CharlieL | Indy Week

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Re: “Midwives seek autonomy in N.C.

This will be my last posted comment.

"No, there is no scientific evidence in neuroscience or neonatology that shows that babies remember or are affected by mode of delivery."

This is patently false. I encourage others to explore this issue on their own. Dr. Verney's book discusses this at length and cites sources perhaps of interest to those seeking more information.

But even if you were correct, which you aren't, that there is no evidence that babies retain memories of their own births and are affected by the quality of that experience -- something mothers have intuitively known for much longer than science has -- since we can never prove a negative, you certainly couldn't prove that it's not true. So it seems awfully arrogant to me to deny another human being the experience of coming into the world peacefully on the very small chance it's going to save a life.

What this discussion is ultimately about is what we value. Our medical culture has shown over and over again that all we seem to value is a live body and our overwhelming fear of death leads us to make decisions that have negative consequences for those who live. There is quite a gradient between living and thriving, and it doesn't take someone particularly aware to see that many American kids these days are not thriving. We are willing to subject women and babies to an enormous amount of trauma to perhaps save a few babies.

Wouldn't it be interesting to track the life-long prognosis of babies born at The Farm and compare them to the general population? Dr. Verney discusses some studies in his book that suggest that birth trauma has a direct and significant correlation with increased rates of criminality and other pathological behavior later in life. And regardless, there is quite a bit in the psychological and medical literature documenting different types of birth traumas with specific emotional, mental and physical issues later in life. Forceps deliveries are known to cause life-long neck and shoulder pain in some individuals, and I am one of them.

Denying that babies are affected by the quality of their own births seems to me to be an all-too-convenient excuse to subject them to all matter of pain and fear -- being ripped out rather than participating in the process of being born; being separated from their mothers, the only being familiar to them in the world, at birth so they can be handled by people unfamiliar to them and who almost certainly don't have the same compassion and tenderness as their own parents; denying babies the ability to immediately bond and imprint with their mothers; subjecting them to cold, sterile nurseries instead of letting them reacquaint with the sound of their mothers heartbeat; subjecting the overwhelming majority of their mothers to unnecessary and painful procedures that affect their ability to bond and care for their infants.

Is this a model really worth defending? How many doctors have ever even witnessed a home birth as simply a point of comparison? It was only 25 years ago that we still routinely performed brain, heart and other major surgery on newborns without anesthesia because doctors believed newborns didn't feel pain or remember it if they did. Denying that babies in the process of being born and thereafter are sentient beings is not a record that I would like to stand behind.

"I notice that you have avoided giving a direct answer to my question: 'It's okay for some babies to die so that a few women can have the birth "experience" that they want?'

"I guess that you do think it is acceptable for some babies to die so their mothers can have the birth 'experience' that they want. You are entitled to your opinion, but I can assure you that most mothers are much more interested in the health of their baby than the quality of their 'experience'."

And you are entitled to yours, but don't impose your value system on my family. That's exactly what laws like the ones in North Carolina that expressly prohibit independent midwives function to do.

I have addressed your question, primarily by pointing out that it is not selfish for women to care about their birth experience, because it affects their babies as much or as more as it affects them. And what if the tremendously creative and empowering process of birth is Nature's ultimate preparation for parenthood? In any case, it seems extraordinarily unwise to routinely mess with that which we have so little understanding. It seems rather short-sided and narrow-minded to systematically deny that the birth experience affects the long-term health and wellbeing of human beings.

"Instead of comparing homebirth at the Farm with hospital birth for low risk women during the same year, they compare homebirth at the Farm with a study of HIGH RISK hospital birth for the same years."

Again, untrue. The Farm birth statistics were not compared to high-risk births. They were compared to 14,033 physician-attended hospital deliveries. It would be even more interesting to see perinatal deaths on The Farm -- at least 9 out of 17 of which would have had the same outcome had they occurred in a hospital -- if the sample size was larger. The lack of an large sample size continually works against homebirth studies.

The study was published in the American Journal of Public Health and here is the abstract:

"Pregnancy outcomes of 1707 women, who enrolled for care between 1971 and 1989 with a home birth service run by lay midwives in rural Tennessee, were compared with outcomes from 14,033 physician- attended hospital deliveries derived from the 1980 US National Natality/National Fetal Mortality Survey. Based on rates of perinatal death, of low 5-minute Apgar scores, of a composite index of labor complications, and of use of assisted delivery, the results suggest that, under certain circumstances, home births attended by lay midwives can be accomplished as safely as, and with less intervention than, physician-attended hospital deliveries."

