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What is a Doula?

posted Jun 28, 2014, 9:14 PM by Lisa Baracker

A Guest Blog by Ana Rapoport

Doula : pronounced : "doo-la" A doula is a woman experienced in childbirth who provides continuous physical, emotional, and informational support to the mother before, during and just after childbirth. Doulas can advise laborning women on comfort measures such as breathing, relaxation, massage, movement, and positioning. Doulas do not offer medical diagnoses or advise but may facilitate positive communication between provider and client, helping both partners and providers address and consider the woman's emotional needs, questions, and fears. Doulas respect patient self-determination and do not impose personal values on patients. They follow a code of ethics and are committed to patient confidentiality.Doulas are trained to offer support during c-sections as well as vaginal births.

What is a Doula? Many definitions have been assigned to the word doula. Birth coach, labor assistant, childbirth companion and labor supporter to name a few. In Greek the word doula means woman caregiver. Today’s doulas are a combination of all these different definitions, in some ways the actions of these women are the definitions and they change with every birth. Labor and giving birth is a very individual process, there are as many different labors as there are women, therefore a doula brings something different to every woman’s birthing experience depending on the wants and needs of the mother and her partner.

A doula is a non-medical assistant, she does not perform any procedures, medical checks, or make any diagnosis or decisions. Instead she dedicates herself entirely to emotionally and physically supporting the mother, her partner and any other friend or family members present at the birth. A doulas role in a mother’s life usually begins several months prior to the birth of the child. It is during this time that the doula becomes acquainted with the mother and her partner and learns their wants and needs for labor. Furthermore, she becomes familiar with the mothers emotions, preferences and desires. During labor, the doula will assist the mother through every contraction using breathing exercises, different body positions, visualizations, verbal encouragement or simply through her presence. Consistent aspects of a doula’s role include: “Providing specific labor support skills, techniques, and strategies. Offering guidance and encouragement to laboring mothers and their families. Building a team relationship with nursing staff. Encouraging communication between patient and medical caregivers. Assisting mothers to cover gaps in their care” (Gilliland p.2). According to The Doula Book, by Klaus et al., the most important thing that a doula can do for a mother is reassure her that she will be with her the whole time.

In recent years research has started to show that the presence of a doula decreases the need for pharmaceuticals, assisted deliveries and Cesarean sections. A recent couples study done in Clevland with 555 couples showed that the couples supported by a doula showed a statistically significant decrease in Cesarean section and mothers choosing an epidural. With no doula’s the percent of C-sections was 22.5 and 76.8% rate of epidurals. Couples that did have the continuous support of a doula had C-section rate of 14.2% and an epidural rate of 67.6% (Klaus et al. p. 79). Another more extensive study done in Houston Texas showed that the presence of a doula decreased length of labor, use of oxytocin, maternal fever and Cesarean deliveries while increasing the amount of natural vaginal births. Length of labor for women with a doula decreased from 9.4 hours to 7.4 hours, use of oxytocin decreased form 44% to 17% and forceps deliveries decreased from 26% to 8%. Furthermore rate of cesarean decreased from 18% to 8% and maternal fever decreased from 10% to 1%. The number of mothers that had natural vaginal births was 116 out of 212 for women with a doula and 23 out of 204 for women without a doula (Klaus et al. p.83-89).

Other studies have also been done to look at the effects of a doula on the mothers and infants well being postpartum. A study done in Jahonnesburg showed that six weeks after delivery women who had a doula were more likely to be breast-feeding exclusively, demand feeding and experiencing few feeding problems. Furthermore mothers reported fewer health problems with the baby compared to mothers who did not have the support of a doula (Klaus et al. p.104-105).

In addition a doula often serves to bridge the gap that often exists between the mother and the medical staff. Sometimes the mother is restricted in her choices for a medical professional whether by insurance or medical issues and a doula helps to provide familiarity and support as well as a link between the professional and non-professional world (Gilliland p.1). A doula can form an amazing team with the obstetric nurses, who often have the desire but not the time to dedicate their full attention to the mother, each bring a very unique skill set to the birth and help make sure that the mother is never alone, scared or unattended to. A doula will encourage the mother to communicate with her care providers and talk to her about the type of questions to ask and how to best make her desires heard and understood by medial professionals without causing conflict. Working on a birth plan can be a big part of this process, helping the parents verbalize there wishes in a respectful and concise manner can greatly ease communication between parents and staff members ( Gilliland p.4-6). During a birth that requires intervention, such as a C-section, the doula, if she is allowed in the operating room, can help the mother understand what is going on during the procedure and reassure her afterword if the baby has to be taken to the nursery. She can stay with the mother while the partner goes with the baby and serve as a messenger between the two places, providing information, pictures and encouragement.

Furthermore, after the birth the doula can facilitate the mothers first moments with the baby whether it is breast-feeding or simply skin-to-skin contact. The doula can help parents write down their birth story and fill in any gaps they may have during that time period or any misconceptions or guilt they may feel. A doula can often reassure the parents about the experience help them understand anything unusual that happened which may have scared the parents or made them feel guilty or discouraged (Gilliland p. 7).

A doula should always maintain a level of professionalism and be able to clearly understand the boundaries of her scope in practice. A Professional Doula should meet certain expectations without overstepping boundaries or pushing her own beliefs. Having this kind of assistance can be a great resource and support system for the parents and, with good communication, a positive asset to hospital staff.

*What is a Doula? is published here with permission from from Ana Rapoport

On The Road Again...

posted Jun 19, 2012, 9:37 AM by Catherine Walters   [ updated Oct 5, 2012, 2:20 PM by Lisa Baracker ]

As I  pack and prepare for another summer road trip  (traveling east to our mountain lake home in WV) I can't help but reflect on the first 6 months of 2012.
This was not only a period of growth for our practice, but for me personally, as well. Never in my wildest dreams did I envision being in this place at this phase of my life - what an adventure!

When I first dove into the Doula world I thought I knew a lot about women and birth, based on accumulated knowledge from my nursing background and personal experiences. Since then I have had the honor of sharing in the wondrous birth journeys of so many amazing, diverse women + partners; the more "experienced" I became, the more I realized how much more I had to learn. Every birth brings something new to cherish and explore.

So - I became a student for the first time in over 30 years, enrolling in the Lamaze "Passion for Birth" childbirth educator classes and the "Heart & Hands" advanced midwifery /intensives course
taught by the world renowned, Elizabeth Davis. I had homework, research papers, exams - and an older brain! But - I made it though and now feel confident that I am even a better Doula, more empowered - just like the mama's we support.

I will miss being with our current clients as they become parents this summer, but look forward to returning and meeting your beautiful babies! You are in good hands.
See you in September! xo

(6/19/2012)

Disparities in Home Birth

posted Jan 17, 2012, 6:10 PM by Lisa Baracker   [ updated Mar 7, 2013, 3:12 PM ]

I present to you one of my MPH writing assignments for Health Disparities & Community Organizing which I completed with Felicia Dunlap in the Fall of 2011.


Disparities in Home Birth: The Status of Home Birth in the US

by: Lisa Baracker & Felicia Dunlap

Touro University California


Abstract

This paper highlights the state of home birth disparities in the United States. It seeks to explore the reasons that home birth is not as main stream as evidence suggests that it could be among women who have low-risk pregnancies. The paper focuses on 5 key issues in home birth, each with a resounding need for change. Considering the culture of birth in the US, socioeconomic disparities among home birthers, insurance coverage gaps, issues with public policy and current legal struggles within the US maternity system as a starting point for change, this paper outlines several recommendations to alleviate the disparities that are currently impeding the progress towards safer home birth in the US. Inherent in the US maternity system, as it exists today, there is a fuming war between physicians and midwives; hospitals and home birthers, and all sides are dead set in their convictions for their way of birthing. This paper aims to bring forth yet another reason to find common ground when it comes to birth; the people for whom this debate is having the greatest impact, pregnant women and their babies.

