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Thursday, May 24, 2012

The Hypocrisy of Midwifery

I'm growing weary of the hypocrisy that permeates much of midwifery and the accompanying NCB (Natural Child Birth) advocates that can't see the forest through the trees, despite their own great experiences. Those who "sell" natural childbirth say that it is safe and put it on a pedestal. But when a baby dies, they quickly change their tune and say that it was the parents "choice."  Never mind that the risks were never part of the conversation from the start, at least not in an honest way.

How is it that midwives can claim that home birth is safe - as safe as life gets, safer than the hospital - BUT the minute a baby dies the mantra shifts dramatically to place responsibility on the parents as having made the "choice?"  

Dear midwife, ...Wait a minute, I thought you said it was safe?  Isn't that the "choice" I made, choosing something safe, the educated choice that was better for me, for my baby?  I don't remember making a choice to put my baby's life at greater risk?  Did we talk about risks?  I don't remember talking about them, but I do remember talking about how close the hospital was, how sure you were that you could spot trouble with plenty of time, how we are born to do this and babies know how to be born, how you've been delivering babies for 30 years with a spotless record.  I remember choosing you because you told me this was safer for me and for my baby.  I remember all the awful things you taught me about what the hospital and doctors would do to me if we went there.  

I remember you telling me that a breech baby is just a variation of normal, that they tend to fall out.  I remember you telling me that you were confident in delivering him, that we didn't need another, more experienced midwife to be here.  I remember you telling me that recent research supports vaginal breech delivery and that we were good candidates for said delivery.  I remember you telling me you watched a video once on breech birth, was it Ina May's from 1980?  I remember you teaching me to trust birth, and building a relationship in which I would trust you, and I did.  Turns out that trust is exactly what blurred my rational thought.  Our baby never came home.   I trusted you to know what you were doing and to tell me the truth about risks involved so I could make a "choice".  

Instead, the choice people speak of was taken from me, by intentionally manipulating information and conveniently avoiding conversations about real risks involved.  Perhaps I should coin the phrase "choice rape" here. 

Things get even uglier when NCB advocates start defending negligent midwives by saying, "Don't take my choice away just because things went wrong for you.  Maybe you should  have done more research and picked a better midwife."  Why is it that in the Natural Child Birth movement, women are continually exhorted to "educate yourself, mama!" and "take responsibility" for your birth? We don't do that with any other aspect of medical care -- we don't tell women take responsibility for their own breast cancer treatment! Plus, to what degree can a person truly educate themselves when their main tool is the trust they have with their care provider (one who claims to be a professional), and frankly, Google?  I am not a researcher, nor am I a physician.  I am a mother who trusted her care givers to be professionally competent & honest in an area that they posed as an expert.

Dear midwife, . . . Why is sharing the truth about adverse care so viciously attacked?  Why does your good experience with a midwife mean you were smarter than me or did better research?  Why does your good experience mean we should excuse situations that weren't handled properly?  Do you not care about the fact that negligence is happening and being brushed under the rug?  Why should we not hold midwives professionally accountable?  Why should they fly under the radar without reporting outcomes, getting a degree, or carrying insurance?  Why is this about hoping you get lucky in whom you choose to attend your birth and not about consistently reliable standards of care & ethical practice? Why does asking for midwifery to improve its practice, be accountable, and function in a way that is professionally safe, somehow threatening to a woman's choice?  Holding midwives accountable is about doing the right thing, about making negligence known, and ensuring bad things don't happen to other families, not about taking away anyone's choice!   Why wouldn't we aim to improve midwifery if it really has something to offer?   

The hypocrisy has to stop.  Either out-of-hospital birth is safe, or it's not.   
A midwife is either ethical and responsible 100% of the time, or she's not.  Women are being educated about real risks or they are not.  
We're either making a truly informed "choice" or we're not.  
Midwifery is a profession of highly educated professionals, functioning on behalf of the safety and a well-being of mothers and babies...or it's not.     

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8 comments:

  1. LauraTMay 24, 2012 at 9:36 AM

    This is such a painful aspect of home birth advocates. There seems to be a disconnect between home birth and hospital birth on so many levels. The "de-medicalization" of childbirth to make it more of a rite of passage or a "bonding event" as opposed to the risky, physiological occurrence laden with potential dangers is rife with problems. To meet the two goals - a beautiful birth experience and the safest birth possible - seem almost diametrically opposed. The fear surrounding child birth, with all of its unknown factors - seems to drive either point of view. I think information and exposure such as you are providing, as well as noticeable efforts on the part of health care professionals and hospital "decision makers" is required to achieve more of a bridge between the two goals. I think that there are hospitals who strive for this and achieve it fairly well, but not enough do. The work continues....

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  2. Safer Midwifery MIMay 24, 2012 at 10:37 AM

    Laura,
    Your comment is excellent. I have been thinking a lot about this lately, wondering why it is so difficult to honor everything that birth is and to do it safely. I agree that many hospitals have a long way to go and that there are some doing it well. In our area (Lansing, MI) it feels so much like we have to pick between one extreme on another. One of our goals as a group is work on building that bridge you're speaking of and offer better options for women here. I don't often write about the hospital and improvements that need to be made there, even though I think the need exists. I'm trying hard to keep my writing focused on midwifery, but perhaps I should work on a post about bringing both worlds together, what it looks like, how it benefits women and babies, and perhaps examples of who is doing it well. If you have any examples, I'd love to learn more! Thanks for the great comment.