Furthermore, many women chose to have their babies at The Farm even though they would have automatically been classified as "high-risk," e.g., twins, maternal age over 35, vaginal birth after cesarean, etc.

Ultimately, this is about choice. I don't really care if you agree with the choices of women to have birth at home with direct-entry midwives or not, but I do care if you impinge on the right of others to do so.

Even if you take what in my opinion is the extraordinarily preposterous view that how we come into the world doesn't have an impact on how we interact, learn to trust and function as human beings, that doesn't mean that those who value the birth experience as sacred and beautiful don't hold a perfectly valid opinion to the contrary, and have every right to express that belief in the way they chose to raise their families, starting with conception and birth. The only people seeking to impose their views on others are those who wish to continue to deny families their right to bring children into the world as they see fit. North Carolina is one of the states still in the dark on this subject.

Posted by CharlieL on 06/07/2008 at 7:23 PM

Re: “Midwives seek autonomy in N.C.

"What are you trying to say? It's okay for some babies to die so that a few women can have the birth "experience" that they want?"

This flippant attitude is not only condescending to women, but a huge disservice to their babies. This line of thinking would have us believe that how we come into the world doesn't matter (or that a cascade of medical interventions at times itself doesn't kill babies).

That babies don't have positive or negative experiences and even subconscious memories of their own births that affect them for life. Piles and piles of neuroscience and other areas of research are proving this old way of thinking completely out of step with what we now know about babies' first memories.

For those who are interested, the book Pre-Parenting: Nurturing Your Child From Conception has a great deal to say on this subject. It's written by a doctor: Thomas Verney, M.D.

Also, the DVD What Babies Want is also very worthwhile:

It's really about time that women who chose to have more gentle and nonviolent births, both for themselves and their babies, stop being vilified as selfish and misguided by those who believe routine and unnecessary medical interventions have no consequences for both mother and baby.

It's highly ironic that we treat pregnant women as fragile and helpless -- don't eat anything that may contain bacteria, nevermind that our bodies are a sea of microoganisms, and don't consume any alcohol for fear of damaging the baby -- but we are perfectly willing to pump laboring women full of drugs, pretending that those substances don't reach the baby within moments.

We tell women not to sleep on their stomaches for fear of putting undue pressure on the baby, but then we are perfectly willing to require women to labor supine on their backs, pushing their babies against gravity and through a smaller pelvic opening, for the convenience of doctors and nurses -- only hours later to declare her body unfit for the job, necessitating forceps or a vacuum to remove the baby, and if that fails cutting a hole in her abdomen and depriving that child the experience of being born.

For what? For some stupid hospital rules, under which the vast, vast majority of Certified Nurse Midwives have to practice and were trained under. I'll take my midwife trained by another philosophy entirely, thank you very much.

As for the notion that direct-entry midwives have worse outcomes than CNMs or OBs, I think these statistics from the Farm Midwifery Clinic in Tennessee are relevant. The women included in this statistics represent a pretty good slice of America, as well, as many of those who lived on the Farm were of many races, ages and backgrounds.

Notice that Ina May Gaskin, the founder of the clinic, has no nursing degree. Nonetheless, the outcomes at the Farm should be model for birth in the United States.

Posted by CharlieL on 06/07/2008 at 2:35 PM

Re: “Midwives seek autonomy in N.C.

"Second, direct entry midwives in Holland are midwives who have been through a 3-4 year university based program that includes hospital based experience and training. Dutch midwives have extensive training and experience in the management of complications. Dutch midwives manage their patients in the hospital and at home. If they transfer a patient to the hospital, they can care for them in the hospital." Okay, so we agree on something. Let's create this very same system in the United States. Where midwives can go to school and be taught by other MIDWIVES and learn to practice midwifery, not learning to be lesser-than obstetricians, which is what obstetricians in the United States have repeatedly sought to do instead. Then midwives could practice in the MIDWIFERY model of care outside the purview of obstetricians and be viewed as peers. When there is pathology or a need for surgery, an obstetrician could step in. Otherwise, their roles as midwives would be totally respected and revered.

And YES, please, let's have (independent) midwives have hospital privileges in the United States so they can follow their patients and provide continuity of care. We finally agree on something.

We don't have this system in the United States because our midwives are somehow inferior. We don't have this system in the United States because OBGYN's don't want to have such as system, and they control all the levers of power.

And with regard to the Dutch study, it did, in fact, address the issue of differing levels of risks in the groups. But high-risk or not, a 10-fold increase in bad outcomes says as much about the model of care as it does about the patients.