Keywords: Home Birth, Midwives, Maternal Health, Culture, SES, Insurance, Law & Policy, United States


Introduction

Since the beginning of mammalian colonization of the earth, human women have given birth at their most frequent place of rest: their home. With the modernization of medicine at the end of the 19th century, childbirth inevitably followed the migration of healthcare out of the home and into the hospital. This movement was advantageous at first; many babies who otherwise would have had a mortal birth outcome were able to receive the medical intervention they needed. However, this movement has led to the almost complete abandonment of the practice of giving birth at home. As a result, childbirth in the United States has been unnecessarily medicalized, private and public policies are often unfavorable to home birth, and women who do seek out a home birth option are often self-selected to be older and more educated, as well as have many other advantages that are unrepresentative of the general population. In this composition, we will seek to establish that the medicalization of childbirth has led to serious consequences such as unnecessary interventions and a perception that childbirth is a dangerous sickness. We will explore the policies of both private and public institutions that sanction practitioners for attending home births, such as denial of admitting privileges to the extreme of criminal prosecutions in some states. Finally, we will look at the demographics of women who choose home birth, specifically the disproportionately low number of minority women of lower socioeconomic status choosing this method of childbirth when it would be beneficial and is actually covered by public health insurance programs.


Literature Review

US Birth Culture & Home Birth:

At the turn of the 20th century, 95% of childbirths occurred primarily at home, and by 1955, this number was down to fewer than 1% of all births in the US (Shepherd, 2011). In this 50-year period, several very significant things happened. First, was the slander and criminalization of midwives, the primary attendants of home birth (Wagner, 2009). Second, the propagation of the belief that the only “safe place to give birth” was in a hospital (ACOG Committee on OB Practice, 2011). Lastly, the introduction of interventions such as forceps, fetal monitors, vacuum extractors, epidurals and pitocin which helped shape the idea of childbirth as an illness that needs to be treated in a controlled hospital environment as opposed to a natural process (Gibson, 2011).

Since the 1970’s, the desire to give birth naturally, and without intervention, has been gaining popularity in American culture. Yet in the hospital, where almost 98% of US women give birth, the use of protocols that are antithetical to the normal physiological birth process continues (Wagner, 2009). In the hospital, a woman’s body is seen as a “defective machine,” and there is a universal premise that if a laboring woman is monitored with better “diagnostic machines” then birth will be safer (Davis-Floyd, et al., 1996). Doctors, Midwives and Nurses in hospital settings spend the majority of their time interpreting the line graphs that are continuously running from fetal monitors despite countless studies which have proven that continuous fetal monitoring does not result in improved birth outcomes. Providers also routinely employ practices and procedures which the Coalition for Improving Maternity Services (CIMS) has outlined as unsupported by scientific evidence (CIMS, 1996). By routinely inserting IV’s for all labor & delivery admissions, asking women to lie on their backs when they are pushing out their babies (Davis-Floyd, 1990 & 1994) and not allowing women the choice to labor and birth submerged in water (Cluett, et al. 2004), hospitals and the providers that work in hospitals undermine normal physiological birth. Most women are aggressively monitored, screened and tested throughout pregnancy and childbirth and give birth to their babies hooked up to no less than 7 medical devices (Block, 2008). All of these practices are a part of the routines of many labor & deliver units in the US, which CIMS has shown are out-dated and are due to routinized care rather than mother-centered evidence-based care (Angood, et al., 2010). 

In a healthy population, normal labor that respects the physiological process of birth without interventions is a single contiguous biological process that is not dominated by an air of anxiety (Gibson 2011). Are pregnant women submitting themselves to a presumably oppressive and dehumanizing obstetric care system (Tanassi, 2004)? With a full range of choices available to women, it appears as though there is a gap between the authoritative knowledge of the provider and the intuition of the pregnant mother that is detrimental to providing quality care to laboring women. In fact, many women in the US acquiesce to their providers requests to use biomedical interventions to facilitate successful delivery of their babies (Browner, 1996) and hence the obstetrical rituals of power and self-interest that pose a major barrier to quality childbirth care continue with no end to these practices on the horizon (Reiger, 2011). And hence, women are turning to home birth.

There are many driving factors for the women and families who are choosing home birth outside of the hospital, and a desire to give birth without medical interventions or pain medications is right at the top of that list (Mayo Clinic Staff, 2011). Since Obstetricians attend 90% of all births in the US, compared to 75% midwifery attendance in all other industrialized countries (Wagner, 2009), it’s not coincidental that women have to look outside of the hospital to find midwives to attend their births. The American College of Nurse Midwives (ACNM Board of Directors, 2005) and the American Public Health Association (APHA, 2001) have policy statements supporting the practice of planned out-of-hospital birth in select populations of women. One study in 2005 even showed that planned home birth had similar intrapartum and neonatal mortality rates as low-risk hospital birth (Johnson, 2005). Yet still the social stigma associated with home birthers can be seen as the reason for the disparity within the community (Gibson, 2011). 

Home Birth SES Disparities:

Prior to 1976, African American women and White women experienced childbirth in vastly different ways due to segregation in the south creating separate labor & delivery wards for pregnant women; African American women giving birth had better outcomes than White women because they were supported through physiological childbirth (Gibson, 2011). However, by 1976 hospitals began using the medical model of care on all labor & delivery patients regardless of race, and ever since then the maternal mortality rate has been going up, especially in women of color (Amnesty, 2010). Socioeconomic status (SES) has had a direct impact on women of color and low-income women. SES originally impacted access to hospital birth, because women of color and low-income women couldn’t afford to pay for it (Pérez, 2011), but today the opposite is true. 

Hospital birth is wide spread among women of lower SES, due to changes in Medicaid covered services, while home birth access is virtually unavailable in most cases due to financial constraints and little to no insurance coverage for home birth. As it turns out, 1 in 98 White women are giving birth at home; compared to 1 in 357 black women and 1 in 500 Hispanic women (Shepherd, 2011). Those women who do chose home birth are typically older at the time of pregnancy, have the means to pay out-of-pocket for their midwives and tend to have attained higher levels education (Pérez, 2009). 

Insurance Coverage for Home Birth:

Home birth services generally are not covered by insurance, except where required by law. In the states where services are covered, practitioners and patients alike often find themselves fighting with adjusters who try every excuse possible to avoid following through with their financial obligations (Piard et al., 2011). In states where coverage is not legislated, families who opt for a home birth are required to cover the midwives’ fee entirely on their own. According to the website What It Costs, the average fee for a home birth with a midwife is $4,400. Here in northern California, the average is $4,200 (Barcelo, 2011). Obviously, the lack of will of our current insurance system to pay for home birth plays a big part in the SES of women self-selecting into home birth.

Lack of insurance coverage both drives women towards home birth and bars them from it. According to the editorial Parturition: Places and Priorities, in 1984, about 25% of all home births in the United States occurred in Texas, “with state sources reporting these as mainly births to Mexican nationals or immigrants attended by lay midwives” (Pearse, 1987). Some states require that women have a signed proof from a doctor that they are pregnant before the woman is eligible to have her prenatal services covered through their state Medicaid program (Amnesty, 2010). Both of these situations can result in a woman giving birth at home, most likely with an unskilled or poorly skilled attendant. In states that provide presumptive eligibility Medicaid to women suspected of being pregnant, a woman who desires a home birth often cannot find a home birth provider that Medicaid will reimburse. 

Another factor affecting women’s access to home birth is the policy of most insurers. Those who cover childbirth, typically only reimburse certain healthcare professionals for childbirth services; those covered are usually either a physician, or a Certified Nurse Midwife (CNM). Since most of these professionals work primarily in hospitals, women are once again financially pushed towards a hospital delivery.

Most home births are attended by midwives who have one of the other three midwifery designations as a Certified Professional Midwife (CPM), a Lay Midwife (LM), or a Certified Midwife (CM). Unfortunately, neither Medicaid nor private insurance will pay for the services of any other midwife except those designated as a CNM (Pérez, 2011), those who have additional training as nurses on top of their midwifery training.

Policy Issues in Home Birth: 

It is no secret to anyone who has worked in healthcare that the “birth center”, or labor & delivery unit, of a hospital is one of their largest income generators. According to the documentary, “Pregnant in America”, about 66% of hospital revenues come from childbirth services, making the hospital birth the largest moneymaker for hospital corporations (Buonagurio, 2008). 

One tactic that hospitals use to limit the practice of home birth is by threatening to revoke the admitting privileges of childbirth practitioners who attend home births (Annas, 1988). Such practices are still endemic in our current hospital system. Interviews with practitioners who are associated with Alta Bates Regional Medical Center report being required to sign an agreement not to attend home births, lest they lose their admitting privileges. According to George Annas, lawyer and public health expert, such agreements have dubious legal grounding: 

“It has nothing directly to do with in-hospital care and therefore can make no pretext about being for the safety of hospital patients. As to non-hospital patients, the hospital has no legitimate concern with their free exercise of the legal option of home birth. The only interest it seems to have is economic; and if the attempt is to join in a conspiracy to restrain trade in home births, the activity might also be challenged under anti-trust laws. Finally, the promulgating authority seems ambiguous... and summary revocation of privileges is inconsistent with the doctrine that staff qualifications must not only be ‘reasonably related to the operation of the hospital,’ but also ‘fairly administered’.” 

