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What SUVs Can Teach Us About Maternity Care

December 6th, 2009 by avatar

Twice last week, analogies between sport utility vehicles (SUVs) and the organization of our maternity care system came up in blog comment discussions. In a spirited discussion between Katharine Hikel and AcademicObgyn.com‘s Nicholas Fogelson on Hikel’s post, Disputed Territory, she proposed, “maybe it’s time to change from the SUV model to the compact hybrid…The ACOG hospital model is neither sustainable nor affordable.” In a thoughtful post about military terminology and philosophy in healthcare at e-Patients.net, again conversation turned to the American enhusiasm for SUVs.

Henci Goer and I decided it would be fun to share a sneak peak excerpt of our book, Obstetric Myths versus Research Realities, 2nd edition, due out late next year. With apologies to those who drive SUVs, here it is…

What SUVs Can Teach Us about Maternity Care
Excerpt from Goer, H. & Romano, A. (In Press)
Obstetric Myths versus Research Realities, 2nd Edition, The University of Michigan Press: Ann Arbor, MI.

A recent advertising campaign for a large sport utility vehicle (SUV) offers an excellent analogy to conventional thinking in maternity care. Parallel to the “just in case” approach of obstetric management, the ads acknowledge that the average SUV driver will hardly ever need the heft and power of an SUV, but the “one percent” chance of being caught in a blizzard or hurricane means the driver would be wise to own a vehicle that can safely navigate treacherous conditions. The SUV, the ads declare, is “built for the one percent.” Let us see how the flaws in this argument translate to maternity care.

SUV creative commons1

  • The technology that makes an SUV superior in severe adverse driving conditions provides no benefit to the driver 99% of the time because severe adverse driving conditions are rare. Likewise, the technology that can improve outcomes in very problematic pregnancies provides no benefit to most women and babies most of the time because these conditions are rare.
  • Most SUV drivers live in temperate climates, where the likelihood of a blizzard or similar natural disaster on any given day is extremely low. Likewise, most pregnant women are healthy and at low risk of experiencing a “natural disaster” during childbirth.
  • The driving conditions in which an SUV offers an advantage are usually predictable. Blizzards and hurricanes, for example, rarely take a driver completely by surprise. Likewise, we can often predict which women will develop complications in pregnancy or birth. Most pregnancy and labor complications develop slowly, giving plenty of time to avert them or access the resources needed to safely manage them.
  • Individuals and society as a whole expend resources to build, fuel, and maintain SUVs and to accommodate them on our roadways despite the fact that most people could drive smaller cars most of the time and be equally well off—or better off. Likewise, technology-intensive obstetric management is extremely costly and requires specialized staff resources and physical infrastructure to support it, despite the fact that a lower-technology approach with access to technology when it is indicated provides equivalent or better outcomes.
  • Although the SUV’s bigger size and greater weight offer some protection when collisions occur, these same characteristics make them more prone to accidents. The weight of the vehicle makes it more difficult to brake to avoid collisions and the higher center of gravity is responsible for more rollovers. The net effect is that SUVs may actually be more likely than smaller cars to be involved in serious or fatal accidents to drivers or passengers. Likewise, obstetric interventions can be beneficial in some circumstances, but their use frequently results in iatrogenic harm. The net effect is that women and infants often fare worse than if they had not been exposed to the intervention in the first place.
  • Some people choose an SUV because they genuinely need one for the road conditions under which they do most of their driving. In these cases, an SUV makes sense. Likewise, women who have medical problems or are likely to develop pregnancy or labor complications will benefit from intensified use of obstetric technology. These women are likely to seek out specialist care.
  • Although we can measure the degree to which weather or traffic conditions are poor and accidents more likely, this information cannot tell us which cars are destined to get into accidents or whether any individual accident will be minor or major. Similarly, screening tests (e.g., fetal surveillance, electronic fetal monitoring) and prenatal risk or candidacy for VBAC scoring systems have poor predictive value and lead obstetricians to over treat. They also fail to distinguish problems where intervention can help from problems where it cannot.
  • Most accidents are fender-benders that cause no more than minor harm no matter what kind of vehicle is involved. Likewise, most complications in pregnancy and birth are minor and will not result in any serious or long-term harm to mother or baby no matter what kind of care they receive.
  • Some accidents will cause major injury or death no matter what kind of vehicle is being driven. Likewise, some babies and even some mothers will suffer severe morbidity or die no matter what kind of care they receive. Even in the best-equipped hospitals with superbly qualified staff, in some cases, nothing can be done to prevent the worst from happening.

