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Disputed Territory: A doctor reviews “Birth Territory and Midwifery Guardianship: Theory for practice, education, and research”

This is a guest contribution from Katharine Hikel, MD. Dr. Hikel is a writer on women’s health for Medscape/WebMD. Peer-trained in feminist women’s health clinics, she is also a graduate of Harvard and the University of Vermont College of Medicine. She lives in northern Vermont with her family.

Birth TerritoryReview:
Birth Territory and Midwifery Guardianship: Theory for practice, education, and research
.
Edited by Kathleen Fahy, Maralyn Foureur, Carolyn Hastie.
Butterworth Heinemann (Elsivier): Books for Midwives. 2008

The next vital revolution in maternity care may well be the overhaul and redesign of the birthplace. In “Birth Territory and Midwifery Guardianship,” writers describe the relationship of the birth setting to the emotional-physiological state of laboring women.  In this regard, ‘Birth Territory’ encompasses not only physical space, but also personal relationships, power structures, and access to knowledge.

Maternity care as we know it has evolved along divergent roads: the midwifery, expectant-management ‘natural’ approach; and the obstetric, interventive, ‘actively-managed’  model.  Midwifery care is a woman-centered approach; it relies on relationships which support women’s natural abilities to give birth. The obstetric model, designed by and for doctors, operates on  principles of academic exclusiveness, described by Louis Menand:

It is a self-governing and largely closed community of practitioners who have an almost absolute power to determine the standards for entry, promotion, and dismissal in their fields. The discipline relies on the principle of disinterestedness, according to which the production of new knowledge is regulated by measuring it against existing scholarship through a process of peer review, rather than by the extent to which it meets the needs of interests external to the field…

[T]he most important function of the system is not the production of knowledge. It is the reproduction of the system. To put it another way, the most important function of the system, both for purposes of its continued survival and for purposes of controlling the market for its products, is the production of the producers

Academic obstetrics is impervious to knowledge and input from other disciplines; it exists in a closed, parallel world; it exists not for the purpose of taking care of women, but for the purpose of taking care of itself. The chief concern of any obstetrical unit is the viability of the department, of the program; if outcomes figure into that, well and good; but women’s actual experiences and opinions, because they are not part of the published literature, are of no concern.  Small wonder, then, that so little thought has been given to the environment of hospital birth, other than for the convenience of hospital practitioners.

Meanwhile, midwives have continually concerned themselves with what the authors of Birth Territory and Midwifery Guardianship call ‘the elements in the geography, architecture, and metaphysics of birth spaces to which women will consciously and unconsciously respond.’

In their book, the writers – midwives, and an architect of birth spaces – asked women what they wanted in their birthing places. Responses included:

  • A pleasant place to walk
  • Sufficient pillows, floor mats, bean bags
  • Availability of snacks and drinks
  • En suite toilet, shower, bath; a birth pool
  • Comfortable accommodations for companions and families
  • A homey, non-clinical environment
  • Control over temperature
  • Control over brightness of light
  • Privacy; not being overheard by others
  • Not being watched
  • Control over who comes into the room

The majority of birthing women surveyed did not have these options. The authors argue that lack of a woman-centered birthing environment, and little control over that environment, are reasons for high rates of obstetric intervention. Labor and birth are whole-being experiences; the autonomic nervous system will shut the whole process down if the woman perceives stress, threat, or danger.  In typical hospital settings, with shift changes, strangers walking in and out, bright lights, confinement to bed and monitor, and restricted oral intake, it is no wonder that the process doesn’t go as smoothly as it could. “Failure to progress” – the diagnostic reason given for 50% or more cesareans – is largely an environmental issue.

Katharine Hikel, MD

Katharine Hikel, MD

Birth territory is also defined by relationships; yet medical obstetrics has constantly worked to sequester birthing women away from all sources of comfort, including non-medical practitioners; only in the 1960s were fathers and partners invited into hospital delivery rooms; and only lately, with the advent of doula practices, has one-to-one attendance – the cornerstone of midwifery – become recognized as a significant predictor of good outcome.  But few hospital practices are relationship-centered. Prenatal visits are fifteen or twenty minutes long, mainly focused on weight gain and lab work. There’s usually a team of doctors and midwives; the person who’s available at the time of one’s birth is not a matter of preference, but of the practice’s call schedule.

Obstetrics is statistics-based, not relationship-based; obstetricians know that the average due date is 40 weeks from the last menstrual period; they know that if a woman is laboring (in a hospital) with waters broken for over 12 hours, her chance of infection skyrockets; they know that the Friedman labor curve shows that the average progression of dilation is one centimeter per hour; they know that the average pushing phase is under two hours. They are under pressure to make everyone fit those statistical norms, and they have the tools to make it so; and that’s what they do.

The best birth territory requires the best attendants. Fahy and her coauthors argue that birth is a reflection of relationships – with oneself, and with others; that relationships depend on love, and spiritual development (words you will never see in any obstetrical textbook).  In developing the best birth attendants, they see open-heartedness as a requirement for good practice; they describe the characteristics of a good practitioner in Buddhist terms of ‘right relationship’: empathy; ethical behavior; self-awareness; capacity for love. In a chapter called “Reclaiming the sacred in birth,” they describe the conditions for nurturing ideal midwives: ‘to know and nurture themselves within their own families and communities,’ and emphasizes working on personal development, as well as clinical skills, with a supervisor or professional partner. The training environment of midwives should encourage the development of nurturing and intimate, though professional, relationships with her clients; it is that relationship that forms a necessary part of optimal birth territory.

The territory of obstetrics residents is largely devoid of patient-relationship considerations; it is rather consumed with concerns about on-call hours, clinical rotations, numbers of procedures, and one’s place in the departmental hierarchy. The knowledge itself is based in pathology – ‘problem-oriented’ – a diagnostic/treatment approach that assumes there’s trouble, and goes about finding it. This works well in the rest of medicine, which is really about disease; but colors the teaching approach to the normal, healthy event of childbirth.  The knowledge that’s important – taught and practiced – is all within the limits of academic obstetrics, which ignores, if not devalues, ‘nonscientific’ knowledge. The ‘permitted’ knowledge supports what the authors call the ‘metanarrative’ of academic medicine: the postmodern myth that the safest and best place to give birth is under obstetric management. Any knowledge that counters that myth is disputed or ignored.

The history of obstetrics is also viewed differently from within the specialty than without. The obstetricians’ view, reproduced in most obstetrical textbooks, is the development of one intervention after another, all by men – from forceps to vacuum extractions. The authors present a larger-scale view:

Medicine in the late 19th and early 20th centuries was composed almost entirely of men who shared the same power base as other dominant males: they were white, well-educated and from economically richer families. It was these males who owned or managed every institution of society: the army, the church, the law, the newspapers, the government, etc. These privileges, combined with an informal brotherhood of dominant men, created a powerful base for the success of the medical campaign to subordinate midwifery.

The authors describe the territory of hospital birth as disputed ground, where the biological requirements of birthing women are at odds with the design of institutions.  They provide ample evidence about how the dominance of obstetricians’ needs over women’s welfare has contaminated the culture of birth. In a wonderful section on oxytocin – the hormone of love, bonding, social interaction, birth, and lactation – they describe the effects of this natural hormone:

[T]he higher the level of Oxytocin, the more calm and social the mother; thereby stress is reduced; levels of the stress hormone cortisol drop; pain threshold is increased…  body temperature is regulated… and heart rate and blood pressure are lowered… Women’s response to stess may not be the automatic ‘fight or flight’ response seen in men, but is more likely to be the ‘calm and connection’ system integrated by Oxytocin.

These oxytocin-mediated events are most necessary during labor and birth; they are best enabled if the birth territory includes oxytocin-positive relationships.  Oxytocin is thought to be the source of women’s power to endure labor and birth; and its pathways are the most likely to be deranged by the institutional birth environment – the lack of oxytocin-facilitating relationships of trust and love, as well as the routine administration of oxytocin-blocking drugs such as epidurals and Pitocin – a form of artificial oxytocin that has never been proven safe in long-term outcome studies. Blocking oxytocin, whether through fear, disturbance, or Pitocin, leads to disrupted or painfully difficult labors.  These authors suggest that disruption of normal oxytocin pathways, and supplanting them with intrapartum Pitocin exposure, may also result in serious mental health problems on the love-and-relationship axis: schizophrenia, autism, drug dependency, suicidal tendencies, and antisocial criminal disorders. It’s not just the mother who’s affected by the birth territory.

But what is the best birth environment?  In a chapter called “Mindbodyspririt architecture: Creating birth space,” architect Bianca Lepori describes her designs for hospital-based birth rooms that are meant to enhance, not counteract, women’s abilities to give birth. She created suites of rooms with “Space and freedom to move; to be able to move to the dance of labor; to respond to the inner movements of the baby; to walk, kneel, stretch, lie down, lean, squat, stand, and be still.” The rooms have “Soft and yielding surfaces; or firm and supportive surfaces; different textures; the right temperature; soft curves; darkness or dim light.” A birthing woman can be ‘immersed in water, flowing or still; respected, safe, protected, and loved.”  Access to the suite is through an antechamber; the bed is farthest away from the lockable door, and not visible from it, so that privacy is respected.