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    1. LauraTMay 24, 2012 at 5:15 PM

      I am located in the Los Angeles area and in California we certify midwives who do not have formal medical training (Certified Professional Midwives, Direct Entry Midwives, and Licensed Midwives). There are many of these types of midwives in my area, particularly on the West side of Los Angeles where wealthier people live. These midwives charge upwards of $4,000 to $7,000 for their services. We have many hospitals in the area as well and a real mix of ones that are "good" and ones that are less desirable. We have a few hospitals that allow CNMs to deliver, but not enough in my opinion. I am back in school and am aiming to become a CNM in the next 8-10 years. I have had 4 good births and 2 horrible hospital births. Improving hospital births is my passion. I also know many relatives and friends that have had home births with varying outcomes - good overall. Too many of them had risk factors that I feel should have prevented home birth. Just my opinion, though. Anyway, here's a link to one organization doing some very good things http://cmqcc.org/
      I look forward to your next post. Your voice is very important in the birth community for the entire US - not just Michigan. Good to start at home, though!

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    2. Safer Midwifery MIMay 24, 2012 at 9:12 PM

      Thank you Laura for sharing this perspective and for the resource. I'll save it and refer back to it soon as I plan to do some research and writing about exemplary collaborative care models that really aim at best practices for women. This was very helpful!!

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  3. jackMay 24, 2012 at 12:32 PM

    Very, very well said! I think that's at the heart of what's been mugging me about NCB since the birth of my son (planned homebirth w/CPM, non-emergency c-section after 2 1/2 days of labor, everything turned out fine, very thankfully). Either birth can be trusted and it works, or it can't. If it can't be trusted all the time then we're talking risk assessments and I never had a frank conversation about that risk assessment with my midwife. True, I never asked but I shouldn't have had to. When I chose a homebirth I thought the higher risk was negligible - if I'd put a number on it I might have said 1 in 10,000, or more. And I was willing to accept what I perceived as that small level of risk. But now I think the real risk was much higher - why did no one tell me that? I heard all about the disadvantages of hospitals, why didn't I hear about the disdvantages of homebirth? How can you be expected to "take responsibility" if you aren't given all the facts, just misleading, incomplete information? And when something goes wrong - or, in my case, more like just not according to script - there's no explanation, the undesired outcome must be the mother's/parents' fault. Of all the women who choose out of hospital births, I'd guess there are only a small number who truly understand what the risks are and have made an "informed" decision. But I'd guess the vast, vast number of them (including me) really believed a homebirth is pretty much as safe as a hospital birth. There's alot of false advertising (to put it mildly) going on, most of us aren't getting what we thought we were getting and then all too often blame ourselves for it!

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    1. Safer Midwifery MIMay 24, 2012 at 1:00 PM

      Thanks for the great comment Jack. I know we aren't the only family out there feeling like we were not informed honestly about the risks of out of hospital birth. The more I talk to other families, our experience seems more and more like the majority of what's happening out there. I'm working on a post for next week about informed consent and "choice" that will resonate with you too. Thank you for sharing your experience.

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  4. Mel CisumMay 24, 2012 at 7:14 PM

    This is a lovely piece of writing. I work in women's health, and so of course I am likely to be a biased advocate of hospital birthing. Having said that, I do think that both worlds could take a page from one another. Many of the home birthing mothers I encounter turn to the crunchy life style because they had an experience in a hospital that they did not under stand. As healthcare providers, I think it's fair to layout that birth is inherently dangerous. Epidurals, inductions and C/sections are not without consequence, obviously, but still safer for mother and baby in many situations. Explaining all potential risks and helping a patient weigh those risks against the benefits of any choice is imperative, even if we feel strongly about the safest course of action. And I think we could really take a page from the book of the home birthers and empower women to connect with the process. I was blessed with a certified nursing midwife delivering my first child in a hospital setting. It felt very natural and beautiful, and I was able to deliver easily without any medications whatsoever. More importantly, I delivered in a way that I could be reassured that even if I hadn't been able to deliver my son who was determined to come out in brow presentation, I was surrounded by a team who cold easily intervene on behalf of his safety when the moment was right. I never felt rushed, I was encouraged to assume all fours, (which felt terrible to me, turns out I prefer being on my back, but at least I got to try) and constantly offered alternative ideas to aid the process of my delivery. Though the idea really disgusted me, my midwife's suggestion to labor in the tub really speed the process up. She was there to offer guidance and respect my decisions, but could also offer the expertise and equipment to intervene had my cervix not professed, as many mothers with sunny side up babies experience. The second time around was equally as satisfying. I felt blessed knowing that when my son was cold and somewhat lethargic (despite a very quick and seemingly simple delivery) and I was hemorrhaging severely that there were well educated hands there to stop the bleeding and separate staff to do whatever magic was done to get my Benjamin pink and screaming. It does not need to be all or nothing. We as healthcare providers can work within the frames of safety for mother and child and allow for as much maternal choice as reasonably allowed, and we can better communicate the issues that women are going through when they have tall issues of safety. I think when we start providing this add a more intimate, personalized service, we'll met the needs of most misinformed home birthing mothers. Because labor can and should be intimate and beautiful, but it MUST be safe for mother and child above all else. I would love to see all hospitals take this approach.

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    1. Safer Midwifery MIMay 24, 2012 at 9:15 PM

      Thank you Mel for sharing your experiences with us. I agree with you, all or nothing isn't the way forward. I too would love to see all hospitals take the approach you're speaking of. Perhaps if women can start to feel comfortable talking about their experiences in child birth (regardless of place) and sharing honestly about what would make it better we can learn from them too. I know we can do better across the US for women and babies. Thank you for your post.

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