And let's please stop pretending that the only negative outcomes of traumatic births, regardless of where they occur, is death, as if every alive patient is the same. What does it say about our culture that the vast majority of our children are quite literally born into violence? I was literally ripped out of my mother with forceps. Please don't tell me that's not violence. Oh, and she was strapped to a table on her back, pushing that baby (me) up hill, after multiple drug interventions were literally forced on her, many of which are known to slow progress (epidurals) and to stress babies (Pitocin).

If we want to create a culture that reveres life, we have to start with birth. Revering life means more than everybody lives. Regardless of what we do, some babies are going to die. I am most concerned about how the vast majority who live (regardless of where they are born) come into the world and eventually function in our society. We are not doing that well.

Posted by CharlieL on 06/06/2008 at 7:12 PM

Re: “Midwives seek autonomy in N.C.

Because homebirth is so rare in the U.S., I think it's wise to look to other countries where it is more common, and thus have greater sample sizes, for guidance. So I am going to just type word-for-word the abstract of a study of homebirths attended by direct-entry midwives in Holland, as it appeared in Obstetrical Myths Versus Research Realities :

{My note. Quotes denote original text of the study. Brackets all included by author of book.}

Tew M and Damstra-Wijmenga SMI. Safest birth attendants: recent Dutch evidence. Midwifery 1991; 7:55-63

"In all economically developed countries except Holland, maternity care has come to be organised so as to give full effect to the theory that childbirth is always safer if it takes place under the management of obstetricians in a hospital provided with the technological equipment for carrying out interventions in the natural process. It is a remarkable fact that obstetricians have never at any time had valid evidence to support the theory they have so successfully propagated."

In Holland, midwives are autonomous practitioners. They train directly as midwives and are not required to have a prior nursing degree. They are the primary providers of maternity care, and they do not practice under obstetrical supervision. About one-third of the population gives birth at home. This unique situation allows an evaluation of perinatal mortality rate (PMR) by midwife versus obstetrician in a system where obstetricians do not control maternity care. Since high-risk births are transferred to in-hospital obstetric care, the effect of this on the PMR for obstetrician-attended hospital births must be taken into account. Data covered all Dutch births during 1986.

In descending order, the PMR was 18.9 per 1000 for obstetricians in a hospital, 4.5 per 1000 for general practitioners at home, 2.1 per 1000 for midwives in a hospital, and 1.0 per 1000 for midwives at home (p < 0.0005 for adjacent pairs). The same gradient is found for all subgroups of parity and age ranges except for mothers over age 34, where PMRs for midwives did not differ for home versus hospital. The PMR for all obstetricians (hospital) versus all midwives (home or hospital) was 18.9 per 1000 versus 1.5 per 1000 (p < 0.000001). Differences were significant for all gestational ages except below 33 weeks (185.5 per 1000 versus 169.8 per 1000, p < 0.6). At term (> 36 weeks), the PMRs for obstetrician versus midwife were 8.1 per 1000 versus 0.8 per 1000 (p < 0.000001). For the 98.2% of babies born after 32 weeks gestation, PMRs are nearly 12 times lower (11.9 per 1000 versus 1.0 per 1000) for midwife-attended births, and [as shown above] for babies before 32 weeks, place of birth and attendant made no difference. No possible confounding factor can explain the 10-fold difference in PMR for obstetricians versus midwives. "At a stretch" it might account for a three- to four-fold difference. "Indeed, [the data] support the contrary hypothesis, that obstetricians' care actually provokes and adds to the dangers."

Posted by CharlieL on 06/06/2008 at 11:34 AM

Re: “Midwives seek autonomy in N.C.

For those who want to read the scientific research for themselves, presented in an easy-to-read format and heavily referenced, check out Obstetrical Myths Verses Research Realities . The hundreds upon hundreds of studies abstracted in that book demonstrate clearly how little of OB care in the US is actually "evidence-based medicine." There is a section on homebirth, as well as loads of other relevant sections, including: gestational diabetes, breech labor, vaginal births after c-sections, active verses expectant management of labor, postdates, and many others.

Posted by CharlieL on 06/04/2008 at 9:09 PM

Re: “Midwives seek autonomy in N.C.

Much of this discussion has focused on neonatal and fetal mortality. But there is another category of mortality that we are not considering, and there I think the evidence points clearly towards the fact that overuse of medical interventions is killing and maiming women, and making their lives much more difficult. Just this weekend the NYTimes ran an article on insurance companies denying coverage to women who have had a previous cesarean. Insurance companies are tired, rightly, of paying for unnecessary surgeries, and with a third of births in the US now occurring through major abdominal surgery, it's not rocket science to figure out we have a problem. So women are between a rock and a hard place: Their doctors are often pushing them into surgery they don't need (I am leaving out elective c-sections for the moment) and then they can't get insurance.