Lepori’s birth architecture reproduces the comforts of home. There is access to the outdoors, and private walking places. There are birth stools, exercise balls, bean bags, hooks for hammocks or ropes for stretching. Tubs and beds are large and accessible from both sides. There are accommodations for families. There are comfortable chairs for nursing. Medical equipment – supplies, oxygen – is tucked behind a screen or put in a closet. A refrigerator and light cooking equipment is available. This ‘birth territory’ certainly outshines the typical hospital OB floor; though it begs the question: Why not just stay home?

The answer, of course, is that, for those four to ten percent of births that truly need intervention, the OR is right there. It’s better not to have to transport a woman whose labor has turned complicated; it makes sense – for many – to have all the birth territory under one roof.

This birthing-suite design indeed takes into account the all-encompassing, body-mind-spirit event of childbirth. It honors laboring, birthing women and families; it respects the process. It worked well for a designated maternity hospital in New Zealand – a facility already designed for childbearing. But most US hospitals are multi-use facilities; and though obstetrics is among the best money-makers for hospitals, childbirth is the only event that occurs there that is not related to illness or trauma.

The real question is, why not remove birth completely from the pathology-centered hospital model? Why not redesign birth territory to maximize best outcomes, minimize intervention, and replace the present medicalized view of birth as a disaster waiting to happen with the more normative, expectant-management, midwifery view? Move the whole shebang, from the waiting room to the surgical suite, out of the hospital and back into the community where it belongs.

Why not indeed. The major obstacle to any redesign of the territory of birth is resistance from the field of obstetrics. The American Congress of Obstetricians and Gynecologists (which recently changed its name from the American College of Obstetricians and Gynecologists, reflecting a major shift in interest from academics to politics) has a 23-member lobbying arm, “OB-GYNS for Women’s Health PAC”, which describes itself on its web site:

Ob-Gyns for Women’s Health and Ob-Gyn PAC help elect individuals to the U.S. House of Representatives and Senate who support us on our most important issues. Individuals who understand the importance of our work, who care about the future of our specialty, who listen to our concerns, and who vote our way. In only a few short years, Ob-Gyn PAC has helped elect ob-gyns and other physicians to the U.S. Congress, and has become one of the largest and most influential physician PACs in America.

Only five of the 23 members are women; all ten of its board of directors are men. Current issues occupying the group are “Stopping Medicare payment cuts, ensuring performance measures work for our specialty, preserving in-office ultrasounds” (though there are still no long-term studies on the effects of ultrasound on the developing fetus, or on women, for that matter); and “winning medical liability reform,” which means limiting liability for malpractice.
Meanwhile,  the Medicaid Birth Center Reimbursement Act – Senate Bill #S.1423 (House Bill HR 2358) – is not on the list of bills that ACOG supports, even though this expansion of birth territory would probably better outcomes, and certainly cost less than the hospital OB model.

The only bad thing about “Birth Territory and Midwifery Guardianship” is that obstetricians will not read it.

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  1. avatar
    Sandi Blankenship
    November 16th, 2009 at 14:57 | #1

    Excellent review! I am currently working in the middle east in a birth territory that is all maternity and gynecology. The labor, delivery and post partum is midwifery-led… a strange place to be for an American midwife! It’s wonderful, rewarding and about 1000 babies a month.
    It’s about what’s best for mom and baby and NOT what’s best for the physicians pocket book. When the U.S. stops making medicine about money, then we might be able to get decent healthcare.

  2. November 17th, 2009 at 03:54 | #2

    Very good review–can’t wait to read the book! I will be particularly interested to read the section that includes the following statements: “These authors suggest that disruption of normal oxytocin pathways, and supplanting them with intrapartum Pitocin exposure, may also result in serious mental health problems on the love-and-relationship axis: schizophrenia, autism, drug dependency, suicidal tendencies, and antisocial criminal disorders. It’s not just the mother who’s affected by the birth territory.” Some of the studies on which these assumptions are based are not adequate to draw such dramatic conclusions–for example, there is definitely a connection between the functioning of the oxytocin system and autism, but to go from that to a cause-effect relationship between Pitocin (as a possible disruptor of the oxytocin system) and autism is quite an unsubstantiated stretch–and a simplistic one, at that! While it may garner some attention to Pitocin use to associate it with such dramatic illnesses as autism, suicidal tendencies and drug dependency, I think it’s a mistake to look for links this way, and can be very misleading. Not that I’m a Pitocin fan, because I’m not, but my own Pitocin research explored the possibility of a relationship with later functioning in children and described what was found. Couldn’t agree more, though, that “it is not just the mother who is affected by the birth territory–we really need to pay closer attention to how the medicalization of childbirth has impacted those children–something that has barely been studied in any meaningful way. I am fully supportive of seeking ways to re-empower women in how they birth their babies and know for certain that both mother and baby benefit hugely from any steps taken in the direction of giving them the right territory for birthing.

  3. avatar
    Katharine Hikel
    November 18th, 2009 at 17:40 | #3

    @Sandi Blankenship
    Sandi, thank you for writing; I would love to know more about the history, practices, & finances at your birth center if you have a chance, as there’s a lot of interest in trying yet again to do this in Vermont. hikelbreck@gmavt.net

  4. November 20th, 2009 at 01:15 | #4

    “This ‘birth territory’ certainly outshines the typical hospital OB floor; though it begs the question: Why not just stay home?

    The answer, of course, is that, for those four to ten percent of births that truly need intervention, the OR is right there. It’s better not to have to transport a woman whose labor has turned complicated; it makes sense – for many – to have all the birth territory under one roof.”

    This book sounds amazing, but while I found myself nodding vigorously as I read through the review, I found myself disagreeing with this statement. We have no evidence that a planned home birth in a low-risk woman with a qualified home birth attendant in an integrated care system confers any excess risk over a planned hospital birth. The book’s primary argument is that environment counts, and when it comes to environment, as has been said, “Many things that count cannot be counted.” Certainly, every woman giving birth in a hospital deserves a place in which to labor designed to meet her needs and preferences, and many women eligible for home birth would not choose one, but who knows what the benefits may be for a laboring woman to be in her own territory where sights, sounds, smells, and textures are all familiar to her and where she is attended only by people she knows.

  5. avatar
    Katharine Hikel
    November 20th, 2009 at 21:51 | #5

    Henci’s right on. I re-read that para & thought the same thing – and I wrote it!

    As the saying goes: In a hospital, the doctors are in charge; in a birth center,the midwives are in charge; and at home, the birthing woman is in charge (thank you Carol Sakala of the Childbirth Connection!)

    The question really is ‘why not stay home’? Part of the answer is that, largely because of the ACOG-boosted climate of fear, still only 1 to 2 % of births occur at home. The majority of birthing women in the USA are unwilling to even comtemplate that option.

    They definitely want the birth territory all under one roof. The attitude seems to be: Well, if I might need intervention, why not be right there instead of having to go thru the whole rigmarole of ambulance, transport, getting my family there separately, etc.

    And yes, it’s wrong to say that because 4 to 10% of births need intervention, all birth should occur in hospitals. It’s like saying that because 4 to 10% of drivers cause car accidents, cars should be outlawed.

    Many of us do feel that the birth pyramid is upside down, and that in the best of all possible worlds, the great majority of births would be at home; the next smallest tier would be in midwifery-model birth homes; and the remaining few in hospitals.

    Still, in the present underinformed climate, home, birth center, and hospital are all consumer choices.

    The main difficulty people perceive with home birth is really the problem of transfer & backup. In areas where there are supportive community hospitals & enlightened physicians with privileges – family practitioners, DOs, whoever – the transition is part of the best-care continuum, and things go well.

    In other places, a woman moves from the bliss of home to a fraught clinical disaster-prone OB turf when transfering to a hospital, particularly at academic medical centers (like here in the Upper West Side of VT) where there is scant backup for home birth, and where women, families, and midwives transferring in from home are frequently treated negatively, if not punitively, by preprogrammed anti-home-birth house staff and attendings, in a setting that is really not designed to be woman-centered.

    Even if we did move birth en masse to home, if we don’t work on modifying the hospital setting, some percent of women who need intervention are still going to be subject to poor treatment just because they move into a surgical or instrument-necessary setting.

    It doesn’t have to be that way. A woman’s partner, her midwife, her designated doula, etc, can very well be welcomed into a surgical delivery room (and why not – they let every sort of medical student in there). The lighting, noise level, ambient temperature can very well be prioritized to the woman’s (and not the surgeon’s) needs. There can be an engaging and respectful approach to instrument or surgical birth – it is, after all, a birth. I have seen this done; it was very nice.

    In other words, concern with the territory of birth should not stop at the door of the ER or the OR.

    Probably the only way to do this is to get all maternity services completely away from the stale hospital environment as quickly as possible, and start training attendants in the woman-centered approach.
    Starting with the real estate is probably a great way to begin, and this book is a very good how-to manual.

    [Henci, am laughing about this because your book is front and center on my bookshelf.]

    Check out Henci’s recent critique of research on progesterone & prematurity – link below.

  6. avatar
    Augusta
    November 27th, 2009 at 12:47 | #6

    @Sandi Blankenship
    Sandi, where in the Middle East are you? I live in Bahrain and have been informed that the birth climate here is even worse than our birthing climate in the US.

  7. November 30th, 2009 at 16:07 | #7

    Hello!