Midwives Deliver bumper sticker2

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

November 16th, 2009 by avatar

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
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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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Healthy Birth Blog Carnival: Walk, move around, and change positions throughout labor

October 28th, 2009 by avatar

On the heels of our successful “Let Labor Begin On Its Own” Carnival, here is our second Healthy Birth Carnival! This time the theme is Lamaze’s second Healthy Birth Practice: Walk, move around, and change positions throughout labor.

Every single one of these posts is great, and on top of some really thoughtful writing, I’m also excited about the amazing photos, illustrations, and videos our contributors used to show laboring women using various positions and movements. It’s so nice to see active birth rather than the conventional images of women passively laboring in bed connected to a bevy of tubes and wires.

Let’s get moving!

Two phenomenal posts show how important movement is in VBAC labors. Kristin at Birthing Beautiful Ideas writes about how she “moved and grooved” to a healthy VBAC, and the labor and birth nurse at NursingBirth offers another powerful story of how movement and great labor support helped a mother achieve a healthy and triumphant VBAC in the hospital.

Jill at The Unnecesarean points out that, “For first time mothers who have had no exposure to a birth, the time between, ‘I felt a contraction!’ and ‘I have to push!’ is often a total mystery.” She demystifies the in-between time with a plethora of selections from women’s birth stories that illustrate how movement helps.

Wendy at Aruban Breastfeeding Mamas offers “Birthing Positions 101” to an island where women are too often restricted to the lithotomy position to birth, discussing the potential benefits and disadvantages of each position.

The Well-Rounded Mama brings us another incredibly thoughtful and thorough post, this time about the importance of movement in labor and how mobility restriction – and its harms – affect women of size disproportionately.

Do we need to show harms of restricting mobility in order to advocate for freedom of movement? I discuss how a “medical model” approach to research can actually be an impediment to change in my post, “Do we need a Cochrane Review to tell us that women should move in labor?

Carol Van Der Woude shares a story of how 1970′s technology inadvertently helped a woman birth vaginally after progress had slowed. In the course of getting out of bed and going to another part of the hospital to get an x-ray of her pelvis (yes, this was common practice 30 years ago!) the baby finally found the right fit through the woman’s pelvis and was born soon after. Carol’s post also offers a story of how plenty of patience and freedom of movement kept a home birth safely at home.

Jen at Pursuing Harmony shares another simple story of birth at home, in which she followed her instincts to find the right positions and movements to help labor progress smoothly. Lauren Wayne at HoboMama shares a personal story of using movement to give birth to a nearly 12 pound baby vaginally with no drugs. Her story illustrates both how home birth offers optimal freedom of movement and how mobility can be maintained even when a planned home birth results in a transfer to the hospital. Sheridan at Enjoy Birth shares another personal experience, and also answers a common question, “can I still move around if I am using hypnosis in labor?

The hospital bed can be a potent symbol to a laboring woman that she has no choice but to get into it. This summer, Henci Goer wrote a post here at Science & Sensibility about a pilot study showing that removing the labor bed from the hospital room entirely resulted in less use of oxytocin augmentation. But most women birth in environments with hospital beds, and some women need to stay in or near the bed for medical reasons, so Molly Remer brings us a fantastic handout,”How to Use a Hospital Bed Without Lying Down“. The Lamaze-Certified Childbirth Educator and student nurse-midwife at Hands for Catching points out, however, that the bed is not the only element of the conventional birth environment that keeps women from moving while Moms Tinfoil Hat shares a personal story that demonstrates that mobility is an all-too-common casualty of the cascade of interventions. All of these posts reinforce the relevance of Birth Territory, a new theory for labor care that emphasizes the role of the physical environment and individuals’ use of power in promoting optimal labor outcomes. Rixa Freeze introduced this theory in a recent post at Stand & Deliver. (Stay tuned, we’ll soon be featuring an interview with the researchers who developed the theory and a review of their book here on Science & Sensibility!)