In the event that a transfer to a hospital is needed for a planned home birth, the attitudes of the hospital staff can vary depending on hospital policies, the staff’s experience with home birth transfers, and the culture of the hospital work environment. According to a feed on the website www.allnurses.com, nurses themselves even find great variation. One feed participant, using the screen name ‘motherwise’, describes her various experiences as a practitioner in the maternity care system. Now a labor and delivery nurse, she was once a licensed midwife in Washington State and had experiences that represented both spectra of handling by hospital staff, including one where the attitudes of the emergency room staff obstructed appropriate care for a patient: 

“She [the mother] started to push at which time I made a comment to the doctor that she was going to deliver quickly. She [the doctor] gave me a dirty look and turned away. At just that time the woman pushed and baby fell into the garbage...The staff spoke poorly of me and my abilities even though I had made a quick decision to transport and they had dropped the baby” (Motherwise, 2007).

Of course it is hard to ignore the institutional bias for medicalized childbirth. In the documentary, Pregnant in America, the documentarian, Steve Buonagurio, conducts a parking lot interview with a young anesthesiologist outside the hospital to discuss the use of painkillers and epidurals during childbirth. When Steve mentions that he and his wife were not only planning a natural childbirth, but a home birth, the negative, visceral reaction from the anesthesiologist was almost palatable. “Home birth is dangerous.” says the anesthesiologist. When asked why, the doctor responds with the typical claim that birth is unpredictable, and can go badly very quickly. He does not mention that most complications start hours before they become critical, and a well-trained home birth midwife will catch the problem and take steps to remedy it or transfer to a hospital (Wickham, 1999). 

Home Birth’s Legal Struggles:

According to the Midwives Alliance of North American (MANA), CNM’s are the only midwives that are allowed to attend home births in every state in the union. CPM’s, CM’s, and LM’s are criminalized in ten states, and unregulated in fifteen states (MANA, 2011). Since most CNM’s work in hospitals, it can be difficult to find a home birth provider in states where lay midwives are criminalized. This criminalization of home birth midwives has driven many parents and practitioners underground in their attempt to avoid a hospital birth. This underground status of home birth in these states only serves to make the practice dangerous in such states as it discourages practitioners from calling for help if a complication arises that needs medical intervention.

Although the American Medical Association (AMA) and American College of Obstetrics and Gynecology (ACOG) both formally discourage home birth, not all physicians subscribe to such thinking, and there even those who would readily back up midwives performing home births, or even perform home births themselves if the barriers weren’t so great. “Unfortunately, many midwives who perform home births are not able to procure the required supervisory physician. This is because insurance companies are hesitant to provide coverage to doctors who agree to back-up or supervise midwives for home births” (Harmon, 2001).

Since it is such a challenge for midwives to find a physician who is willing to sign on as a backup, midwife organizations in states that have this requirement have been fighting to change state law. In 2000, midwife organizations successfully lobbied the California legislature to sign SB-1479, an Amendment to the Licensed Midwifery Practice Act of 1993. This bill removed the previous physician-supervisor requirement for midwives in California, allowing them to be care providers in their own right (Harmon, 2001).

Despite the oftentimes contentious relationship between physicians and midwives, the truth about the midwife model of maternity care is that it does not work without successful and respectful collaboration between midwives and physicians. “"Public health experts and researchers are recognizing that midwifery will not disturb the system of obstetrics. Instead, international research indicates that the two professions are compatible, complementary, and necessary to each other for an efficient and cost-effective system of care" (Harmon, 2001).


Discussion

With all of the interventions occurring in US hospitals, it’s no wonder that there is a group of pregnant women who wish to stop giving birth in hospitals. Trust and respect of birth as a physiological process is very difficult to find amongst providers who attend birth in the hospital setting. Coincidentally, it is also hard to find providers in the hospital who are supportive of, or have seen many, normal physiological births that are without interventions and occur spontaneously without the disturbance of the medical system. Our current medical model dictates relieving symptoms and providing treatments for any conditions that deviate from the patient’s baseline. Trying to fit pregnancy and childbirth into the medical model is like trying to fit a round peg into a square hole. Birth is a natural process, and for a model used exclusively to treat disease, birth is a conundrum. There is an inherent risk in life, and birth is one of those risks. But it is a risk that a woman’s body is naturally prepared for.

One reason for choosing home birth that is prevalent among the community is the desire to have informed consent and egalitarianism between the family and their care provider, which is diametrically opposite to the informed persuasion and authoritarianism of the hospital and its doctors. In hospitals, broad consent documents, including anesthesia and c-section consent forms, are commonly signed as soon as you are admitted to labor & delivery. In home birth settings the midwife comes to the family’s home, and thus, egalitarianism is set-up from the beginning of the client-provider relationship; the midwife has birth-specific information to share with the mother and family to help guide their decisions and the mother is treated as the expert on her body and pregnancy from the intuitive perspective. Informed consent in home birth doesn’t merely include the benefits and risk, but also the alternatives, the mother’s intuition and the option of doing nothing and waiting for nature to take its course as long as the mother and baby’s safety are not in question. The ladder is almost universally unacceptable in hospital birth settings. In fact, some home birthers have had previous traumatic birth experiences at hospitals attended by doctors and wish to give birth guided by their intuition with midwives. Home birth midwives spend time with their clients and are not influenced by the policies of the hospitals, and they do not use medical interventions to hurry the labor process along. Even hospital midwifes or “medwifes,” as Marsden Wagner, MD has coined them, are more likely to use interventions to aide in the facilitation of childbirth in the hospital than are midwives attending home births. In home birth, pregnancy, labor and delivery are not the disease that the medical model sees them as.

Home birth is the subject of ongoing controversy. Most families who chose to birth at home are treated like outsiders by their peers. Home birthers do not see birth as a medical event like the 98% of women who are giving birth in hospitals in the US. Home birthers question the authority that doctors purport to have over nature. And in the US, women have a lot of reasons to believe that home birth is not the rebellious choice that the maternity system makes it out to be. “Home births attended by lay midwives can be accomplished as safely as, and with less intervention than, physician-attended hospital deliveries” (Duran, 1992). Just look at the Netherlands, they are a developed country with a much higher rate of home birth than the US. About 30% of women give birth at home in the Netherlands, attended by a midwife, and their maternal and infant mortality rates are lower than in the US (Declerq, et al., 2011). A 2009 study concluded that in a group of 529,688 low-risk labor & delivery patients, over 60% of whom planned to give birth at home, “planning a home birth does not increase the risk of perinatal mortality and severe perinatal morbidity (de Jonge, et al., 2009).” This was a nationwide study. If home birth is this safe in the Netherlands, then what is propelling US women into the hospital to birth their babies? The answer is almost always socioeconomic status.

On the surface, self-selection appears to be playing a huge role into or out of home birth. However, home birthers are not only a self-selecting population of women, but a population of woman who can afford the price tag. With the cost of a home birth midwife averaging at around $4,200 in the California, SES further isolates women of color and low-income women from being able to exercise this birth option safely. Regardless of race, women who chose home birth in the US must have the means to pay for a midwife to attend their birth or birth unassisted because insurance simply doesn’t pay for home birth at rates that make it accessible to women of lower SES. This is not the only disparity that appears in home birth.

The reality is that over the course of over a hundred years midwives were hunted like witches and forced to practice midwifery underground. Hospitals took the reins of labor & delivery and asserted themselves as the safest place to give birth, with doctors at the helm. First hospital birth was only available to white women. Then women of color could give birth in the hospital, but weren’t allowed to use pain medication or even labor on the same floor as the white women (Gibson, 2011). It was during this time that the last of the higher proportion of good birth outcomes for African American women were probably recorded. As soon as ‘all persons were being treated equal without regard to race,’ maternal and infant mortality rates started going up. This was in 1972. African American women now had the right to use pain medication and use it they did. Who could blame them? But the atmosphere of support of physiological labor went away as quick as the pain medications for labor took hold. When Medicaid began covering labor & delivery and other pregnancy related services, the fate of “where” women of color and low-income women would give birth was sealed: they would birth in the hospital.

