Maybe this is just to big and broad of a discussion for me, or maybe I just don't understand other people. For me, I choose a care provider who I trust and who I believe is knowledgeable. I do my own research and see if our ideas match up. If they differ, I take another look at things and also think about the care provider's reasoning. I pay close attention to how I feel. Do I have any mental or physical concerns? Is my care provider concerned that this method of keeping track of myself could lead to me missing something important? How likely is that thing to happen? What would be the concerns if it did happen? Are there risks to testing/treatment?
None of that has to do with laws. I'm glad there are professional schools, tests, boards, certification, etc. for all care providers. It helps me narrow down the pool of people that I could hire to assist me. But I see a lot of problems when limitations are put on either the provider or the mother. I guess I am on the far end of wanting to be involved in my own care. I wonder if there is a place for me in this discussion.
That said, I am definitely an advocate of OOH birth and feel it is safe, if not safer, than a hospital birth for LOW risk women. For me, that would risk out VBAMC, breech birth, severe anemia, twins, amongst others. I realize this isn't always a popular opinion and absolutely many of the above situations could and do go swimmingly, but as a hypothetical midwife, I wouldn't put myself in that situation. If a client of mine chose to UC instead, that would be her business and not mine.
In my opinion, adequate care for OOH births includes definite assessment of risk and subsequent referral out if necessary, continued monitoring to ensure patient stays low risk (that's a whole other post in itself and definitely a gray area, I will admit), and thorough attentiveness during labor and delivery. I don't have a lot of experience so I am certainly not speaking from a professional standpoint, but only from my limited experience in the HB world.
It's a great topic and I've really enjoyed the answers this far.
I agree with this, but the other side of the coin is taking professional responsibility for taking this type of risk - and this could possibly include being sued for acting outside of a professional scope of practice, or being found negligent and perhaps losing one's license. Sure, the professional should be able to take on these risks, but not without consequence if the outcomes are poor. Actually, the professional should expect to take some heat even if all the outcomes are good. Being a member of a profession should mean something. Taking on a higher-risk client should be a VERY DIFFICULT decision. Not one of whimsy.
Yep. And who's the champion when it's the professional who's "comfortable" taking on a client with certain risk factors? That "comfort level" is a very powerful means of persuasion.
I'm just giving my opinions, I haven't read anyone else's post on the thread yet. I also have no medical training and so am giving my utterly lay opinions on this matter.
- Should risk factors and HB be regulated
It's complicated. People who feel strongly enough about a HB will just UC if they can't find a willing midwife. Which I think indicates a problem with the nature of hospital births that needs to be changed. I've never seen someone feel that strongly because "Well, I just don't care about my/my child(ren)'s well being"- the reason for feeling that strongly is due to things like past birth trauma at the hand of hospitals or the local hospital not offering enough.
I think that people with risk factors, especially multiple risk factors, need to be genuinely educated about the risks so that they can make an informed decision. That, at minimum, should be the case. If a MW genuinely believes that HB is a bad idea, the MW should say so. If the MW doesn't feel able to give the necessary level of care, the MW should say so and not take the person on as a client.
Birth as a whole shouldn't be medicalised. But risk factors- those aren't the body working as it should, then it does get into the realm of medical problems that often need medical solutions.
- What are the ethical considerations when a MW takes a client with risk factors?
I think that taking a client when an MW genuinely believes that HB is unsafe for that person is unethical because it is helping that person to take risks that they should not take.
Taking any client means accepting risks. If the MW doesn't feel adequately prepared to handle the risks, that MW should not take on the client. MWs should also not put undo pressure on people ot HB. Some people have told me that their MW demanded a non-refundable downpayment before the birth- I think that this is ridiculous and puts undo pressure on people to have a HB that they aren't comfortable with. If, in the last few weeks, complications arise or the person just realizes they aren't comfortable with a HB, "but I already put down the downpayment" should feature nowhere in the decision process.
(The MWs I work with told me that, while they do take payment beforehand, it's refundable if you end up not needing them- say due to emergency hospital birth/whatever before they could show up to attend the birth. I think that's a good compromise.)
- Do we consider risk to be on a spectrum? Or would we like to see some hard lines about what is considered risk and what is not?
Yes, it needs to depend on the risk factors and individual case. Some people have loads of risk factors that make a home birth incredibly dangerous. Some people have one mild risk factor. Those two cases can't be treated the same, it needs to be decided on a case by case basis- unfortunately, our system dislikes doing that.
