. She provides emotional encouragement, coaching, education, and some physical support such as massage, hand-holding, etc. Doulas do not, however, perform any clinical or medical tasks, nor are they trained to deliver babies. They may, however, have had instruction in emergency childbirth and/or infant CPR.

An emergency childbirth kit can be purchased for about $25 on eBay and includes things like a bulb syringe, cord clamps, sterile gloves, disposable pads, etc.

Often, doulas may come to the mother'’s home to provide support during early labor before accompanying her to the hospital or, in the case of a homebirth, before the midwife arrives. It happens very rarely that when a doula arrives at the home, it is apparent that labor has progressed more quickly than expected, and baby is on his way, with no time to go anywhere. Should a doula carry an emergency childbirth kit in order to be prepared for such an event?

The legal issue: Could a doula, by carrying an emergency childbirth kit, be charged with "practicing midwifery without a license"; or, in states where direct-entry midwifery is not entirely legal/regulated, "practicing nurse-midwifery" or "practicing medicine without a license"? What steps could she take to protect herself from liability? Are "Good Samaritan" statutes applicable?

Here are some suggestions made by non-lawyer birth professionals:

• Call 911 right away, and follow the instructions given to you over the phone while you wait for help to arrive. (Nevermind that EMTs typically have less than 5 hours instruction in emergency childbirth, while a certified Doula has 16 hours of classroom instruction and 15 or more hours observing actual births prior to certification. We'’re talking legal liability, not actual ability, here).


• Suggest that the parents themselves keep an emergency childbirth kit just in case. In fact, a doula could sell such a kit to her clients, and then repurchase it after the birth if it was not needed.


• Inform the parents that you are not acting in the role of a Labor Doula anymore, but as a concerned friend. Obtain their permission to assist the birth, or have them formally ask you for help.


• Do not accept payment for the labor support.


• Let Dad do the actual catching. This has the added benefit of keeping the Doula's name off the birth certificate.


• Make sure that parents have a birth plan which would state they were planning to go to a hospital. Preferably this would already be on file with the doctor or hospital.

Non-legal discussion centered around whether or not the items in the birth kit were necessary; i.e. it is not usually necessary to clamp the cord or suction the baby.

Personally, I think that some, if not most, of the above suggestions for reducing liability would be ineffective. So, I was hoping for some additional lawyer brains. Were any significant issues missed? What do you think?

Unassisted Births

The Pensylvanian Times Leader has published a story, Charged midwife's clients making other plans for home births about the options left for clients of Judy Wilson, the midwife arrested in April (see my April 29,2004 post).

One caveat: Vicki Pasterik, the client quoted in the article, has since claimed the reporter distorted what she said, saying: "The fact is, the first quote and the last attributed to me in the article are accurate. The rest are not." She does not promote unassisted birth, and has not yet contacted any other midwives, as the article states.

Nevertheless, the article brings up a good point, one that I have observed myself from women across the country who do not have access to homebirth midwives: many will "go it alone" at home rather than opt for a hospital birth.

Those who believe that homebirth is unsafe do women and babies no service by legislating or prosecuting out of existence those who attend homebirths. A better course of action would be to make homebirth safer (it is already safe, but that is another post) by ensuring that attendants such as midwives have access to quality training, are authorized to carry life-saving drugs such as pitocin and oxygen, and do not fear criminal charges or social disapprobation when properly transfering a patient into the care of doctor or hospital when compilcations arise.

Links:
Times Leader article.
Same article from PennLive.com.
Ebay auction for Judy's Legal defense.

BIRTH STORY

The Blomme Family has posted an amazing birth story. Twin girls were born in an unplanned, semi-unattended homebirth, the second a breach baby. While I certainly wouldn't recommend doing it this way given the choice, it is a wonderful testament to the ability of our bodies to birth naturally.

MIDWIFERY

The Austin Chronicle's November 12, 2003 issue featured the cover story, Will Women Have a Voice at the New Women's Hospital? The fight for midwives and reproductive choice at Brack. Though the article deals mainly with local Austin politics, the online version of the issue features some great articles (some new, some reprinted) on midwifery and homebirth. A couple of these I clipped out of the Chronicle when I lived in Austin ten years ago and still have in my file. Don't miss Midwives: Certified and Direct-Entry, Midwives and the Law in Texas, Our Midwife, High Tech vs. High Touch, and Midwives: From L.A. to Santa Fe.

Also, the nurse-midwifery practice at the University of Chicago has been eliminated. Read stories about it from the Chicago Sun-Times, the Chicago Maroon, and the News Release from the American College of Nurse-Midwives.

HOMEBIRTH

Last weekend, we had another couple over for dinner. They are suing their doctors for medical malpractice which occurred pursuant to the birth of their 12 lb. baby which resulted in a brachial plexus injury. After interesting dinner conversation about broken ultrasound machines, discrepancies in medical records, mismanaged shoulder dystocia, and excessive lateral traction, we took them on a tour of our house. It came up in conversation that our 9-month old was born at home in the bedroom. At which point the wife turns to me and says, "my, you are brave."

YET ANOTHER REASON TO HOMEBIRTH

Yahoo!Health/AP reports Part of Newborn's Toe Cut Off in Hospital while a hospital employee was removing a security tag.

The head of the pediatrics department is quoted as saying, "Clearly we are as bothered as the family is. We all feel terrible for the family and feel terrible for the child."