    As an Academic OB/GYN physician, I read your comments with interest, and try not to take offense at the generalizations. We are all in it for the same reasons I think.

    I believe you are right that for low risk pregnancies, obstetrics/labor would better be done in a low risk birthing center. Birthing at home is likely also safe, as long as proper precautions are taken to identify patients at high risk prior to labor. Laboring a low risk woman in hospital likely increases the rate of cesarean without strong benefit, though in order to know this for certain we would need a randomized trial.

    I have seen some cases where lay midwives, believing that any labor should occur at home, have labored malpresented twins, VBACs, or even term breech infants at home, sometimes to terrible outcomes. It is these types of cases that darkens the view of an obstetrician who is receiving a home birth transfer.

    I also find it striking that a large population of women (and some men) want to discount the striking decrease in maternal and neonatal morbidity that has come with the onset of modern medicine. In the past the most common cause of death in childbirth was hemmorhage and sepsis, which are now nearly unheard of given the availability of strong antibiotics and blood banks. “Died in childbirth” is not so uncommon if you go back 150 years, and even less uncommon if you go back 300 years. Now it is nearly unheard of, and when it happens it is typically via a freak event such as an amniotic fluid embolism. There is a big focus on having a “natural birth”, but a failure to recognize that maternal and neonatal death and injury are all part of nature. Mothers and infants die in labor throughout the animal kingdom, and we are no different, lacking intervention when they are needed.

    I know of course of our own history of contributing to puerperal sepsis prior to the onset of routine handwashing, but to discount the natural occurrence of maternal infection in labor is to ignore thousands of years of documented history.

    A previous commenter >> And yes, it’s wrong to say that because 4 to 10% of births need intervention, all birth should occur in hospitals. It’s like saying that because 4 to 10% of drivers cause car accidents, cars should be outlawed.

    I appreciate the simile, but there are times when the intervention is required more quickly than could be achieved if the patient were at home. If we knew who would need intervention up front, we could just section those few women and let the rest labor at home. But of course we do not. To extend your simile, we don’t know who is going to have a car crash today, so we all better drive carefully!

    Check out http://academicobgyn.com/2009/11/08/protracted-thoughs-on-protracted-labor/ for some extended discussion on the same topic, probably by some of the same authors.

    Nicholas Fogelson MD

  8. avatar
    Katharine Hikel, MD
    November 30th, 2009 at 17:57 | #8

    The point would not be to offer women a ‘low risk’ birthing center where they would have to be transported to the nine circles of OB hell if intervention is necessary; but to design a full-service, all-inclusive, comprehensive-care ‘medical home’ for women and babes thru pregnancy, labor and birth – however they occur – postpartum, neonatal and infant care all designed on the patient-centered model. Which obstetrical care is not, never has, and never will be.

    The point is to offer a wholly different setting for full-range maternity care, and bring on the cmparative-effectiveness studies.

    We have all counted far too many cases of malpresentations, twins, hemorrhage, uterine rupture, sepsis, 4th degree tears & lacerations, iatrogenic prematurity, amniotic fluid embolism, placenta accreta/percreta, and maternal and fetal deaths occurring in hospitals, so better check your stats on those (CDC, March of Dimes, Childbirth Connection ‘Evidence-Based Maternity Care’, etc).

    To extend the simile: OBGYN is still pushing SUVs when the market is turning toward hybrids. The design, construction, building, maintenance, training, and folow-through involved in each product is different. Like car buyers, women should have the broadest possible range of choices — for all phases of maternity care. Right now we have none.

    And- I must point out that even now, 90% or more of OBGYN departments are run by men trained in the old-school interventive disaster model – most of whom have never fully attended a healthy birth from start to finish (not to mention never having experienced pregnancy, labor and birth). The culture of training is a huge part of what has to change.

    Men will take a far step out of the way in the woman-centered model. But – to paraphrase our President – anyone who likes the current plan can stay with it.

  9. November 30th, 2009 at 19:40 | #9

    @Nicholas Fogelson

    “There is a big focus on having a “natural birth”, but a failure to recognize that maternal and neonatal death and injury are all part of nature.”

    Two things here.

    1. This is a red herring in any birth discussion that amounts to “Look at the crazy wimminz who want metaphysical communion with Nature and don’t care about their babiez.” It’s a way of putting down the view of the views of anyone who hasn’t gone to medical school, even though it’s their body that is affected.

    2. A frequent accusation on blogs frequented by physicians is that anyone calling for change in obstetrics is clearly leaning on the naturalistic fallacy in forming their arguments, that a reduction in the use of unnecessary procedures on women in childbirth is a desire to return to a healthy, natural past which never existed.

    If you listen to what most maternity care advocates are calling for, its accountability, transparency and the judicious use of obstetric interventions as needed and as wanted. The decline in maternal mortality was multi-factorial and clearly partially attributable to access to emergency obstetric care. To deny that would be unreasonable.

    I understand your defensiveness and I can assure you that obstetricians and their skill set are highly valued. OBs Gone Wild are not. Decisions about a woman’s care made based on defensive medicine which are dishonestly sold to the patient as “playing it safe” are not appreciated and are unethical. But every woman that I know personally that gave birth out-of-hospital had a solid contingency plan that included transfer to a hospital where they would be cared for by… obstetricians.

    As the cesarean rate and induction rates continue to rise and VBAC rates drop due to fears of litigation, I believe more women will continue to seek out-of-hospital options to avoid giving birth in hostile territory. I’ve sat there before and tried to reason at 37 weeks pregnant with doctors and CNMs who saw POTENTIAL LAWSUIT before they saw REASONABLE PREGNANT WOMAN. Hopefully women can be viewed as competent and capable of making their own decisions about their and their fetus’ bodies. Wouldn’t that be great?

  10. November 30th, 2009 at 23:25 | #10

    Hi Jill –

    I really don’t feel defensive about this, as I’m pretty secure in my beliefs, and honestly there isn’t a lot of danger of me being out of a job. Believe it or not, I am a big supporter of midwifery and home birth. My brother’s mother and law is a lay midwife, and she and I have had many long discussions about our careers, and find far more in common than in difference. I welcome midwife transfers and have never had an unhappy transferred patient or midwife that I am aware of.

    >> It’s a way of putting down the view of the views of anyone who hasn’t gone to medical school, even though it’s their body that is affected.

    I’m not putting anyone down, I’m just asking you all to accept that labor is not a completely safe process. Women can be and are injured in delivery, as can be infants. Proper care, wherever and by whomever it is delivered, is necessary to decrease maternal and neonatal morbidity.

    I share your distaste for the idea that decisions might be made based on fear of litigation, but this is a reality of our world. I’m not sure that anyone can really prevent a lawsuit by doing one thing or another, as long as one practices within the standard of care. But many people do feel that they can take certain actions to decrease the likelihood of a lawsuit. Once somebody has been sued they will do a lot to prevent it from happening again. Sadly, a lawsuit can be very damaging to a physician even it is successfully defended. I suppose a woman could prevent her physician from ever considering this by signing a release preventing a future lawsuit at the onset of pregnancy care.

    >> Hopefully women can be viewed as competent and capable of making their own decisions about their and their fetus’ bodies. Wouldn’t that be great?

    Every woman is competent to make their own decisions, but that doesn’t make every woman an expert in pregnancy care or labor management. Having a singular experience does not replace study of the science behind it all. Ultimately a single person’s experience is just one anecdote. Each practitioner should be able to tell a patient what the data says, and when the patient’s anecdote is not in line with this, they can decide what they want to do.

    Nicholas Fogelson, MD

  11. November 30th, 2009 at 23:43 | #11

    >>> We have all counted far too many cases of malpresentations, twins, hemorrhage, uterine rupture, sepsis, 4th degree tears & lacerations, iatrogenic prematurity, amniotic fluid embolism, placenta accreta/percreta, and maternal and fetal deaths occurring in hospitals, so better check your stats on those (CDC, March of Dimes, Childbirth Connection ‘Evidence-Based Maternity Care’, etc).

    But what does this statement even mean? Sure there are complications in childbirth, but your statement is one sided. You imply that in comparison out of hospital births are necessarily safer, but provide no evidence for that. Saying that complications happen in hospital without providing some comparison group is saying nothing at all.

    What do you mean you’ve counted malpresentations and twins happening in hospital. I wasn’t aware we caused these problems.

  12. avatar
    Katharine Hikel MD
    December 3rd, 2009 at 14:45 | #12

    Dr. Fogelson hit the nail on the head: childbirth is a natural process, and like all natural processes, turns out fine most of the time but also lke all natural processes ay encompass a variety of outcomes, including death. There are no guarantees.

    ‘Obstetrics’, as they like to call it, has falsely elevated people’s sense of guarantee around birth – despite malpresentation and twin deaths (what I meant to say), hemorrhage, rupture, laceration, etc (mostly occurring in hospitals because that’s where 95% of births occur in the USA). And Dr. F. is exactly right – ACOG has prevented the development of any parallel management systems so that true comparative- effectiveness information can be counted.

    In many states home birth with a midwife is illegal (ACOG legislation). Where it is legal – as here in Vermont – ACOG docs have lobbied hard to curtail that choice for women: no breeches, twins, VBACs, preexisting medical conditions, etc. There is immense pressure on OBs NOT to back up home births; women who are transferred are treated like less-than-second-class citizens.