- How does the issue of lack of availability for care options in the hospital impact this issue. For instance, is the lack of availability for VBAC in a local hospital justification for HVBAC?
I definitely think that hospital care is a HUGE impact on this. I've never seen someone who had risk factors say "I don't care about risk factors, I don't care about my or my baby's health"- people who have risk factors and still want to HB very often want to HB because they've done the research, believe they can do things the hospital won't let them (ex. VBAC), so feel that HB is their only option.
Birth trauma from past hospital births also features into this, from what I've seen. Based on the reading I've done on birth trauma, most research indicates that birth trauma comes more from how people are treated than from the specific procedures being done/complications arising/etc. A person who wanted a natural birth and ends up needing an emergency c-section is less likely to feel traumatized if they feel supported, respected, and like their needs were prioritized. A person whose birth went off without any complications or pain may feel traumatized if they felt ignored, disrespected, and like the hospital's convenience was put over their needs. Hospitals need to work on preventing this.
- What role (if any) does choice regarding testing impact risk?
I don't really know.
I know I said I didn't, but I'm actually briefly browsing other responses while reading this,a nd one person talked about how people can't choose to get testing if their MW tells them it's unnecessary or downplays the importance, and that reminded me of what happened to me.
I needed to get a fetal echocardiogram. The OB I'd been working with told me the second he heard about my mother's heart condition that I'd need to get one, that I'd have to go somewhat far away because only one hospital in the state does them, because every child I have has an increased risk of having it. The risk is very small, but the condition is severe enough that HB would be a bad idea, probably life threatening, if my baby had it. I needed to get that echo before I could truly decide to HB.
The midwives I was working with dragged their feet. The first time I mentioned my mother's heart condition I didn't say exactly what it was, but I said I needed an echo and she acted as though I was mistaken, giving a derisive "did the doctor tell you you needed that?". After that response, I tried telling her exactly what it is (it's a technical term that I was still in the process of memorizing, I never asked exactly what it was before I got pregnant), she cut me off and didn't bother listening.
It took over 2 months to get them to agree to let me get the ultrasound, 4 weeks after it's suggested to be done. Very soon after this happened, they posted a link on their facebook group about scaremongering of "ultrasounds might cause autism!" (there weren't even any studies listed, the science behind it was damn weak). I'm not 100% positive, but I really think this is why they pushed me not to get the ultrasound I needed to ensure that my HB wasn't putting my baby in severe danger. I can understand not feeling ultrasounds are necessary when there's no indication that there's a problem- but dragging their feet on allowing someone with my family history to get one? That is not responsible.
....this is probably off topic, just, uh, wanted to share.
- Do you think that a woman choosing HB in the presence of risk factors is primarily driven by the mother or by MWs? What are the ethical implications of this difference?
It really depends. I've mostly seen people choosing to HB in the presence do so before finding an acceptable MW, and only doing so because their OB/hospital wouldn't give them the options they wanted (ex. VBAC), so MWs are not the ONLY driver. In cases where risk factors show up late in the game, I fully believe MWs can be part of the problem.
I think OBs are sometimes part of the problem as well. I really wanted to work with MWs AND an OB throughout the pregnancy just in case. My mom has a heart condition that, if any child of mine inherits it, would make an HB not an option- so, if nothing else, I at least wanted to work with a MW and OB until I was sure that HB was a definite chance. The OBGYN I'd been working with refused to do this, apparently their office is really anti-HB so get offended by the idea that someone will see them for routine prenatal check-ups then give birth at home. They told me straight out that if I requested that my records be sent to the MWs, then they would stop considering me a patient.
At one point in pregnancy, while I was reading about the birthing center at our nearby hospital (VERY nearby, literally 5 minute car ride away), I actually had a moment of "Wow, I think I'd actually be okay giving birth there". The options they had sounded really nice, I'm pretty sure that they're a baby-friendly hospital, etc. But at that point, I was at 35 weeks- even if I found a OB right then, I'd only have been working with them for a few weeks before the birth, I wouldn't have established enough trust. Not that I established enough trust with the MW who actually attended my labor...
I don't know if I would have actually decided to have a hospital birth, but this was definitely a big pressure not to change my mind about the HB. If I had to do a hospital birth- it would have been with complete strangers, not with doctors that I'd been working with and getting to know throughout my pregnancy. That's a terrifying thought for me, and I'm sure many people.
I don't know how common this is- I'm really hoping that the OB I was working with was just a megajerk- but if it's common, that's part of the problem.