And last but not least, the News Moms Need blog reminds us that moving our bodies offers health benefits in pregnancy and after giving birth, not just in labor. The blog also offers tips and guidelines for exercising safely while pregnant. Our bodies were made to move!

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Mad Birth: Are Today’s Women Better off than Betty Draper?

September 22nd, 2009 by avatar

I’m a huge Mad Men fan. For readers who aren’t familiar with the show, it depicts the goings on at a New York City advertising company in the 1960s. The show has earned critical acclaim not just for its stellar acting and story telling, but for the show’s authentic depiction of the styles, trends, and attitudes of the era.

Don and Betty Draper, with Baby Gene

Last week, the main character’s wife, Betty Draper, gave birth to her third child. While her husband, Don, sits in the waiting room drinking scotch with another nervous expectant dad, Betty is subjected to 1960′s “standard of care” obstetrics. Left alone in a labor room, she is shaved, given an enema, and then receives the crown jewel of her modern childbirth experience: medications to induce twilight sleep, which also induce a mad stupor and land Betty in restraints because of her erratic, combative behavior. As a midwife and a mother, the most difficult part for me to watch was when Betty awoke from her stupor, swaddled baby in arms, with no memory of the experience. You can watch all of the birth-related clips from the show at Jezebel.

This season, there are several feminist blogs keeping tabs on Mad Men and the various depictions of women’s rights and abuses thereof. It’s not difficult for feminists to recognize that birth in the twilight sleep era was nothing less than violence against women. But I have seen very little chatter on the blogs about the aspects of the childbirth experience that remain paternalistic, misogynistic, and violent half a century later.

Are today’s women better off than Betty Draper? Clearly, most of us are. But I believe we’ve traded a visible, blatant form of labor ward paternalism for a new paternalism and a “standard of care” that presents to women bogus assurances of safety and autonomy.

I was recently asked by Jill at The Unnecesarean to nominate one of my favorite blog posts for “Best of Week” at her blog. I sent her my choice before I had even watched last week’s Mad Men, and the timing is serendipitous. Rather than select one of the many Science & Sensibility posts I am proud of, I decided to nominate the very first blog post I ever wrote. In it, I write about my own births and those of the three generations of women in my family who birthed before me. If anyone wondered how I became so radicalized about childbirth and women’s health, just have a look at my sorry family history. And ask yourself: What will our daughters think of today’s style of “modern” maternity care, once they have the benefit of hindsight?

"Best of" Week

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Home Birth: The rest of the story

September 11th, 2009 by avatar

As most readers of this blog are probably already aware, The Today Show ran an inflammatory piece about home birth this morning that parroted ACOG’s long-standing scare tactics and anti-midwife rhetoric.

Since I just wrote a post on the safety of home birth, I thought that rather than repeating the same old story that home birth is safe for healthy women with qualified attendants and access to referral, I would share with readers some other thoughts, culled from this blog, the rest of Lamaze.org, and other trustworthy resources.

One of the first posts I wrote for Science & Sensibility (actually written as a guest post at the Giving Birth with Confidence Blog while this site was getting up and running) was titled, “Why the Largest Study of Planned Home Births Won’t Sway ACOG.” ACOG prefers to hold home birth to a standard of evidence to which hospital birth was never held.  Even while actively compiling the lowest form of evidence on the supposed “perils” of home birth in a membership survey, ACOG repeatedly calls for a randomized controlled trial comparing perinatal death rates in the two settings, fully aware that such a trial is literally guaranteed never to happen. I discuss some of the reasons why in my post, concluding that we face much more urgent research priorities for the study of planned home birth than a full-scale clinical trial.