    That the selection of a place and style of birth is is not a woman’s choice, compatible with her degree of comfort and awareness, is wrong. ACOG’s position should be: we are here to help women have the best, most beautiful births they can envision, and we will go to any lengths to support the broadest range of choices needed for that to occur.

    What is the future of OB? Maybe hospital OB departments and training programs need to downsize. Maybe there are too many OBs running around drumming up endless interventions (from induction to controlled cord traction). Maybe it is time to change from the SUV model to the compact hybrid. Maybe it is time to decentralize and deregulate (and listen to the consumer). The ACOG hospital birth model is neither sustainable nor affordable. Nor is it realistic: In Williams Obstetrics, the ‘normal’ duration of labor has gone from 36 hrs (1930s) to 24 hrs(1960s) to 12 hrs. Have women’s bodies changed that much, or has our arificial, ‘scientific’ view of birth strayed so far away from Nature’s intent?

    Rather than concentrating its efforts and energies to preserving its own power and status — the Congress — ACOG should return to its roots — the College — and work toward a truly ‘collegial’ approach to bring women the most favorable birth experiences possible.

    In large part this would call for removing childbirth from the hospital setting completely, preferably to full-service birth centers, and to women’s homes.

  13. December 6th, 2009 at 17:43 | #13

    I appreciate your effort to identify our common ground.

    ACOG is basically the OB/GYN union, but does not necessary represent the views of every OB/GYN. I appreciate their publications (esp the Green Journal) and most of their literature, but do not agree with a number of their committee opinions. That’s OK. They are not the law, and I am not bound by their documents. I am happy to take transfers from homebirths if needed (though my current position prevents me from backing up midwives in a formal way) – though I certainly would if I were in private practice. I think most OBs would be OK backing up homebirths, preferably with some contact made during the pregnancy.

    OBs do worry that a midwife is going to mismanage a home birth, show up to the hospital with a bad outcome in the making, and that they are going to get blamed for it and possibly sued for it, which is a legimitimate concern. The technical term for this is “being handed s**t on a plate.” One case like this can sour an OB against midwifery forever. Lay midwives usually do not carry much malpractice coverage. CNMs may or may not. The OB has lots. Who’s going to get blamed?

    I have experienced a number of these cases, including malpresented twins being labored 40 minutes from a hospital, home VBAC attempts gone awry, and severe hemorhage with failure to diagnose significant vaginal lacerations. When you add a patient and midwife that have preconceived antagonism against OB/GYNs, you can see how many would be loathe to get involved.

    Some of my experience has led me to believe that midwives are not so good at policing their own, and keeping those who are really poorly trained out of practice. This is particularly an issue with lay midwifery, which doesn’t seem to have a standard of care I can identify. My brother’s mother in law is a brilliant lay midwife who I have complete trust in. Some others – not so much. I think I’m more understanding than most on this issue, but there are limits.

    Each midwife should be judged on their own merits, but in reality the whole field gets maligned by a few fringe players I think. Keeping control from beginning to end is one way that OBs keep from having to deal with this.

    Nicholas Fogelson

  14. avatar
    emjaybee
    December 6th, 2009 at 18:13 | #14

    “Some of my experience has led me to believe that midwives are not so good at policing their own, and keeping those who are really poorly trained out of practice. This is particularly an issue with lay midwifery, which doesn’t seem to have a standard of care I can identify. My brother’s mother in law is a brilliant lay midwife who I have complete trust in. Some others – not so much. I think I’m more understanding than most on this issue, but there are limits.”

    Thank you for your openness and willingness to comment, btw.

    The major midwifery organizations have done an *enormous* amount of work on this issue. Consistent certification requires first, recognition of midwifery as a legitimate field of practice in all states. Many of their efforts in this area have been, sadly, blocked or fought by ACOG, though there have also been triumphs.

    But as with all medical fields, certification and licensing can be used effectively to reduce unqualified practitioners or get rid of bad ones.

    Which, as I am sure you know, are *not unknown* in the field of obstetrics, either.

    Can we acknowledge the elephant in the room here? Money. Fully institutionalized and implemented midwifery care would reduce the number of OBs needed, conceivably. Or radically change OB training such that it would become much more similar to midwifery.

    ACOG knows this, and while I do think OBs, like any doctor, mostly genuninely care about patient health, they also care about income. And in the beginning of obstetrics to now, midwives were seen as threats to that income.

  15. December 6th, 2009 at 18:25 | #15

    >>>> Can we acknowledge the elephant in the room here? Money. Fully institutionalized and implemented midwifery care would reduce the number of OBs needed, conceivably. Or radically change OB training such that it would become much more similar to midwifery.

    Of course this is part of it, but lets acknowledge the other elephant which is far less sinister. Delivering babies is awesome! Do I want to give up every low risk patient and only work with people with all the problems, or new onset trainwrecks? Hell no. A lot of obstetricians go into the field because they love delivering babies. Why would we want to stop practicing what we do? Sure I do it a little different than midwives do it, but I’m happy with the way I practice, and by in large so are my patients. I have to give this up because midwives think I do it wrong? And you think ACOG wouldn’t fight against that?

    Lets be clear – ACOG is the American College of Obstetricians and Gynecologists, not The American College of Obstetricians and Midwives. Then it would be ACOGM, which would be harder to say. Of course they defend the interests of OB/GYNs. I know many ACOG officers who are supportive of midwifery.

    >> But as with all medical fields, certification and licensing can be used effectively to reduce unqualified practitioners or get rid of bad ones. Which, as I am sure you know, are *not unknown* in the field of obstetrics, either.

    No doubt there, but you cannot hang up a shingle and say you are a obstrician/gynecologist, which apparently cannot be said for lay midwives in many states. Furthermore, the oral board exam process for OB/GYNs is pretty stringent. If you pass, you know your stuff pretty well. It is up to argument if that stuff we’re supposed to know is correct, of course.

  16. December 6th, 2009 at 18:25 | #16

    Oops I misspelled my own career.

  17. avatar
    Katharine Hikel MD
    December 6th, 2009 at 23:44 | #17

    “A lot of obstetricians go into the field because they love delivering babies.” That is THE diagnostic doctor-centered statement of obstetrics.

    What was I just saying about woman-centered care? [How many doctors does it take to change a light bulb? One. He just stands there and the whole world revolves around him.]

    The term midwives use for people who ‘love delivering babies’ but don’t much care for the rest of the program is “Birth Junkies.” Medical students, EMTs, hopeful midwifery apprentices, doulas, friends, relatives – anyone can be bitten by that bug.

    Miracles are addictive. But just because a person feels that way doesn’t mean the whole area of childbirth is there to gratify his wishes, or that that makes him the best choice of an attendant (especially after years of Training From the Dark Side).

    Midwives – independent, CPMs, CNMs – write and speak freely about the sacredness of the relationship between midwife and birthing woman, which starts at the first prenatal. That is the basis of woman-centered care. It is all part of the ‘privilege’ of practicing any kind of medicine – except that maternity care and childbirth is not part of medicine, because it is a natural, not a pathological process; and that’s where obstetrics has it wrong, wrong, wrong.

    This is not just about childbirth. It’s about women’s place in the world, and control and jurisdiction over our own processes, and even in the definition of those processes.

    Obstetrics can well be categorized as the misdefinition of womankind.

    The term “lay midwife” is another OB pejorative. The appropriate words are ‘independent midwife’ or, where applicable, ‘certified professional midwife.’

    Licensure, certification, board exams notwithstanding, the question of what ‘stuff’ OB’s know ‘pretty well’ is indeed under discussion. Obstetrics is a surgical specialty. The motto of surgery? “A chance to cut is a chance to cure.” Look on the Web pages of obstetrics residency programs, and this is what you will see as bait to attract applicants: “A High Volume Of Surgical Cases!”

    The Amerian College of OBGYNS is actually now the American CONGRESS of OBGYNs – reflecting a regrettable shift away from knowledge-sharing to protecting its own political power.

    But obstetricians are notoriously bad at policing themselves. They are highly proficient at selling women a lot of unnecessary interventions wholly designed to make the doctor feel better about the birth process; at doing so with shoddy short-term, never mind long-term, outcome data; at masking iatrogenic, intervention-related maternal mortality with causes of death such as ‘cardiac arrest’ so they will not be counted in obstetrical statistics (yes – Ina May Gaskin and others are amassing data on this); at allowing any serious encroachment on their turf; at disregarding patient feedback; and most egregiously, at understanding what woman-centered care really means.

    On any obstrical floor you will hear all about the Friedman curve; about the three Ps: the powers, the passage, the passenger; you will see bags of hundreds of plastic amni hooks for rupturing membranes; you will see ‘The Board’ in the hallway, which is a chart showing who’s in labor and how she’s progressing. On a busy McBirth service, “managing the board’ is the most valued skill residents can show: slowing down or speeding up women’s labors artificially so they all don’t deliver at the same time.

    You learn very fast as a medical student that birth from the doctor’s point of view is very much an in-and-out kind of affair.

    Read OB history: Jennifer Block’s book ‘Pushed’ is an excellent place
    to start. Her bibliography is essential for understanding the context of this problem. The film “The Business of Being Born” should be required viewing for all medical students.