To make a change in the “where” women of color and low-income women give birth will take a substantial effort, especially when considering the numbers. For each African American woman that gives birth at home 3.5 white women give birth at home. For each Hispanic woman that gives birth at home 5 times as many white women give birth at home (the statistics of other ethnic groups were not available). This phenomenon does not happen because only white women know about home birth; there are a multitude of factors in play here. Can women of lower SES afford home birth? No. Does insurance cover home birth? Not really. Are women of lower SES respected in their healthcare decisions regarding pregnancy? Not usually. Does the medical system who put women of color and low-income women in the hospital to birth their babies think that they should be having babies in their “economic situation?” Most of these things never come up in the debate about home birth, but they are at the crux of the matter.

It is always a challenge to convince medical insurance companies to pay for services that they have previously excluded, but reimbursement for home birth has been an especially difficult one. Currently, insurers only cover home birth in states where they are legislated to do so, and most will only cover home births attended by a CNM (Piard et al., 2011). Given that CNM’s generally practice in hospitals (Harmon, 2001); this often results in a financial conundrum and a legal one as well. The Patient Protection and Affordable Care Act of 2010, while expanding Medicaid coverage to millions of Americans, fell short by only extending coverage of midwife services to those births occurring in birth centers run by licensed midwives (Pérez, 2011). When pushed about denying payment of services for home birth, most insurers will cite the economically motivated guidelines of ACOG that recommend the hospital as the safest place to give birth, as well as studies from Washington state and Australia that show “a higher risk of births that occur at home for women who have had complicated pregnancies” (Piard, et al., 2011). However, insurers will conveniently ignore that these same studies find home birth a suitable option for uncomplicated pregnancies (Piard, et al., 2011). The driving force behind the United States for-profit health insurance industry is their bottom line. The theme that stood out the most from our review of the literature is that home birth is a safe, cost-effective alternative for women presenting with a low-risk pregnancy. While data and dollars pile up, politicians and insurance CEO’s will be looking for ways to cut costs in healthcare, and policies will eventually come into line with the known safety, quality, and affordability of the midwife model of maternity care. 

While insurers drag their feet on paying for home birth, the archaic policies of our birthing institutions also play a pivotal role in women’s access to home birth providers. Hospitals often refuse admitting privileges to lay midwives, and we have discovered that some hospitals even go so far as to require their in-house nurse midwives to sign agreements not to attend home births, lest they lose their own admitting privileges. “The ACOG and the AMA policies prohibit physicians from collaborating with CPM’s, which contributes to the hostility, and which may in fact contribute to a birth outcome that's worse than if a woman's choice had been supported and the midwife and physician had been encouraged to collaborate” (Block, 2009). It is institutional policies such as these that block women from seeking home birth, and limit providers available for home birth. However, the literature makes legal arguments for challenging such policies. One such argument is that a hospital has no right to try and control their staff’s interactions with non-hospital patients (Annas, 1988).

Currently, ten states criminalize the practice of midwifery, except for CNM’s (MANA, 2011). Such laws drive the practice underground in those states, endangering the lives of the women and babies who chose to deliver at home. Although politicians uphold such laws based on the inaccurate assumption that home birth is unsafe, the simple existence of such laws create risk and unsafe situations for pregnant women. In the states where lay midwifery is legal, there is no regulation in thirteen states (MANA, 2011). This also puts women choosing home birth at risk as it doesn’t allow women to be fully informed about their chosen lay midwife, and her official history in those states. Through our research, it has been overwhelmingly clear that laws that outlaw midwifery outright are dangerous and do nothing but harm women who seek the best environment for them to deliver their babies. In places that it is unregulated, midwifery can be a legal gray area that can still present some dangerous situations. Midwifes operate best where they are integrated with the local healthcare system. For example, in Washington State, CPM’s are covered by the Medicaid system, and home deliveries are twice the national average (Pérez, 2011).


Recommendations

Changing the culture of birth in the US is one of the fundamental recommendations that have come to the forefront. In order to even begin to make a dent in the number of hospital vs. home births we must educate people about normal physiological birth. A good start is to encourage media networks to portray birth on current TV, film and related media in a realistic light with consultation from midwives. Portrayals of birth in the media need to include both home and hospital birth so as to show women in the US all the options from a very young age. As well, news media outlets should be regulated to cover home birth with a representative ratio of good outcomes to emergency transfers as continuing to propagate that home birth is dangerous is disingenuous and slanderous.

Changing the way we educate women with regards to childbirth is another recommendation that must be implemented in order to bring about change in US birth culture. Currently, childbirth education, while occasionally offered for free at the local hospital, is an out-of-pocket expense for women that is not covered by insurance. We suggest that insurance coverage for thorough childbirth education provided outside of the hospital by a certified childbirth educator be mandated. This will increase the knowledge base of pregnant women in the US and will aid in the re-building of an oral-tradition in childbirth, which has long-since been replaced by birth horror stories. In addition to mandated insurance coverage for education, we acknowledge the need for mandated insurance coverage for doula/childbirth support services and lactation support. With coverage for these key support services, US women will build confidence over time to birth outside of the hospital and eventually at home. 

While the US is transitioning towards having a home birth rate closer to that of the Netherlands 30%, women will still be birthing in the hospital. Therefore, more research into the efficacy of water birth in the hospital is needed and we suggest that this might be one area of childbirth that a randomized controlled trial might prove ethical. Incentives for midwifery education that are equal to those available to physicians are also needed. Not just for CNM’s, but for all types of entry into the field of midwifery. While women can birth with a midwife in the hospital, the majority, about 90%, still birth with physicians and some hospitals do not even have midwives on staff. As such, broad consent forms in labor & delivery units must be eliminated to encourage informed consent between patient and provider for every intervention suggested. Hospitals would also do well to hire doulas to work on their labor & delivery units in order to provide the much needed support that is required for normal physiological labor. 

In order for women to call forth their power to birth in a normal physiological manner, childbirth education must start before women are pregnant or capable of becoming pregnant. This goes back to the media’s portrayal of pregnancy and childbirth as something “easy” or “scary,” and also as an over-medicalized event in a woman’s life. Childbirth can be both of those things, but it’s not that way for everyone or for every situation. For this reason, we recommend challenging these “cultural norms” as early as middle school and high school by mandating childbirth education provided as a part of sex education by a certified childbirth educator. If this education is provided at these critical ages in public schools and includes detailed education regarding home birth and home birth practices as the new “cultural norm,” this education will become a powerful tool for women of lower SES to empower themselves to demand change in the system that keeps them from birthing at home in the first place.

The recommendation for more education programs for young mothers about home birth must be coupled with legislation to prevent physicians from maintaining their dominant control over the population of women who are on Medicaid in the US. The federal governments should therefore make changes to the Medicaid law to mandate that all low risk pregnant women be assigned to a midwife during pregnancy. In addition to this, Medicaid should restrict claim payments to doctors whose low risk patients have not seen a midwife during their pregnancy. These two actions will send a message to the US maternity system; enough is enough. No longer will physicians be handed an entire population of already marginalized women to treat; these women will instead be cared for by midwives and only transfer to a physicians care if their pregnancy becomes high risk. 

Once American society catches onto the safety and affordability of home birth, the next barrier in the way will be insurance. Finding the money to pay for home birth will continue to affect women of lower SES so long as the insurance industry is allowed to deny claims for home birth. Since private insurance usually follows suit after government insurance programs start paying for a service, the first step in this arena would be to mandate that Medicaid cover home birth services the same way that they cover hospital birth services. This would also help to eliminate the perception of home birth as an “outsiders” choice.

We have known for quite a while that the reimbursement system in this country for medical services rendered needs to be fixed. In no other place is this more pervasive than in birth care. In our current pay-for-service system, doctors are reimbursed more for deliveries via c-section than they are for vaginal deliveries. Since c-sections are more predictable and offer physicians more control (and money!), it is no wonder that our cesarean section rate is around 30%. Our recommendation in fixing this issue is to change the pay-for-service system, and offer providers one lump sum for maternity care, regardless of the birth ends up at home or in the hospital. If the birth does end up in the hospital, the midwife should be given reimbursement for the prenatal care and labor support provided before hospital transfer.

Currently, only CNM’s, and CPM’s in some states, are able to take insurance, especially Medicaid. This disparity is a key factor in the accessibility of home birth, especially to poor women and women of color. By requiring all midwives, including lay midwives, be paid by insurers, we would be able to greatly expand the accessibility of badly needed prenatal and postpartum care. Such a change would start to work towards bringing the demographics of women choosing home birth more in line with that of the general population.