We need more and better research on home birth. We can use data from the Netherlands to determine the safety of home birth in systems that support and integrate home birth midwifery. After all, it is the only place left with a maternity care system that lends itself to home birth safety research, and national registers to conduct that research soundly. In the U.S., we must study how we can reform our maternity care system to provide access to midwife-led care in all settings, and best practices for caring for the women who rightly and inevitably will continue to desire birth at home.

Why exactly do women desire to birth at home? It’s is not because they are hedonistic or selfish, as ACOG likes to suggest. Judith Lothian, PhD, RN, LCCE, wrote recently about the qualitative research she will present at next month’s Lamaze Conference. (Rixa Freeze, PhD, Lamaze International’s 2009 Media Award recipient, has conducted similar research.) Judith asked women themselves why they planned to give birth at home, and then observed them doing so. Their responses describe motivations far from reckless desire and hedonism. She writes:

I was surprised that all of the women described themselves as “mainstream”. They all wanted a natural birth. All the women came to believe that “intervention intensive” maternity care increased risk for them and their babies. They valued the personal relationship with their midwife and believed that this relationship increased safety. They believed they could manage the work of labor more easily and more safely in their own homes. They all expressed confidence that a hospital and skilled physician care were available if needed. ‘Being Safe’ emerged as the theme that captured the essence of women’s decision to plan a home birth. In stark contrast to the current thinking, that birth is safer in hospitals under the care of an obstetrician, these women believe that giving birth at home is safer for them and their babies.

It seems likely that women believe that home birth is safer than hospital birth because word is getting out that hospitals routinely deprive women of the style of care that is proven to produce the safest, healthiest outcomes. Just last week, Lamaze released the third revision of the Healthy Birth Practice Papers, a collection of evidence-based articles about the care practices that ease and facilitate labor, prevent complications, and protect breastfeeding and early mother-infant attachment:

1. Let labor begin on its own

2. Walk, move around, and change positions throughout labor

3. Bring a loved one, friend, or doula for continuous support

4. Avoid interventions that are not medically necessary

5. Avoid giving birth on the back and follow the body’s urges to push

6. Keep mother and baby together – it’s best for mother, baby, and breastfeeding

The 2006 U.S. Listening to Mothers II Survey revealed what anyone who advocates for home birth could tell you even without the data: almost no one who births in a hospital actually experiences these care practices. The survey found that fewer than 2% of women had all 5 of the care practices that the survey measured. (The practice they were unable to measure was “no routine interventions”. Since interventions are routine and rampant in hospitals, this likely means that the proportion of hospital birthing women who experienced all six care practices was effectively zero.)  Instead, the authors of the survey tell us what is happening in current, hospital-based maternity care:

The data show many mothers and babies experienced inappropriate care that does not reflect the best evidence, as well as other undesirable circumstances and adverse outcomes. This sounds alarm bells…Few healthy, low-risk mothers require technology-intensive care when given good support for physiologic labor. Yet, the survey shows that the typical childbirth experience has been transformed into a morass of wires, tubes, machines and medications that leave healthy women immobilized, vulnerable to high levels of surgery and burdened with physical and emotional health concerns while caring for their newborns.
- Maureen Corry, Executive Director of Childbirth Connection.

In fact, ACOG themselves acknowledged in a press release today that the current style of obstetric practice (high-tech defensive medicine) “ultimately hurts patients“.

I continue to believe that if hospitals provided the Six Healthy Birth Practices as the standard of care and offered evidence-based treatments for women and babies experiencing complications, hospital birth would be safer and so would home birth. That’s because midwives would initiate transfers with more confidence that it would improve the outcome, women would transfer more willingly, and care at the receiving facility would be safe and effective. What’s not to like about that plan, ACOG? Now, let’s make it happen!

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