    That the miniscule minority of OB program grads has ever truly attended an entire, normal, natural delivery (unless she was a practicing midwife, or unless she given birth herself, or has attended a loved one’s childbirth) guarantees that “Birth Junkies” are largely what OB programs select for. The attending relationship is wholly destroyed during training: 10-minute visits, weigh-in, lab work, fetal heart tones, see you in three weeks, call the office if you have any concerns, and I’ll be at your birth if I’m the one on call that night; and at the birth, it’s the Four P’s: the powers, the passage, the passenger, and the Pitocin.

    Meanwhile, midwives advertise “Hour-long prenatals!”

    And, because an OB in training has to be a high-grade ‘birth junkie’ to put up with the ridiculous, unhealty residency schedule; and because ‘procedures’ are handed out as rewards, you also get ‘procedure junkies’ (a chance to cut…).

    So what you have is this OB culture where midwives and nurses (and now the latest craze, doulas) do the real work of attending labor (until their shift change), and the OB shows up for the delivery. (To get that ‘fix’)

    To paraphrase Eliot: This is not what we want at all.

    Anyone can be a surgeon (look at who’s accepted into surgery and OB residencies). But if you are not a woman, if you have never experienced pregnancy, labor and birth, if you have never attended a variety of births from start to finish, you do not have the necessary physical knowledge, empathy, and awareness to be a truly first-class maternity care practitioner.

    No woman-centered practitioner would conceive, much less utter, the pejorative ‘shit on a plate’ when faced with a woman in need. That is pathognomic of OB culture.

    I suspect that the majority of delayed transports from home for 2nd births are due to a previous awful hospital birth experience and the woman swearing she will never go back no matter what, with blood gushing, heartbeat crashing, and her midwife and her husband begging her to get in the car. It’s a primal, Pavlovian aversion reaction, and I can’t tell you how many times I’ve heard that story.

    (The doctors blame the midwives, and the midwives – being women-centered practitioners – never shift the blame onto their clients.)

    So transfer to hospital is to be avoided. In a woman-centered practice, you bring the surgeon to the woman, not the other way around.

    Anyone can design an ‘office surgery’ for heaven’s sake (and they have).

    Top choice for a full-service family-centered community birth home would be a general surgeon or (best case) the woman’s FP who’s trained (probably out West)to do surgical births. An OB would have to go thru 6 months to a year of deprogramming before being allowed anywhere near our clients. There is that 5-15% need for skillful, competent intervention, and there is room for a new model of care.

    Childbirth is not a medical condition. It only becomes so when medical intervention is needed. That’s why the support systems for birth have to be redesigned anew from the foundation up: to create a woman-centered, health-promoting environment where intervention is (to paraphrase the Stones) just a shot away (even if the OR is used as the card room most days of the year).

    We would have a small core of highly-trained, midwife-friendly, experienced, invested, interested surgical specialists who would be pre-trained in our culture and vetted before being allowed the privilege of attending our clients (Note! They are not ‘cases’!) AND supporting all home births in our catchment areas. We will offer a beautiful setting, atmosphere, facility, and faculty; we will have on hand everything a surgical specialist would need to assist in a complicated birth, as well as a small NICU with neonatal support as well. We would transfer to tertiary care as necessary once the mother-baby pair is stabilized, and we’ll design a motherbaby specific limousine ambulance service as well.

    The Medicaid Birth Center Reimbursement Act just passed the Senate and is now part of the Health Care Reform Bill.

    The antitrust community is looking askance at hospitals’ anticompetitive practices regarding consumer choice. It’s a good time to start something new.

    Likely candidates? Send your CV. And bring your skis.

  18. December 7th, 2009 at 00:25 | #18

    My lord. Its all a great idea and a lot of patients would be happy to have care in such a center, but man I feel unfairly attacked. You are so damn sure you understand the inner self of every OB/GYN out there, and its just ridiculous.

    But here’s the thing. OBs like doing what they do, and there is nothing wrong with that. Many patients like their OBs, and have great birth experiences with them. Its like you think that somehow these patients are under mind control and actually they don’t realize that they’re having such a bad experience? I’d love to show you my file drawer full of thank you cards from happy patients. I’m sure you think it is somehow too proud of me to keep the cards to look at when I’m feeling a bit down.

    Surgical numbers are very important in an OB/GYN training program. As you said, surgical skills are necessary sometimes, and it takes experience to get skill. The idea of having an FP around to do your cesareans is unusual. I wouldn’t want my wife to have a cesarean by anybody who couldn’t do a cesarean hysterectomy. Cesareans are not terribly dangerous, but if you are incapable of dealing with life threatening bleeding, you shouldn’t do them. Most FPs can’t do that surgery safely, nor can general surgeons, at least not in the US where they have basically no training in obstetrical and gynecologic surgery.

    At least in Oregon, lay midwives call themselves lay midwives. Maybe you should let them know they are calling themselves the wrong thing.

    Believe me, I am a pretty progressive OB. I’m not a midwife (midhusband?) but as OBs go I’m progressive. Ask my midwife aunt-in-law. The thing I don’t understand is why midwives are on the warpath against us? I’m not on the warpath against you. I want to collaborate. I make one post honestly expressing some of the concerns that OBs have with midwives, in legitimate dialog, and the response is like nuclear war. Its like you’re Iran telling the Israelis they have no right to exist. What kind of communication is that? It leads nowhere good.

    >>>>Midwives – independent, CPMs, CNMs – write and speak freely about the sacredness of the relationship between midwife and birthing woman, which starts at the first prenatal. That is the basis of woman-centered care.

    Good lord. I have had great relationships with so many patients before, during, and after their pregnancies. It is this relationship that makes us like delivering babies. Believe me, the joy of my field is helping a delivery with a patient I have gotten to know through her pregnancy. That is why we like what we do. Helping a total stranger to deliver, as you seem to think we all are to our patients, can be less satisfying.

  19. December 7th, 2009 at 08:54 | #19

    The thing I don’t understand is why midwives are on the warpath against us? I’m not on the warpath against you. I want to collaborate.

    There’s “you” being Dr. Nicholas, singular; then there’s “us” being OBs as a collective. You seem to be the kind of OB I’d like to have, if I needed an OB; you’re one of the few who would willingly back up a midwife — yet you admitted up-thread that you cannot do so openly. And that is the problem — or at least, one evidence of the problem.

    I agree that there needs to be less “us and against them” mentality; but… honestly… take a step back from this discussion, and look at the US as a whole, look at the midwifery care system as a whole, look at OBs as a whole (not just you and other “progressive” doctors you may know, but as evidenced by, oh, I dunno, ACOG’s anti-homebirth statement released in the wake of The Business of Being Born, specifically lashing out at Ricki Lake, although they edited that, and the AMA’s statement released on ACOG’s coat-tails), and then ask yourself again, who is lashing out against whom? Midwives serve less than 10% of all women; out-of-hospital births are about 1% of all births in the US. Doctors own and/or control everything — all hospital-based midwives have to practice within hospital guidelines; not bad in and of itself, as long as the hospital is practicing evidence-based medicine. But often, midwives are forced to practice in ways they’d rather not, because of external pressure placed on them — being threatened with losing privileges if they do or don’t do such-and-such. And even out-of-hospital midwives often have to have collaborative care agreements with doctors — again, not a bad thing necessarily to have; it would be good to have some degree of continuity of care, instead of having to sneak around, have “shadow care,” or just show up at a hospital. But often, these agreements stifle midwifery autonomy to the degree that it forces them to be “mini-doctors” instead of midwives.

    So, with 99% of births happening in hospitals, and almost 100% happening directly or indirectly under obstetricians’ or hospitals’ guidelines dictating what a midwife can or cannot do; and with midwifery legislation (which can help to weed out bad midwives who can’t make the cut in certification — something doctors should want) being fought tooth and nail by ACOG and even many times by hospital-based CNMs, to hear you asking, “Why are you on the warpath against us,” is a little brain-jarring. I shake my head, and ask, “Did he really say that? Does he really think that?” Because it’s rather like a giant stepping on a kitten, and then asking, “Why is that kitten scratching and biting my foot? What does she have against me?”

    I agree that there should be more collaboration and less fighting; but you’re not asking the aggressor why he’s being aggressive — you’re asking the people who have a severely minority position in power, prestige, and privilege, why they’re “on the warpath” against the established, strong, wealthy, and powerful organization that is bent on wiping them out! Hello?

    I’m not angry here — my words may have been strong, but it’s not personal, and based on what I’ve read from you, you seem a likable guy, and someone that is “on our side,” as it were. I’m just trying to get you to see the perspective of the other side. And a history lesson wouldn’t hurt, to see how doctors came to control 99% of birth, starting with a vicious anti-midwife campaign in the first few decades of the 20th century. They painted midwives as dirty, and spreading diseases and killing women with their care, when the reality — which the doctors knew!! — was that midwife-attended home birth had the lowest maternal and infant mortality and morbidity; doctor-attended home-birth was safer than hospital birth but not as safe as with midwives. Yet, because doctors had been to med school (where they might have witnessed fewer than a dozen births, and assisted at almost none), they were perceived as being more skilled than a lay midwife who had been attending births since her teens, or a skilled midwife who had gone through a program requiring a minimum of 20 hands-on births (plus having seen another 40-80 before being allowed to assist).