Unfortunately, not getting insurance may be the least of some families' worries. Ina May Gaskin recently wrote an excellent article for Mothering Magazine (March/April 2008) on the appalling maternal mortality rates in the U.S., and how we are not even counting most of them because states have no uniform and effective way of doing so. Here is a link to the article, but unfortunately you have to be a subscriber (well worth it, it's an amazing magazine):

Here is a summary: ( Here is a quote: "Maternity-care systems in countries with low maternal death rates (the US is not among these) plan for the certainty that some percentage of previously healthy women will be in danger of a late postpartum hemorrhage, uterine or perineal infection, breastfeeding problem, postpartum depression, or some other post-birth complication requiring special attention. These countries -- Australia, England, the Netherlands, New Zealand, Norway, Northern Ireland, Scotland, Sweden, and Wales, to name just a few -- send specially trained nurses to make home visits to new mothers during the first ten days following birth."

It should be noted that virtually the only kind of practitioner who follows this commonsense practice in the United States are midwives.

These countries actually work to prevent postnatal maternal death, in addition to compiling detailed accounts of each one and reports recommending ways to lessen them. The U.S. barely even keeps track of mothers who die after childbirth. The CDC admits that it's maternal death stats are likely underreported by a factor of three, and the U.S. isn't doing that well even with reported numbers.

So U.S. women are given some of the most medicalized births in the world -- and birth interventions are known to drastically increase maternal death, often days or weeks after birth -- then sent home quickly with little to no followup care. Sometimes their babies die in their homes with them, and nobody notices until its too late.

What's wrong with this? And it's is not immaterial that this scenario is exactly the opposite of what happens with midwives, especially homebirth midwives, who routinely do at least one and usually two home visits following birth. Midwives, on average, also help women to have drastically lower rates of the very interventions that are often associated with postnatal maternal death.

And despite the inferences of Dasher from Durham, it is well established that prenatal care attended by midwives lowers rates of preterm birth, low-birthweight babies and other complications such as preeclampsia, regardless of where women under their care give birth.

Even using the CDC's own underreported numbers, the U.S. has 7.5 maternal deaths per 100,000 live births, four times higher than it should be. And there has been no improvement in the U.S. maternal death rate since 1982. These are appalling statistics. The rate of maternal death for black women in the U.S. for 2004 was almost 35 deaths per 100,000. Most countries with rates like that are applying for international aid. And those are the CDC's grossly underreported numbers.

What is wrong with birth in this country?

This article, by a U.S.-trained doctor who spent 15 years as the WHO director of women and children's health, is a start: (

And death and lack of insurance isn't the only problem for women who have unnecessarily complicated labors that land them on the operating table with a c-section (and I say unnecessarily complicated because clinics such as The Farm Midwifery Clinic run by Ina May Gaskin in Tennessee have shockingly low rates of just about every kind of intervention, including c-sections at about a tenth of the national average, with a cross-section of the population) also face problems in the future, including fertility problems and an increased risk of uterine rupture in their next pregnancy.

Complications from c-sections are five times that of vaginal birth (NIH, 1981). Maternal death rates from c-sections are four to five times higher than vaginal birth. C-sections cause far greater rates of bowel problems, future miscarriage and other fertility problems than vaginal birth. Perinatal mortality is also higher in subsequent births, as future babies are statistically born smaller, sooner and sicker.

All of this and maternal death rates are going up in the U.S.

It's worth mentioning too, that the c-section rates tripled before malpractice became the issue it is today. And countries with far less maternal and perinatal mortality rates than ours have c-section rates in the 10 percent range, whereas ours is more than double that in most states and more than triple that in others.

This is a long way of saying that this debate about access to midwifery care isn't just about fetal and neonate deaths. And it's not just about women wanting to have a more pleasurable birth experience for themselves -- a demeaning accusation the American College of Obstetricians and Gynecologists makes in its statement on the subject (

It's also about women. Women dying. Women having a cloud over the rest of their reproductive and sexual lives because of choices that were made for them.

Women should have a choice in what happens to their bodies. Contrary to popular myth, these choices are routinely denied them in hospitals. OBGYNs could stop a lot of the clamoring for homebirth and direct-entry midwives if they would just fix the disaster that hospital birth is for many women and their babies. Regardless, women deserve a choice.

Posted by CharlieL on 06/04/2008 at 3:36 PM

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