- What about consent? Are mothers who choose HB with risk factors given adequate information about HB and risk factors? What would/does this look like?
I don't know if they are, but they need to be. The MW needs to make sure that the person understands the complications and risks. Most people aren't medical doctors, it needs to be laid out in a way that a lay person can understand.
- What do you think about the term "variation of normal"?
I think it has it's place. That doesn't mean it isn't overused.
- How do your own experiences with HB impact your opinion this issue?
I don't think it does, I felt the same way beforehand. MWs, like doctors, vary. Hospitals sometimes push patients to do things that help hte hospital without regard for the patients' needs. MWs sometimes push patients to do things that go with their philosophy without regard for the patients' needs. Both are irresponsible. The only difference is that hospitals usually have the tools on hand so that, when it goes horribly awry, people are less likely to die.
I was frustrated with both sides going into it- the highly medicalized treatment of birth is something I never want to experience, the highly idyllic "nothing ever goes wrong when nature takes its course" is naive at best and deadly when things do go wrong.
I'm frustrated with both sides for what happened with my birth. I'm incredibly upset with the MW who attended my labor, I still hesitate to call what I experienced birth trauma, but it was traumatic. I'm also very upset with the OB for drawing a line in the sand of "Well, if you want to set yourself up for a safe home birth, then I refuse to work with you".
As a midwife the thing I always worry about is how the woman who has just given birth will be able to care for herself and her baby after a blood loss. For some women, it doesn't take a lot of blood loss for them to have trouble getting out of bed. Others can lose what I think is a lot and they seem to be fine. My job as a midwife is to check their hemoglobin (or better a CBC) to be sure it is in a decent range and help them keep it there. The other part of my job is to minimize blood loss after the birth so she can enjoy the baby. We never know how any amount of blood loss will affect any given woman, but we do know that a postpartum hemorrhage can damage the pituitary gland and seriously effect her milk supply, possible never recovering even for another pregnancy and a baby who nurses well.
Always better to err on the side of caution and have a couple of back up plans in case the first line of treatment doesn't work. Having access and knowing when to administer Pitocin, methergine, and cytotec is key, as well as knowing when too much blood loss is too much and transferring in to the hospital.
This happened to me. After reading the thread, I think I had low iron (I was tested at 29 weeks and had been fine, but the week or two before birth I just got horrible in every way- low iron is definitely possible). After the birth, someone I know hw's a nurse and heard what happened kept asking me about my iron/hemoglobin levels. I don't know when/how often people usually test iron, the change probably happened pretty late.
No one had talked to me about iron since the first trimester, though... :/
Proud Formula Feeder, I support how ALL parents feed their babies. Breast or bottle, formula or breastmilk, and any combination thereof.
Happily married since 4/30/2009 Our first was born 4/23/2013
My 6th child is a perfect example. My 5th child was a 35 week preemie. I felt from the get go that his being preemie was the result of stress from a medically over managed pregnancy. I started the pregnancy higher risk due to a sub chorionic hematoma. I was put on bed rest. At 12 weeks I went to the ER for severe vomiting and had been told to go. The ER Dr told me I lost the baby. I was shocked and stunned. The Dr wanted me admitted for a D&C then. My CNMW and I refused. The diagnosis was made based on my HCG dropping 50% in a week. I said but at 12 weeks the placenta takes over and you can see a drop. I was told not that much. Midwife learned an U/S was not done and ordered one ASAP. My baby was fine but my bleed was larger.
20 weeks the bleed was finally gone and my pregnancy was now normal risk!! Yay. Only now I was told since that since I was high risk to start and refused to consent to induction at 37 weeks like the head OB wanted I was not allowed to see the CNMW any more. I stressed and tried to find a home birth midwife (and toyed with a UC) till a migraine due to stress hit at 35 weeks and raised my blood pressure to an unsafe level. I consented to pain meds because of the blood pressure. I did not react properly because as soon as the meds too effect labor started.
So with my 6th child I was confident as long as I could avoid pressure to induce too early and stress from OBs I could go longer. The CNMWs said I had to see an OB because I was over 35, multipar, and had a 35 weeker. I asked if I could transfer to a midwife at 36 weeks. I was told I would be lucky to see 35 weeks pregnant I would never see 36 weeks. I felt with attitudes like that the midwife was right. I switched to an awesome Homebirth midwife whose only concern was would I deliver early and if I did I would have to transfer. Well my baby was born on his EDD.
I was fine the risk factors were ther e but they were not an indication I would have issues.