One aspect of home birth that is essential to it being a safe alternative for low-risk women is its integration into the local healthcare system. Our current hospital system often reacts with outright hostility towards home birth midwives, including refusing to give formal backup to home birth midwives. Such policies are yet another hindrance towards preserving the continuity of care for home birth patients who find they need to transfer to a hospital. After the transfer to a hospital, currently patients suddenly find that their midwife is no longer the practitioner helping her make decisions. In some instances, hospitals will not allow a home birth midwife to accompany her transfer into the hospital. Such restrictions only lead to more distress and harm for the mother and baby. It would be wise to include lay midwives in the continued care of home birth transfers.

 One tactic that we have explored that hospitals have tried to use to stamp out home birth is that of requiring the CNM’s and physicians employed by them sign an agreement not to attend home births lest they lose their hospital admitting privileges. While such an agreement has been deemed to be of dubious legal grounding, a legislative mandate solidifying the illegality of such a requirement would strengthen the home birth movement.

The most obvious legal change to increase home birth would be to legalize all midwifery in all fifty states and set up national standards and licensing. Such a mandate would bring more trust and credibility to the profession. As it stands right now, most midwives cannot afford the price of malpractice insurance. In fact, most lay midwives cannot even get a policy. To remedy this problem, it would be necessary to require that the underwriters of malpractice insurance follow the risk/benefit analysis when writing policies for midwives, as multiple studies show that for low-risk women home and hospital births are equally safe options. Another aspect of the malpractice insurance field that needs to be reformed is the practice of blocking physicians from providing back up to home birth midwives. This is usually achieved through threatening to cancel the malpractice insurance policy or sharply increasing the rates. It is time for this to stop as it neither improves patient safety nor reflects the true risks of home birth. 

Another recommendation is that the federal government recognizes midwifery and physician obstetrical practice as independent professions; as opposed to the physician-supervisory model we have today. The midwifery model of care works best when midwives and physicians work in collaboration with one another, freely referring patients to each other’s practices. As doctors refer healthy, low-risk pregnancies to midwives and midwives refer risky pregnancies to physicians a delicate balance can be achieved. Such a model of care would foster egalitarianism between physicians and midwives as well as bring stream-lined efficiency (cost effectiveness!) to maternity care.


Summary

Home birth is a part of healthcare that has been ridiculed and seriously dismantled by the medical establishment over the last 100 years. As a result, childbirth in the United States has been unnecessarily medicalized, but thanks to a backlash against this trend in childbirth, home birth is once again seeing resurgence in modern US birth culture as a safe, cost-effective, holistic birthing option. There are many cultural, institutional and economic obstacles in front of women desiring a home birth, making this birth choice less accessible to women of lower SES. Many women on public health insurance programs, as well as those with private insurance, are not thoroughly informed of their birthing choices. This makes home birthers appear to be an unrepresentative population of older and more educated women who may also have many other advantages that are unrepresentative of the general population. The truth is that private and public policies are often unfavorable to home birth, and women who do not seek out a home birth are simply doing what they are expected to do and fall in line with the US cultural norms with regards to childbirth. 

Changes in the payment structure and reimbursement policies of public and private insurance would help increase all women’s access to home birth. However, the powerful and wealthy hospital lobby sees home birth practitioners as competitors for a share of the birthing market, and often employs policy practices that aim to reassure their 98% share of the market is protected. As home birth midwives make headway in legislation and policy, their importance to the health of our maternity system will become more apparent, and more women will chose their services. With traction growing in all these areas home birth can again be a mainstream choice in US birth culture.


References

  1. ACNM Board of Directors. (2005). American College of Nurse-Midwives Position Statement on Home  Birth. Retrieved November 30, 2011 from: www.midwife.org/siteFiles/position/homeBirth.pdf 
  2. APHA. (2001). Increasing access to out-of-hospital maternity care services through state-regulated and nationally-certified direct-entry midwives. APHA Public Policy Statements, 1948 to present, cumulative. Washington, DC. Retrieved November 30, 2011 from http://mana.org/APHAformatted.pdf 
  3. American College of Obstetricians and Gynecologists Committee on Obstetric Practice. (2011). ACOG Committee opinion No. 476: Planned home birth. Obstetrics & Gynecology. 117(2 Pt 1):425.
  4. Amnesty International. (2010). Deadly Delivery: the Maternal Health Care Crisis In The USA Summary. Retrieved October 10, 2011 from http://www.amnestyusa.org/pdfs/deadlydeliverysummary.pdf
  5. Angood PB, Armstrong EM, Ashton D, Burstin H, Corry MP, Delbanco SF, Fildes B, Fox DM, Gluck 
  6. PA, Gullo SL, Howes J, Jolivet RR, Laube DW, Lynne D, Main E, Markus AR, Mayberry L, Mitchell LV, Ness DL, Nuzum R, Quinlan JD, Sakala C, Salganicoff A. (2010). Blueprint for action: steps toward a high-quality, high-value maternity care system. Womens Health Issues. 20(1 Suppl), S18-49. [Transforming Maternity Care Symposium Steering Committee].
  7. Annas, G. (1988). Judging Medicine. Humana Press.
  8. Barcelo, R. (2011). What It Costs For a Midwife Assisted home birth. What it Costs. Retrieved November 20, 2011 from http://people.whatitcosts.com/midwife-home birth-pg3.htm
  9. Block, J. (2009). Birth wars : Who's really winning the home birth debate. babble.com. Retrieved November 3, 2011, from http://www.babble.com/pregnancy/giving-birth/winning-home birth-debate/
  10. Block, J. (2008). Pushed, the painful truth about childbirth and modern maternity care. Da Capo Press.
  11. Browner, C. H. and Press, N. (1996). The Production of Authoritative Knowledge in American Prenatal Care. Medical Anthropology Quarterly. 10(2), 141-156. 
  12. Buonagurio, S. (Writer/Director) (2008). Pregnant in America: A Nation’s Miscarriage [Documentary]. United States: Intention Media. Retrieved November 12, 2011 from www.netflix.com 
  13. CIMS (1996). Mother-Friendly Childbirth Initiative: The First Consensus Initiative of the Coalition for Improving Maternity Services. Coalition for Improving Maternity Services. Retrieved October 4, 2011, from http://www.motherfriendly.org/MFCI 
  14. Cluett, E. R., Nikodem, V. C., McCandlish , R. E., & Burns, E. E. (2004). Immersion in water in pregnancy, labour and birth. Cochrane Database Syst Rev.
  15. Davis-Floyd, R.E., and Davis, E. (1996). Intuition as Authoritative Knowledge in Midwifery and home birth. Medical Anthropology Quarterly. 10(2), 237-269
  16. Davis-Floyd, R.E. (1994). The Rituals of American Hospital Birth. Conformity and Conflict: Readings in Cultural Anthropology, 8th ed. 323-340. Harper Collins. Retrieved November 5, 2011, from http://davis-floyd.com/the-rituals-of-american-hospital-birth/ 
  17. Davis-Floyd, R.E. (1990). The role of obstetrical rituals in the resolution of cultural anomaly. Social Science & Medicine, 31(2), 175-189
  18. de Jonge, A., van der Goes, B., Ravelli, A., Amelink-Verburg, M., Mol, B., Nijhuis, J., Bennebroek Gravenhorst, J., Buitendijk, S.E. (2009). Perinatal mortality and morbidity in a nationwide cohort of 529 688 low-risk planned home and hospital births. BJOG. Retrieved October 13, 2011, from: http://www.internationalmidwives.org/Portals/5/Home%20Birth%20-%20Netherlands%20-%202009%20BJOG.pdf
  19. Declerq E and Stotland, N.E. (2011). Planned home birth. UpToDate 19.3. Retrieved October 16, 2011 from http://www.uptodate.com/home/index.html
  20. Duran, A.M. (1992). The safety of home birth: the farm study. American Journal of Public Health. 82(3), 450-453.
  21. Gibson, F. (2011). Traveling Through Time to Normal Birth. Birth: Issues in Perinatal Care. 38 (3), 266-268.
  22. Harmon, J. (2001). Statutory Regulations of Midwives: A Study of California Law. William and Mary Journal of Women and the Law. Retrieved November 7, 2011 from: http://scholarship.law.wm.edu/cgi/viewcontent.cgi?article=1200&context=wmjowl
  23. Johnson K.C. and Daviss, BA. (2005). Outcomes of planned home births with certified professional midwives: Large prospective study in North America. BMJ, 330(1). Retrieved October 10, 2011 from http://www.bmj.com/highwire/filestream/367006/field_highwire_article_pdf/0.pdf
  24. MANA. (2011). Direct Entry Midwifery State-by-State Legal Status. Midwives Alliance of North America. Retrieved October 28, 2011 from: http://mana.org/statechart.html 
  25. Mayo Clinic Staff. (2011). Home birth: Know the pros and cons. Mayo Clinic: Labor and delivery, postpartum care. Retrieved November 16, 2011 from http://www.mayoclinic.com/health/home-birth/MY01713 
  26. Motherwise. (2007). RE: How do you treat home birth transfers? [Online forum comment]. Allnurses.com. Retrieved October 28, 2011 from http://allnurses.com/ob-gyn-nursing/how-do-you-202909-page3.html 
  27. Pearse, W. (1987). Paturation: Places and Priorities. American Journal of Public Health. 77, 923-4. Retrieved October 12, 2011 from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1647254/?page=1
  28. Pérez, M.Z. (2011). Home Birth Is Safer, Cheaper and Can End Disparities in Moms Dying. Color Lines: News For Action. Retrieved October 11, 2011 from http://colorlines.com/archives/2011/04/childbirth_care_and_access_to_midwives.html?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+racewireblog+%28ColorLines%29 
  29. Pérez, M.Z. (2009). The Cost of Being Born at Home. RH Reality Check: Reproductive & Sexual Health and Justice. Retrieved November 15, 2011 from http://www.rhrealitycheck.org/blog/2009/03/19/the-cost-being-born-at-home 
  30. Piard,M. , Stockman, M. Insurance Coverage for Home Birth: A Laborious Process. Inside Home Birth. Retrieved October 29, 2011 from: http://web.jrn.columbia.edu/newmedia/2008/masters/birth/insuranceindustry.html
  31. Reiger, K.M. (2011). 'Knights' or 'Knaves'? Public Policy, Professional Power, and Reforming Maternity Services. Health Care for Women International. 32(1), 2-22.
  32. Shepherd, R. (2011). Home Births Rise A Whopping 20%. Medical News Today. Retrieved October 16, 2011 from http://www.medicalnewstoday.com/articles/235523.php 
  33. Tanassi, L.M. (2004). Compliance as strategy: the importance of personalised relations in obstetric practice. Social Science & Medicine, 59(10), 2053-2069.
  34. Wagner, M. (2009). Born in the USA, how a broken maternity system must be fixed to put women and infants first. Berkeley: Univ of California Press.