    So, don’t ask the kitten why she’s scratching and clawing against the foot that is trying to squish the life out of her. Ask the giant why he’s squishing the kitten.

  20. December 7th, 2009 at 11:33 | #20

    Wow, folks, thanks for all the spirited debate. I think this conversation is really enlightening. We are definitely talking about two different cultures with different languages, assumptions, etc. But the thing is, the safety of planned home birth (or any midwife-attended birth, for that matter) has everything to do with how smooth are the articulations between the primary care setting and emergency obstetric services. Robbie Davis Floyd has a nice article illustrating case examples where care at the receiving facility was delayed or given poorly because it was a home birth transfer. (Many of us have our own “anecdotes” about this.) I also love Melissa Cheyney’s work looking at midwives’ and obstetricians’ attitudes about home birth transfers. It echoes a lot of the points made by Dr. Fogelson. I agree that it’s not OK to think of a woman in need as “shit on a plate,” but I also think midwives need to recognize that that is how transfers are perceived and work to correct that perception. My own midwife for my daughter now works in British Columbia, where the provincial government is proactively trying to increase access to midwifery care including planned home birth. She told me that in her area, when a midwife has a client laboring at home, the hospital is notified and the woman’s name gets written up on “the board”. Then if she gives birth at home, her name is erased. If she comes in, she was already considered part of the “caseload” and the hospital presumably had a copy of her medical record and had some idea about how the labor had progressed before hospitalization. This is absolutely a system we could not implement in all but the most progressive parts of the US because everything is so fragemented and antagonistic. It is so great that Dr. Fogelson is supportive of home births and willingly takes transfers. But he is one doctor. I certainly know the feeling of praying that a certain doctor will be on call when I bring a woman into the hospital. And we had a “real” collaborative agreement. And I had hospital privileges to actually care for her there! But I still knew the experience would be markedly more stressful (and potentially less safe) when certain doctors answered the page. In the end, we lost our privileges because we lost our backup because the un-homebirth-friendly doctors in the group got their way. And we had really never brought in any shit on a plate. All of the VBACs we did at that hospital (all were planned hospital births) had vaginal births, all of our breeches consented to cesareans, and the babies of transferred moms were fine. It’s a fragile house of cards even when you do everything “right” (be a licensed practitioner, have good outcomes, strive for effective communication, and even compromise what we think is right sometimes in order to preserve the relationship (see “all breeches consented to cesareans,” above.)

    So we *have* to work together and understand each others perspectives in order to improve outcomes. But we also have to recognize the power dynamic that currently prevails in which women and the midwives supporting them are often left out of decision making entirely. Women take risk management seriously, but the current antagonism in our system leads women to actually avoid discussing risk with medical professionals. (See this article.). Nothing good can come from a system that implicitly tells women their concerns are invalid and it’s better to ignore the possibility of a bad outcome rather than consider it carefully and arrange for the most appropriate care. This is never more true than in the case of “high risk” births at home, which give the rest of home birth a bad rap (because so many “horror story” anecdotes batted around by doctors are high risk births that come in needing urgent intervention, or too late to try). Many if not most women who have breeches or twins or VBACs at home would presumably much rather give birth in the hospital, if the hospital was going to let them have a say in how the birth was managed. A woman considering a VBAC at home may factor in the possibility (supported by some good but not decisive evidence) that a uterine scar rupture in VBAC labor is less likely and a vaginal birth more likely if the labor is “managed” physiologically, even if the risk associated with scar rupture are higher the farther she was away from emergency obstetric services. But if she lives in an area with a VBAC ban, she is actually faced with a different and more complex risk calculation. In addition to the obvious stuff that we all recognize goes into that decision making (safety, recovery time, likelihood of postpartum complications, impact on subsequent pregnancies) she now must also factor in the emotional impact of “submitting” to something she does not in fact consent to in exchange for a promise that her own and her baby’s physical safety will be preserved. Not to charge this already supercharged discussion with the word “rape”, but Joy Szabo who faced this exact situation said it best (painted on the back of her SUV), “Enter my body without my permission: sounds like rape to me” (She drove hundreds of miles to get a hospital VBAC, rather than planning a home birth that she didn’t want.) No, I’m not saying that every woman who gets cesarean surgery when she might have opted for a VBAC if anyone supported such a choice is raped. But some certainly see it that way. And that is indeed a “risk” that *some* women factor in, and lead them to make choices that seem crazy in the context of a system that values only certain defined “clinical risks”.

    All this is to say that I think we MUST address some major woman-unfriendly practices in hospitals if we ever want to change attitudes or outcomes around home birth.

  21. avatar
    Katharine Hikel MD
    December 7th, 2009 at 14:11 | #21

    To reiterate to our dear young warm-hearted and chronically self-absorbed OB correspondent what Amy and all of the above writers have been chorusing: This is NOT about the individual OB. There were, of course, a few good Germans. This is about the culture of Nazi Germany.

    A man attending a birth is like a bear riding a bicycle. He can be well-trained, dignified, applauded, respected, and earning good money for his contrivances. Every circus has one. But it is not a natural or a wholesome event.

    Given the power dynamics of our culture, its history, and the present dearth of choice, women will choose male OBs, 15-minute prenatals, epidurals to the gills, scheduled inductions and cesareans, and the full hospital McBirth package. They will also choose breast implants, liposuction, Botox, collagen injections (now offered widely by ACOG-trained OBGYNs), tummy tucks, brow lifts, regular applications of toxic chemicals to their hair; they will gorge on junk food, swill booze, put on six-inch spike heels, and date guys in gangs. I defend to the end our right to unimpeded freedom in all of those choices, but I would not offer any of them as a standard best-practices approach to life and health.

    This all makes one long to know the proportion of male obstetricians who seek out female urologists for their own pipi problems. Would anyone take a Ferrari to be looked at by someone who can’t drive?

    On one OB rotation I worked on, there was a notorious senior attending on whom we were required to fill out ‘incident reports,’ due to his terrible record of cervical lacerations from manual dilation, wound problems from shoddy technique, etc. ad infinitum. His patients loved him – all the while he was patronizing, flirting, joking, shmoozing, & convincing ‘his ladies’ that whatever poor outcome had occurred was their fault, and that he had saved the day. Most of them swallowed it whole (but not the Utilization Review Board). So, beside warm personal testimony, the best thing to look at is outcome.

    What’s the cesarean rate? For what indications? What’s the induction rate? What percentage of births are ‘actively managed’? Is ‘pit to distress’ included in the package? What’s the prolonged 2nd stage rate? What’s the vacuum assist rate? What are the prematurity & NICU admit rates? What’s the maternal readmit rate? What’s the VBAC rate? To name a few.

    This is not about who’s handsome, distinguished, or popular with patients.

    Surely there are a few OBs out there who have low intervention scores, great outcomes AND delightful personalities, and we will find them.

    Required reading: The Millbank Report, “Evidence-based Maternity Care: What It Is and What It Can Achieve”, available at thechildbirthconnection.org.

    Also available at that site is the excellent “Listening To Mothers” survey series. Read it and weep.

    Or not. The biggest ongoing problem in obstetrics is its ignorance of quality information that exists outside its own narrow and parochial boundaries. Obstetrics maintains a cult-like approach to knowledge. There’ a whole world of data beyond The Green Journal, and it’s lamentable that OBs are oblivious to it.

    But. As Dr. Fogelson points out: The training of surgeons is of immense concern. Another adage in the field: “Surgeons are little boys who are very good at putting on a complicated pair of shoes.” What that means is that, given a certain level of innate manual dexterity, proficiency with anatomy, and responsiveness to complex variables, the best way to train anyone in surgery is by having them do the same thing over and over on as many patients as possible. This begs the question: What is the ideal training venue for surgical specialists in maternity care? You cannot rethink maternity care without addressing this question.

    Woman-centered childbirth reform does not stop at the door of the ER or the OR.

    At the ideal childbirth care center (where we will indeed follow and support the progress of all home-birthing women), training in surgical interventions will follow the midwifery model: it will be competency-based, and it will be a ‘lifestyle’ choice, as the ideal applicants will be women (and men) with a commitment to a love- and family-centered paradigm (the definition of ‘family’ is broad) – not only for clients but for staff. Some trainees may take 2 years and 20 procedures to achieve competency; others might take 5 years, and 50 procedures, and so on. This requires a commitment similar to that of traditional midwifery. If the number of procedures done is not for the benefit of the surgeons but for our clients, it will significantly reduce the numbers of procedures that now occur to ‘keep up the numbers’ in the present training milieu. It would also attract a highly talented and motivated, but small, group, thus self-limiting the numbers of yahoos and ‘procedure junkies’ in the field.

    There are several ways to produce excellent maternity-care surgeons from a woman-centered platform. One approach, for full-service practitioners who, like Dr. Fogelson, would devote themselves to the widest spectrum of maternity care, is to start off learning the basics of woman-centered care, by applying as a novice, either as MD, medical student, apprentice, or fellow in a full-service maternity center (coming soon to your neighborhood); then progressing via apprenticeship under an affiliate surgeon, or (for those ‘grandfathered’ in, in terms of previous training) becoming an affiliate via private practice.

    (Dr. Fogelson would probably be up to snuff after a 6-week intensive ‘feminist guerilla training camp’ orientation which would include reading all the books he’s clearly been avoiding.)