First Assist

posted Jan 11, 2012, 10:49 AM by Lisa Baracker   [ updated Jan 11, 2012, 10:49 AM ]

It's funny how things just land in your lap, don't you think?  There I was talking to another student at school, when the midwife I work with at a local birth center calls me and texts me to see if I can come assist at a birth later that day. "Sure," I say thinking that would be a fun thing to do tonight.  I have waited for this day to come for so long, that I had forgotten that it could even happen.  So, I get some lunch and go to a postpartum visit with one of my amazing families.  Going about my day like nothing is really any different.  I was surprised about the lack of nerves I was experiencing.  After getting deep into conversation about how to maximize the amount of sleep to new parents can get while caring for their brand new baby, I get a phone call from the birth center that they need me to head on over.  Such is the life of a doula/midwife assistant, I'm always on call and it seems like every time I make plans with friends, family or even clients, I get called away to a birth.  This is especially true when I really want to hang out with someone special like my husband.

So, I explain to my clients that I will need to come back in a few days to finish up with our conversations because duty calls.  They are excited for me and now I am really excited too.  I'm going to assist!  Right now, not tomorrow, yay!  This is going to be fun.  I love birth, truly I do.  I get into the car and call my husband to let him know that I won't be home tonight.  I had to leave a message, which was sad, because I really wanted to tell him in person.  He's going to miss a very important networking mixer tonight and I felt bad.  Why can't babies come when things aren't planned?  Sigh.

I get to the birth center to find mama in the birthing tub moaning and groaning and was immediately put to task charting heart tones, getting more drinking water and reheating her rice sock.  Everything looks great.  Papa is in the tub supporting mama on one side, with her doula on the other.  The head midwife was nearby watching and tells me that she thinks that she's almost complete, the student midwife looks back at me and smiles mouthing the words...  "she's doing so awesome!" 

The she being referred to was the mom, and awesome is right; she was working so hard and doing fantastically. She didn't complain of pain , she just took each contraction one at a time smiling in between.  Just then, she wanted to get out of the tub and was grunting the familiar sounds of pushing.  The room was filled with a new energy.  The mom was wondering when her water would break, which was an awesome moment for me because rarely do I see a mom get to complete in the hospital without the doctors and midwives wanting to break the water and speed things along.  This mom had intact water and was complete and feeling strong urges to push.  I wondered why the mom had come out of "labor land" to inquire about her membranes?  The head midwife indicated that there was really no need to break them and that they would probably break on their own after just a few pushes.  Mom wanted her midwife to break her membranes, she was ready to have her baby.  Her midwife commented on how the mom probably knew it was time.

When the midwife checked on the mom's next push the membranes broke easily and there was a tiny bit of meconium.  This is something that we would normally transfer a mom and baby to the hospital for , but the baby was very low and doing very well.  The midwife talked to the mom about how she had to work really hard to get the baby out, so that we didn't have to transfer her to the hospital and mom nodded her head in agreement.  She didn't want to go anywhere, she just wanted to push her baby out. 

The next 90 minutes were full of intensity.  I charted, while the student midwife took heart tones and the lead midwife gave perineal support. Mom got into her pushing rhythm while we supported her every move.  Out of the bed, onto the birth stool, standing up, laying down and finally squatting her baby out with glorious relief!  The lead midwife hadn't even gotten her new gloves on before the baby came slipping out! The tears and kisses commenced between mom and dad just as their new baby received a little suction to keep her from swallowing meconium.  It was an amazing sight... there I was holding this new precious life in my hands to that she wouldn't wiggle around too much while being suctioned.  I dried her off with blanket after blanket and soon she let out a cry.  

It was an amazing experience, one that I won't forget any time soon.

Pregnancy & Childbirth Education Policy

posted Jul 27, 2011, 5:44 PM by Lisa Baracker   [ updated Jan 11, 2012, 10:53 AM ]

I present to you one of my MPH writing assignments for Health Policy & Management Class which I completed in the Summer of 2011.


Expanding & Adjusting CPSP: A National Policy Proposal

OVERVIEW: The current health care system in the US has a significant black hole when it comes to the care of pregnant women and their babies; physicians tend to utilize the medical model of wait and see rather than the midwifery model of prevent, educate and inform. This is a serious gap in prenatal coverage, which needs to be bridged, so that pregnant women are not treated as diseased but rather accompanied on a journey. Besides, when is comes to pregnancy what is there to treat? Is pregnancy a disease?  The answer is a resounding no. Pregnancy is a normal event in the life cycle of a woman.[i], [ii], [iii] In order for women and their babies to be safe in pregnancy and labor, egalitarianism needs to invade the practices of all care providers in the US, so that shared decision making with pregnant women is the norm.[iv]  In order to accomplish this, pregnancy & childbirth education needs to be offered to all women regardless of their ability to pay and qualified educators need autonomy and monetary incentives to provide such education.

PROBLEM: Quality childbirth education is usually provided by private childbirth educators at a cost to pregnant women and is unattainable by low-income women. “Traditional ways of passing information about birth from generation to generation: storytelling, woman-to-woman support, and making birth part of everyday life by using analogies that help women make connections with what they already know”[v] have gone by the way side leaving women scared and anxious about their pregnancies and about childbirth.  These women usually end up going to childbirth classes at the hospital where they are giving birth because those classes are free, but which are not comprehensive and whose pedagogy is wrought with information about how to be a patient at the hospital rather than information about healthy pregnancy, labor and birth. Comprehensive childbirth classes that teach physiological normal birth are essential to healthy birth outcomes.  These classes should be 10-13 weeks in length and should cover not only normal birth, but also medical interventions, healthy pregnancy, breastfeeding and the postpartum period. When physicians spend prenatal appointments looking for risk diagnoses rather than educating women about pregnancy and childbirth, pregnancy becomes a risky business rather than a normal part of life.  Through childbirth education, women are empowered to become engaged the decision-making process[vi] with their care providers. Pregnancy is not something to be diagnosed; however, in the US providing care in an egalitarian manner is almost universally not the norm. Pregnant women look to care providers to guide them through their pregnancy, but the reality is that most care providers are not able to be with women during every moment of their pregnancy, labor and birth, so education is a must-have to mitigate further deleterious effects on pregnancy outcomes. Recently attendance in childbirth classes has dropped5, [vii] and this puts women at even further risk for complications during pregnancy and labor. “The problems of contemporary birth, including the standard “intervention-intensive” labor and issues related to litigation and patient choice, should not be an excuse for our failures.”5 We must act now to make comprehensive childbirth education available to all pregnant women.