    For those chiefly interested in surgical management, the best option would be a residency in general surgery followed by an OB ‘fellowship.’ The candidate would then be able to practice surgery without being wholly dependent on obstetric procedures for a livelihood. This would also raise the talent bar rather higher than it is currently set (the old adage among medical students was, “Well, if I can’t get into surgery, I can always go into OB”).

    Academic obstetrics may well evolve into a pure fellowship program, which would be the best thing in the world for all involved.

  22. December 7th, 2009 at 15:15 | #22

    Wow, what an amazing and awesome discussion!

    I do hope Dr. Fogelson is not disenheartened by this torrent; I do have sympathy for his position in such a debate. Birth activists have finally found an OB willing to listen, and boy, they’re lettin’ ‘er rip.

    I’m a relative newcomer to the birth field as a doula and apprentice midwife in a country where the most well-known home birth midwife has just been charged with manslaughter. It is an extremely hostile culture for midwives and doulas.

    I can certainly see why activists who have been trying to change the system, or at least signal that there’s something WRONG with the system, would be extremely bitter after a few decades in the field.

    I also see how the system (at least in this country) totally disempowers the health care workers as well, how they are facing constraints the activists like to ignore.

    I certainly welcome dialogue between the two camps to try to come up with something mutually satisfying. I was extremely glad to find Dr. Fogelson’s blog in which he examines and critiques some of the standard obstetric procedures. It was truly a breath of fresh air.

    I understand that Dr. Hikel has probably spent a great deal of time and energy fighting against the system that Dr. Fogelson is a part of, but I certainly don’t think that the patronizing and belittling asides are helpful to this discussion. I certainly get that she’s angry, but I think this anger is misdirected at the one (or one of the few) of the perceived “enemies” who’s actually open to discussion.

    There needs to be dialogue. I know there are enormous power issues at play, but let’s try to see our partners in conversation as just one person with his or her opinions, not as the embodiment of an entire (hated) paradigm.

  23. December 7th, 2009 at 15:50 | #23

    >> This all makes one long to know the proportion of male obstetricians who seek out female urologists for their own pipi problems. Would anyone take a Ferrari to be looked at by someone who can’t drive?

    I can’t give you a number nationwide, but I can say from experience that something like 15-20% of urology residents are women. I wouldn’t care the sex of my urologist if one day I need one, I just want a good one.

    >>“Well, if I can’t get into surgery, I can always go into OB”

    I really don’t think this is accurate. Both general surgery and OB have enough training programs to train the people that want to go into those fields, perhaps too many on both counts. The strongest programs in both fields are highly competitive, and in both cases they become less competitive as they decrease in certain characteristics. I do not know of a single OB/GYN resident or graduated OB who is in the field because they couldn’t get into general surgery.

    >>I understand that Dr. Hikel has probably spent a great deal of time and energy fighting against the system that Dr. Fogelson is a part of, but I certainly don’t think that the patronizing and belittling asides are helpful to this discussion. I certainly get that she’s angry, but I think this anger is misdirected at the one (or one of the few) of the perceived “enemies” who’s actually open to discussion.

    I appreciate this comment by Reka. Dr Hikel – the underlying message I get from you is that I (or obstetricians in general) do not have the right to exist as I am. This leaves me with very little interest in collaborating with you or reading the books you have written, at this point. If ACOG has created the message that you do not have the right to exist, that is equally unfair.

    As for feminist boot camp, I am in it every time I visit my midwife family.

    I also must clarity that the phrase “s**t on a plate” absolutely refers to the situation, and the emotion it evokes for the receiving OB, and not the patient, who is also put in a difficult situation that we all want to help her resolve.

  24. December 7th, 2009 at 15:52 | #24

    I completely and absolutely reject the concept that there is something wrong with a male in obstetrics or childbirth. At least amont patients that see OBs, some patient prefer women, some prefer men, and most just want someone they like, whatever their sex might be.

  25. December 7th, 2009 at 15:55 | #25

    It is entirely probable that you can create the system you speak of, and that a large segment of women will want that and benefit from it. I believe this would complementary to, but would not replace, the obstetrical model.

  26. December 7th, 2009 at 18:13 | #26

    I absolutely agree that the low risk birth center option is probably optimal for both worlds. But I have to agree with Dr. Fogelson; Dr. Hikel’s attitudes/generalizations toward all OBs if very off-putting. Herein lies the dilemma. If we need each other to make a true collaborative effort at providing optimal care and choices in childbirth to women, it is unfair and insulting to operate under the assumption that only midwives provide “women-centered” care. Having followed Dr. Fogelson’s blog/twitter feed for a bit, I feel that he and I are similar in our approach. Although I have deferred OB for awhile because of my own family’s needs (4 kids and one on the way), I still provide prenatal care and work collaboratively with another OB. My patients seek me out because of my wholistic and respectful approach. Just because I am trained to perform a C-section if I had to, doesn’t automatically negate my sensitivity toward my patients. Maybe Dr. Fogelson and I are the exception rather than the rule, maybe there are more out there like us who are dissatisfied with the mainstream OB paradigm, and maybe the whole system would work better if those of us who have voiced support, are not still lumped in with “the patriarchal US OB system” AKA “the enemy.”

  27. December 7th, 2009 at 19:06 | #27

    Oh, forgot to include a link to a post I did a while back on the concept of “Same team”. This may help show a bit better where I’m coming from.

  28. December 7th, 2009 at 19:39 | #28

    I think that sometimes entire groups are accused of being a single organism with a single goal, when no individual in that group would ever actually agree to that goal. “ACOG wants to destroy midwives” “Republicans want to destroy health care reform” It is just unfair to all those involved. Each individual has unique thoughts and motivations. Large groups of people in organizations are just that, large groups of individual people. It doesn’t take but a moment on this blog that midwives have varying thoughts on various issues – they aren’t a big amorphous blob with a single goal. Why would anyone assume that OBs are?

  29. December 8th, 2009 at 01:14 | #29

    Let me try to explain the motivation behind clumping big groups of people into a single amorphous blob: frustration.

    It must be difficult to conceive of the enormity of the frustration of someone who is caught on the losing side of a power struggle, and has been for decades. Because that’s what the “doctor-vs-anyone else” dynamic is. You might be the nicest OB in the world, but you do still self-identify as one of that group that many in this discussion have had extremely frustrating experiences with, and the balance of power is not always this even, and it is not completely even here, either. Let me give you an example. In my reply, I consistently referred to you and Dr. Hikel by your honorific Dr. title. In your reply, you referred to me by my first name. This creates a power imbalance. YOU probably did not intend it, and would probably not mind if I called you Nicholas or Nick if you prefer, but it does show a certain power relationship, don’t you think? The reason I point this out in particular is because it happens ALL THE TIME to me in my relationships with doctors I work with, and most especially male doctors. I call them by their honorific. They call me by my first name. Believe me, it’s not that I’m that much younger or less educated than they are. It’s a power dynamic. I suspect that this is the power dynamic that Dr. Hikel is getting so angry about, not to mention the other big one, the male versus female one, which I personally don’t subscribe to, but I do see that it is the thing that most feminists get angriest about.

    On a different subject, I completely agree with you that OBs sometimes get handed “shit on a plate” (and I took that statement in the spirit in which it was intended). And the reason I agree with you is that I’ve seen it happen. And only some of the cases are what Dr. Hikel is talking about; that midwives take too long to transfer because the mother had such an aversion going to the hospital, and we need to address those cases of high risk clients who probably should not have been labored at home at all, given the current lack of good cooperation between most home birth midwives and most hospitals.

    Which brings me to my main question. Amy Romano talked about risk assessment and calculations that pregnant women do when deciding their place of birth, which I felt was spot on. I would totally support a woman who was a higher risk category to labor at home IF she SIGNED OFF on the risk.

    Why is that not an acceptable way of dealing with people making individual decisions? Why can’t a woman simply sign a document that states that she is aware of her elevated risk status, and yet chooses to stay at home?

    And since we’re tossing around book recommendations, I’d throw in Birth Models That Work, which describes maternity care systems around the world which the authors have deemed to be positive examples, among them at least a few places where they managed to incorporate home birth into their maternity care on a country-wide level without losing safety points.

  30. December 8th, 2009 at 01:43 | #30

    I for one, appreciate Dr. Fogelson’s comments and willingness to discuss these topics. As an L&D nurse that is definitely more natural minded, I find it refreshing to know that there are doctors out there willing to do so. I also understand, though, why many women and midwives feel the need to attack the medical model. Many, many women have been hurt, abused, and trodden under by people who have subscribed to this model…hence the anger out there. I for one feel like we need to let go some, and push forward. Forgiveness is a hard one, but I have found it to be the most healing. Then maybe we can move on and create a better birthing world where collaboration is possible.

  31. December 8th, 2009 at 01:49 | #31

    Dr Morvay – I have no problem being called whatever, as long as it includes human respect. If you would like to be called doctor, it is certainly within your right as a clinical psychologist, but you better make it more clear somewhere.

    Certainly in hospitals doctors do have a higher place in the power structure. Hospital medicine is a psuedomilitaristic heirarchy, or at least it is in the US. Doctors are near the top, though hospital administration often has parallel if not equal power. It is a shitty feeling when someone above you in this hierarchy is forcing something to happen than what you do not agree with. Believe me I understand this.

    But on other thoughts:

    Here’s a model that I think would work great.

    Physicians continue to practice obstetrics, and women that want that model of care see them.

    Midwives practice midwifery without obstruction from ACOG or OBs without particular supervision from OBs. Women that desire that model of care see them.

    In situations where midwives need consultation with an obstetrician, it is provided in the hospital.

    A law is created that limits an obstetrician’s legal liability in midwife transfer cases to bad outcomes that clearly originate after transfer of care has occurred.

    Create that last qualification and 9/10 OBs who prefer not to collaborate midwife transfers would change their tune.

    Seems pretty simple to me.

  32. December 8th, 2009 at 02:59 | #32

    Dr. Fogelson:

    I would drink a toast to that model! Unfortunately, simple is not always the same as easy.

    As for the honorific, I’m sorry if what I wrote misled you, but I am not a doctor. My highest degree is a Masters. But thanks for the gesture. :)

  33. December 8th, 2009 at 11:25 | #33

    I would love to have that kind of structure, but I think it would be hard to implement. Too many doctors I know, feel very bitter and hard about the whole midwife thing. Where I live, rules are being hammered out as to who can birth at home and what not. We have a committee of doctors, CNMs, and DEM. It was like pulling teeth to even get them to talk to each other, much less come to compromises on issues. In this situation, they had to meet by state law, but that is what it would take to get people to discuss possible solutions together.

  34. avatar
    Katharine Hikel MD
    December 8th, 2009 at 11:51 | #34

    Funny that when a woman simply states her observations and opinions in the field, it’s assumed that she’s ‘angry.’ – A little transference going on here, perhaps?

    I stand by my ‘bear on a bicycle’ analogy, and I hope anyone reading this who subsequently watches a man at a birth will remember that image, and realize how accurate it is.

    There is no reason anyone should have to depend on hospital transfer. Birth centers should be all-inclusive, and anyone who wishes to support the model should be able to come in and do instrument/surgical deliveries right there.

    A hospital is not the only place in the universe that can have an OR. But, if the hospital transfer model is among birthing women’s choices, then I’m all for it. And if they want bears on bicycles, I’m for that, too.

    The bears aren’t doing a very good job reading the literature (like “Evidence-Based Maternity Care” from the Childbirth Connection”).

    I’ve enjoyed this and now I must be off to build the birth center.

  35. December 8th, 2009 at 12:13 | #35

    @Nicholas Fogelson
    I likewise would agree with that model. It is odd to me, that doctors spend so much of their collective time, influence, money, and bargaining power in keeping midwives and home birth out in the cold (again, evidenced by their anti-homebirth statements, and their intensive lobbying efforts every time CPM legislation is proposed in any state where it is not currently legal), and so little time on tort reform. Maybe because it’s easier to step on a kitten than to grapple with the lion of trial lawyers?

    In Sept. 2008, ACOG had its “legislative agenda”, with its #2 point being to stop CPMs, which affects relatively few people (probably fewer than 5% of all women would choose homebirth with a midwife, even if they were legal and easily available in all 50 states); with “medical liability reform” down at #5. This past September, ACOG’s current legislative agenda had the same setup.

    I agree that there needs to be tort reform. I think that there should be protection for those who have done nothing wrong, while still being able to maintain victims’ rights to seek justice. There are a few things that could be implemented, if there were enough will — a medical court system, with jurors who would actually be qualified to judge whether the doctor did wrong (one problem with the current system, is that there is too much protectionism, with doctors unable/unwilling to police each other, which leads frustrated patients to seek “justice” by suing for money).

    Also, a no-fault fund that would sort of work like malpractice insurance, in that doctors would pay into it, and, as an example, if a baby were born neurologically impaired, the parents could draw funds to help support the child, without feeling like they needed to sue the doctor for negligence, even though he did nothing wrong.

    And, what has recently been done here in Mississippi, is making it so that people are held liable as they are at fault, rather than everybody being liable, with the deepest pockets ultimately paying. Why should somebody only 2% liable have to pay 100% of the judgment?

    It comes down to <a href="http://womantowomancbe.wordpress.com/2009/09/08/rights-and-responsibilities/"rights and responsibilities — if the woman has the right to make choices, then she should bear some responsibility with the outcome of those choices. But if the doctor refuses to allow her to make any choices (such as a VBAC ban), then the doctor should bear all the responsibility for any bad outcome.

    Our legal system should reflect that. And, quite frankly, doctors need to work on getting that done. They have huge numbers (50,000 doctors represented in ACOG, I think), and *much* bigger salaries (probably every one of them makes 6 figures). I’m sure that (nearly) any midwifery organization would be glad to join forces (or at least drop any antagonism) to help make tort reform possible, were doctors to stop their efforts at preventing CPM legislation, and particularly if they joined the two items — proposing CPM legalization as a part of health care reform and tort reform.

    The battle with tort reform is not with midwives nor midwifery, but with trial lawyers. You may not be exactly “preaching to the choir” when you talk about a low to limit legal liability, but I don’t think that many (or perhaps *any*) midwives or midwifery organizations would necessarily oppose that legislation. For my part, it seems only fair.

  36. December 8th, 2009 at 23:39 | #36

    If you can find docs that want to be the surgical backup at your birth center, fantastic! I’m not sure I would want to work in that environment, but I think it would be a good thing. I’m not sure what they would do with the 95% of their time when they were not needed.

  37. December 8th, 2009 at 23:40 | #37

    Signed, paddington on a schwinn

  38. December 8th, 2009 at 23:46 | #38

    @Katharine Hikel MD

    >>>Funny that when a woman simply states her observations and opinions in the field, it’s assumed that she’s ‘angry.’ – A little transference going on here, perhaps?

    I think it would be projection. Transference would be that I’m angry at my mother and am becoming angry at you instead. Reka Morvay MS in Psych will be able to tell us.

  39. December 9th, 2009 at 16:10 | #39

    What I would like to see is hospitals, who have the surgical back up, also provide the birth center environment. This has got to extend beyond just the physical make-up, though. And, I really think it should be more researched based. As more and more research is being done by mid-wifes, I hope to see more research done along these lines. I am happy to see that more is being done also. But, I do think Katharine’s idea is good and would also serve a lot of women. It’s all about options, imo.

  40. December 11th, 2009 at 10:05 | #40

    Hi everyone,

    I’m really finding this conversation fascinating and love the different points of view. My masters research explored doctors and midwives perceptions of their interactions in the care of birthing women.

    the dissertation can be accessed here:

    http://hdl.handle.net/1959.13/29305

    I think you would find it interesting, especially the findings and theory generated. I developed two models of interactions. One, where interprofessional power is used in a positive way and one where intterprofessional power is used in a negative manner.

  41. avatar
    Charlene Hamilton
    January 11th, 2010 at 07:13 | #41

    Why not stay home?

    Because, honestly some women have homes that are utterly unhelpful for providing a positive birth environment. If the goal is to give every woman access to that list of ideals, then there needs to be a

    a full-service, all-inclusive, comprehensive-care ‘medical home’ for women and babes thru pregnancy, labor and birth – however they occur – postpartum, neonatal and infant care all designed on the patient-centered model.

    available to women who live in tiny, crowded living spaces… or close quarters apartment complexes…or have homes that might not be so tidy…or who won’t feel relaxed in their own space, and want to nest elsewhere.

    We can’t force women to feel comfortable with a home birth, no matter how much we educate and support them. So why not provide a holistic way for all women to reap the benefits of the patient-centered midwifiery model of care?

  42. avatar
    Heather
    September 30th, 2010 at 00:28 | #42

    @Nicholas Fogelson Unfortunately, Dr. Fogelson, most OB’s will NOT go for that. Your system DOES sound close to ideal. The midwives in this country, by and large, would be THRILLED to be working in such a setup. But the OB’s will NOT play ball. I was involved in the process of legalizing midwives in the state in which I used to live. Our midwives were actually committing FELONY practice of medicing without a license by following their vocation! It took us a number of years, and several different versions of a bill to legalize the practice of midwifery, before we were successful. At least one version did, indeed, include just such a limitation of liability for the OB’s–and they STILL fought it, tooth and nail. They simply were NOT willing to agree to any bill that would de facto allow midwives to practice. In the end, CPM’s were legalized, but that took passage of a bill AND a year-long court battle–and, of course, those in favor of midwifery do not have large, deep-pockets, organizations behind them to pay for such things. The bill was literally paid through donations and bake sales.

  43. avatar
    Laura
    August 31st, 2011 at 10:09 | #43

    @Nicholas Fogelson
    Wow! How perfect is that summary. It seems so logical. It is a shame that there is so much legalistic ‘stuff’ that gets in the way of what appears to be a smart solution… women are taken care of appropriately, intervention is absent when appropriate, and called on when circumstances don’t play out naturally. I’m a student midwife and reading this discussion has been quite intense. I’m forming my own opinions while being educated at university and influenced by the many opinions of numerous midwives I work with daily. But I know that regardless of the bickering and challenges faced between midwives and OBs I never want to change my profession and regardless of the role I play it is the most rewarding job I could dream of. I never want to forget why it is we do what we do and that the woman remains the centre of our attention, that the relationships formed are always precious to the memories they are making, the life they are bringing into this world. Blessed to be a midwife!!

  1. November 22nd, 2009 at 22:55 | #1
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