ALTERNATIVE POLICY: The state of California implemented the Comprehensive Perinatal Services Program (CPSP) in 1987 which aims to “decrease the incidence of low birth weight in infants, improve the outcome of every pregnancy, give every baby a healthy start in life and lower health care costs by preventing catastrophic illness in infants and children.”[viii] Such a program is an excellent model for a national policy to provide reimbursement for childbirth education to qualified childbirth educators. CPSP has notoriously been restrictive; allowing reimbursement only for ICEA, Lamaze and Bradley certified childbirth educators,[ix] if and only if they are practicing under a Medicaid Provider, such as a physician or midwife.  This presents an obstacle because most certified childbirth educators operate autonomously and are not supervised by a Medicaid Provider. “The childbirth educator is also a professional in a core position to play an active role as a change agent in the system through evaluation and dissemination of information.”[x] We need to let the providers be the providers and the educators be the educators. California is one of the only states to have a program such as CPSP and the program provides reimbursement for childbirth education; however, expanding CPSP on a national level is a necessary step to making prevention based prenatal care a reality. 

IMPACT: Self-actualization, health responsibility, exercise, nutrition, and interpersonal support[xi] are just a few of the quality improvements associated with childbirth education.  If childbirth education alone can improve these five areas then why is unbiased childbirth education for low-income pregnant women still not available? Expanding CPSP to all 50 states will make quality childbirth education available to all women.  But before implementing a national CPSP, it needs to be adjusted to allow more autonomy among childbirth educators to increase participation and routes to reimbursement via Medicaid.  National adoption of a revised CPSP will change the way pregnant women approach their pregnancies and childbirth.  Many more pregnant women will have access to quality childbirth preparation, not just in California, but across the US. The evidence is clear; most hospital-based classes are inadequate and provide little preparation to pregnant women in comparison to private childbirth education. The cost of implementing CPSP nationwide with adjustments for educator autonomy is minimal in comparison to the cost savings of improving prenatal prevention through quality pregnancy and childbirth education offerings.  The reduction in intervention alone will be astounding when women have access to quality education during pregnancy. This will lead to healthier outcomes for moms and babies, which is the over-reaching goal of the Coalition for Improving Maternity Services’ Mother Friendly Childbirth Initiative.[xii]

CONCLUSION Healthy pregnancy and childbirth education is essential to improving childbirth outcomes because it normalizes many of the fears and anxieties that women have allowing them to feel less anxious during pregnancy and childbirth.[xiii] This prevention strategy alone is a paradigm shift that will elevate the role of women during pregnancy. It will empower women to make sound informed decisions about the care they receive during pregnancy and childbirth. It will change the landscape of the US maternity system.



[i] Davis, E. Women’s Sexual Passages: Finding Pleasure and Intimacy at Every Stage of Life. 1st Ed. Alameda. Hunter House. 2000.

 

[ii] Gaskin, Ina May. Spiritual Midwifery. 4th Ed. Summertown. The Book Publishing Co. 1975-2002.

 

[iii] Gaskin, Ina May. Ina May’s Guide to Childbirth. 1st Ed.US. New York. Bantam. 2003.

 

[iv] Transforming Maternity Care Vision Team, Carter MC, Corry M, Delbanco S, Foster
TC, Friedland R, Gabel R, Gipson T, Jolivet RR, Main E, Sakala C, Simkin P,
Simpson KR. 2020 vision for a high-quality, high-value maternity care system. Womens Health Issues. 2010 Jan-Feb;20(1 Suppl):S7-17. Comment in J Midwifery Womens Health. 2010 Jul;55(4):392-3.

 

[v] Judith A. Lothian, PhD, RN, LCCE, FACCE. Selling Normal Birth: Six Ways to Make Birth Easier. J Perinat Educ. 2007 Summer; 16(3): 44–46.

 

[vi] Simpson KR, Newman G, Chirino OR. Patients' perspectives on the role of prepared childbirth education in decision making regarding elective labor induction. J Perinat Educ. 2010 Summer;19(3):21-32.
 
[vii] Jolivet RR, Corry MP. Steps toward innovative childbirth education: selected strategies from the blueprint for action. J Perinat Educ. 2010 Summer;19(3):17-20.
 

[viii] Maternal, Child and Adolescent Health (MCAH) Program. Comprehensive Perinatal Services Program (CPSP) Fact Sheet. Accessed via web on 07/01/2011: http://www.cdph.ca.gov/healthinfo/healthyliving/childfamily/Pages/CPSP.aspx.

 

[ix] California Family Health Council, Inc., Comprehensive Perinatal Services Program (CPSP) PROVIDER HANDBOOK. Office of  Perinatal Health, Maternal & Child Health Branch, California Department of Health Services. 1999-2001. Accessed via web on 07/01/2011: http://www.cdph.ca.gov/HealthInfo/healthyliving/childfamily/Documents/MO-CPSP-ProviderHandbook.pdf

 

[x] 12. Philipsen NC. Promoting and implementing evidence-based, best practices in childbirth education. J Perinat Educ. 2004 Summer;13(3):51-4.

 

[xi] Mary L. Koehn, PhD(c), ARNP, LCCE, FACCE. Childbirth Education Outcomes: An Integrative Review of the Literature. J Perinat Educ. 2002 Summer; 11(3): 10–19.

 

[xii] Coalition for Improving Maternity Services. 1500 Sunday Drive, Suite 102. Raleigh, NC 27607. Mother Friendly Childbirth Initivative: The First Consensus Initiative of the Coalition for Improving Maternity Services. 1996. Accessed via web on 07/07/2011: http://www.motherfriendly.org/MFCIb.

 

[xiii] Nolan ML. Information giving and education in pregnancy: a review of qualitative studies. J Perinat Educ. 2009 Fall;18(4):21-30.

 

VBAC Policy Memo

posted Jul 27, 2011, 4:52 PM by Lisa Baracker   [ updated Jan 11, 2012, 10:53 AM ]

I present to you one of my MPH writing assignments for Health Policy & Management Class which I completed in the Summer of 2011.



To: Senator Ed Hernandez, O.D., Chair, Senate Committee on Health
Cc: 
Subject: VBAC Support at Every California Hospital
From: Lisa Baracker, Doula and Birth Advocate, Whatadoula
Date: 23 June 2011

Problem Statement           
California is the most progressive state in terms of healthcare. California’s teaching hospitals and research facilities represent some of the worlds best advances in medicine, its constituents have passed laws allowing access to medical marijuana, and yet California women are still subject to hospital policies that impede their right to birth the way they choose. This is especially true after they have had a previous caesarean section. What’s more shocking is that there are still hospitals in California that are refusing to allow women to attempt Vaginal Birth After Caesarean (VBAC) despite the preponderance of evidence that it is safe for both moms and babies.

Proposed Solution
There is no reason for a limitation on VBAC's at any hospital where women give birth, especially given that "current evidence shows that the majority of women can have safe vaginal births after prior cesareans.” "[1],[2]  Legislation needs to be enacted that requires hospitals who offer birth services to women to also offer VBAC to those women who meet the criteria set forth by the American College of Obstetrics and Gynecologists (ACOG) and widely accepted by the Association of Certified Nurse Midwives (ACNM) and the Midwives Alliance of North America (MANA).  These criteria are very straight forward and simple to assess and now they need to be put into action at an administrative level. "The preponderance of evidence suggests that most patients who have had a low-transverse uterine incision from a previous cesarean delivery and who have no contraindications for vaginal birth are candidates for a trial of labor."[3],[4]

The Criteria for a VBAC:

  • Women who have had one previous cesarean with a low-transverse incision.
  •  Women with a clinically adequate pelvis.
  •  Women with no other uterine scars or previous uterine rupture.
  •  A physician capable of monitoring labor and performing an emergency cesarean should be immediately available throughout active labor.
  •  Anesthesia and personnel for emergency cesarean delivery should be available.

Major Obstacles/Implementation Challenges
Currently, all Hospitals in California that have Labor & Delivery Units are capable of performing scheduled cesareans, emergency cesareans for vaginal deliveries with complications, and are required to have anesthesiologists on call 24 hours a day for emergency surgery.  It is therefore unacceptable that any California Hospital refuse a woman the right to a VBAC to women who meet the aforementioned criteria. The only thing standing in the way of VBAC rights are doctors who refuse to comply with the recommendations of ACOG. Midwifes who offer VBAC services are offering a safe and ethical service to their patients by allowing them a trial of labor after cesarean, yet still hospitals and doctors are limiting this service and clearly this has affected one if not many patients in an adverse, if not wholly improper manner.  Birth is a major life event that significantly impacts a mother's physical and emotional well-being. A cesarean can be a life-saving procedure for a mother and/or her baby, but overall, birth by cesarean puts healthy pregnant women at risk for medical complications.

References, Footnotes, and Exhibits

[1] http://www.vbac.com/

[2] http://www.midwife.org/news.cfm?id=311

[3] Adapted from Vaginal Birth After Previous Cesarean Delivery. ACOG Practice Bulletin, Number 54. The American College of Obstetricians and Gynecologists, 409 12th Street SW, P.O. Box 96920, Washington, DC 20090-6920.

[4] Clinical Management Guidelines for Obstetrician-Gynecologists, July 2004.

 

Are we in the Zoo?

posted Nov 5, 2010, 12:59 PM by Lisa Baracker   [ updated Jul 26, 2017, 11:11 AM ]

When I was in college I took an An

Birth As We Know It

imal Ecology class during my senior summer that was fascinating. We discussed several topics, but the one that always stood out in my mind was Stereotypic Movements in Zoo Animals. These movements are the manifestation of animals being kept in habitats that are not natural to them.  You would never find a tiger pacing at a fence in the wild, because there is no fence in the wild.  You would not find a bear circulating in figure eights in the wild because they would have further to walk then the confines of there zoo habitat.  In fact, the animals in the zoo can rarely be released to the wild because they have all but lost their abilities to be wild animals.  You might be wondering how does this related to birth?  Well, how does it not?

In the US 98% of all pregnant women give birth in hospitals, most of them under the care of an Obstetrician.  These woman are routinely hooked up to an ultrasound device to monitor her baby throughout her labor.  The practice of doing this restricts the woman's movements thus lessening her ability to tolerate pain in most cases.  Can you imagine being trapped within a 6 foot range of a baby monitoring device throughout 12-48 hours in a hospital?  It's not a pretty picture.  A lot of women who I have worked with find that the practice of continuous monitoring is more annoying then anything that they have to deal with during labor.  They ask why are they doing this to me? When can I get off this monitor and get in the bathtub?  These women are listening to their bodies but in most cases are not allowed to listen to their inner voice for more than 45 minutes because they have to be monitored once very hour.  Thus a routine begins; getting a woman in and out of

Business of Being Born Trailer

the bath tub for monitoring because the hospital is not properly equipt to monitor her in the tub (like most home-birth midwives are). 

Now I'm rambling a bit, but here is what I am getting to:  Our system has taken away a woman's ability to be wild and birth her baby intuitively.  Physiologic birth is just not the norm in the hospital.  What do hospital staff do when a woman is in pain during labor?  They offer her pain medicine and epidurals, they tell her that they can make it better and help her.  Why don't they encourage her to feel the labor and listen to her body?  It's almost an impossible task when you think about it because pop culture has been representing hospital birth as the norm for many decades.  This norm needs to be demystified.  Hospitals need to develop evidence based practice and stop using interventions just to keep things moving.  Society is squelching our mother's primal instincts.

If you want to see birth in it's primal form, watch a cat give birth to kittens at home.  If you don't have access to that, watch the Business of Being Born and educate your self about birth in the hospital OR watch Birth As We Know It and see what birth is like when it is given the space to happen without intervention.  And remember, Dr. Huxtable was a doctor on TV played by a comedian Bill Cosby; so just to keep it light, here is what Bill has to say about Natural Childbirth now let's get our woman back in touch with their wild intuition and give birth to their little color changing beings.

Forceps

posted Oct 19, 2010, 2:54 PM by Lisa Baracker   [ updated Jan 11, 2012, 10:54 AM ]

I have always cringed at the used of forceps in childbirth, and I still do, but on Saturday morning I saw a mind-blowing birth.  A mom was laboring very hard to push her baby out and pushed for a very long time.  Something just wasn't working.  This mom was trying for a Vaginal Birth After Cesarean (VBAC) and she was having a lot of pain in her C-section incision scar.  The doctors could have just jumped on it and pushed her into having a C-section, but that wasn't their game plan. 

They were worried about the incision pain that she was having, but they wanted to let her push the baby out on her own.  As much as she tried, she couldn't overcome the pain that she was feeling in her body.  The discussion with the mom turned to options for instrumental delivery assistance and the doctors first choice was to deliver with forceps.  I felt a lump in my throat.  I was very nervous.  I calmed myself down by telling myself that a vaginal birth was possible if she went this route and then she would still have her VBAC.  I knew that the recovery would be better if she had a VBAC, so I supported her through this difficult decision.  When the mom decided to go for it, I was wide-eyed with anticipation.  I was not sure what I was going to see exactly, but I knew that mom was about to have a baby in her arms after more than 21 hours of labor.  It was both nerve-wracking and exciting.

The doctor carefully prepared for the procedure by inserting one side of the forceps at a time.  She placed one carefully next to the right side of the baby's head and the other carefully next to the left side of the baby's head.  With the forceps in place, I was waiting to see the doctor pull the baby out, but that isn't what happened at all. The doctor asked the woman to push with her next few contractions.  She had been pushing for hours, so I didn't see how this was going to work!?!  With me on one leg and her partner on the other we supported her through the next few pushes as the doctor held steady and gentle pressure to bring the babies head down with the pushes!  It wasn't ideal, but what a difference!

Before the forceps, she pushed for hours with hardly any movement; after the forceps, her assisted pushing brought the baby down with ease.  The doctor did not rush and the baby came slowly to the perineum. With the forceps held in place all the way until the baby's head came out, the mom suffered hardly any damage to her perineum.  The doctor didn't even need to cut an episiotomy.

My first experience with forceps has made me realize that training is everything.  This doctor knew exactly what she was doing.  I can only hope that more doctors will be trained as fastidiously as she was and that she will pass her skills on to the doctors of tomorrow.

Experience

posted Jul 14, 2010, 4:18 PM by Lisa Baracker   [ updated Jan 11, 2012, 10:55 AM ]

I was at a birth once where the mother to be was doing an amazing job laboring away, when the hospital staff told us that they had all the experience needed to help her have her baby.  It was sort of out of the blue, but they wanted us (the family and I) to know that they knew what they were doing.  I think that they were trying to reassure the mother that the combined 52-years of experience that they had was going to keep her safe in labor, but I didn't hear it that way at all.  And the question that immediately popped into my head was whose experience is this anyway?  

It doesn't seem to me like the 52 years make one bit of difference if you use them to tell your patients what to do rather than listen to them and what it is that they are asking for.  I think that the mother is the one having the experience and that she should be allowed the space to do so.  I think that the experience of the mother should be protected by the care providers so that the mother doesn't fell like she is just another patient in the assembly line of the Labor & Delivery Department's daily routine.  

Picture this... A mother comes into the hospital to have a baby.  She knows that she is in labor.  She feels the baby as it comes down the birth canal.  She knows when it's time to change positions and when it's time to push.  Her care providers watch her and listen to her as they encourage her through her journey to becoming a mother.  If only this was how it happened.  If only this one experience on this birth day could be held in higher esteem than the egos of the people who care for her once she is in the hospital.  

What would our system look like if it was mother-centered?

Protected = Strong

posted Jul 14, 2010, 9:51 AM by Lisa Baracker   [ updated Jan 11, 2012, 10:55 AM ]

I think that women should be cared for when they are in labor.  I think that means that you should have people around you that protect your birth and care about making sure that you, and thus your experience, will be protected while you are giving birth.  Women are so much stronger than they know.  I hear women everyday tell me that they don't know if they will be able to take the pain.  They just don't know if they can do it.  Well I am here to tell you that you can.  If your circumstances are normal, if your Midwife tells you that you and your baby are healthy and doing great, then you CAN do it.  I know you can.  I see women do it all the time.  I like to think that I can help protect your labor and keep you feeling your strength.  The strength of your contractions is very big, but one at a time they are just hills.  Not the mountain that the whole experience is.

The mountain is within summit to all women if they take it one step at a time.  So read and prepare all that you need or want to, but at some point start taking things one day and one feeling at a time and you will summit the mountain of labor.  You will give birth.  And you will be stronger for doing so.

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