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#91 of 116 Old 09-11-2006, 02:34 PM
 
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Originally Posted by eilonwy
I'm curious about the controls for these studies-- were participants matched for age, parity, and other risk factors? Does it take into account that people who choose CNM attended births are not only healthier in general, but more likely to be educated, not only about birth but in general? There are so many factors that would have to be considered in such a study, I'm just curious as to whether or not they were all considered.
Here's the abstract:
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Midwifery care, social and medical risk factors, and birth outcomes in the USA

MF MacDorman and GK Singh
Centers for Disease Control and Prevention, National Center for Health Statistics, Hyattsville, MD 20782, USA.

STUDY OBJECTIVE: To determine if there are significant differences in birth outcomes and survival for infants delivered by certified nurse midwives compared with those delivered by physicians, and whether these differences, if they exist, remain after controlling for sociodemographic and medical risk factors. DESIGN: Logistic regression models were used to examine differences between certified nurse midwife and physician delivered births in infant, neonatal, and postneonatal mortality, and risk of low birthweight after controlling for a variety of social and medical risk factors. Ordinary least squares regression models were used to examine differences in mean birthweight after controlling for the same risk factors. STUDY SETTING: United States. PATIENTS: The study included all singleton, vaginal births at 35-43 weeks gestation delivered either by physicians or certified nurse midwives in the United States in 1991. MAIN RESULTS: After controlling for social and medical risk factors, the risk of experiencing an infant death was 19% lower for certified nurse midwife attended than for physician attended births, the risk of neonatal mortality was 33% lower, and the risk of delivering a low birthweight infant 31% lower. Mean birthweight was 37 grams heavier for the certified nurse midwife attended than for physician attended births. CONCLUSIONS: National data support the findings of previous local studies that certified nurse midwives have excellent birth outcomes. These findings are discussed in light of differences between certified nurse midwives and physicians in prenatal care and labour and delivery care practices. Certified nurse midwives provide a safe and viable alternative to maternity care in the United States, particularly for low to moderate risk women.
So, every birth in the US in the study year was included (born between 35-43 weeks), and social and medical factors were controlled for.

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Well, I ended my last post by saying that it didn't seem logical or reasonable, for doctors to fail to obtain informed consent or to mention risks involved with surgical birth, not by asking for more from this thread.
What makes you think that doctors, unlike everyone else in the world, act logically at all times?

The evidence is pretty clear that low risk women have better outcomes when cared for by midwives. If doctors ONLY cared about patient outcomes, why wouldn't they adopt a midwifery model of care or refer their patients to midwives?
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#92 of 116 Old 09-11-2006, 03:04 PM
 
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Originally Posted by wifeandmom
Those are interesting stats. Were all of the babies in each group from low risk moms experiencing low risk pg?
Yes.
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#93 of 116 Old 09-11-2006, 03:52 PM
 
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Yes, I think the term is "matched pairs," if I remember correctly.

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If he were an OB, I'd fully expect him to section a woman in an instant if he thought baby might be in trouble.
His c/s rate would be astronomical! IME, "trouble" is the fact that the baby is still on the inside of the mother and out of the doctor's control. I don't mean this snarky. It's inherent in the OB's POV. Trouble is so subjective, fortunately for the surgeons. Guess safe is subjective, too.

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It sucks that it's like that, but I would rather a woman have an unnecessary section if the alternative was DH losing his ability to support our family
I know you're not alone. I guess it's all about the "live baby at the end" mentality that discards that what's best for mom is best for baby and vice versa. The mother's experience in birth is just as integral to the birth as the baby's experience.

It's a sad state of affairs that in order to support a practice/family/etc a physician, who has dedicated her/his life to helping others is reduced to minimizing her/his exposure to lawsuits rather than doing what's in the birthing dyad's best interest. But, singing mostly to the choir here

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#94 of 116 Old 09-11-2006, 05:43 PM
 
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Originally Posted by georgia


It's a sad state of affairs that in order to support a practice/family/etc a physician, who has dedicated her/his life to helping others is reduced to minimizing her/his exposure to lawsuits rather than doing what's in the birthing dyad's best interest. But, singing mostly to the choir here
Yep, it sure is, but unfortunately, those are the parameters within which most physicians practice these days.

Like I said earlier, there are things that are done as a matter of routine in anesthetic administration that are likely unnecessary, however, when it's all said and done, should something go wrong, whomever is administering the anesthetic to the patient had darn well better be able to say they followed x, y, z standard of care. It is really beside the point if they happen to agree with it or not, it's the way things are.

One such example is this business of not allowing a woman to even drink water prior to a scheduled section or once the decision to section is made. That comes straight from anesthesia, and it's largely unnecessary to restrict ice chips so long as mom isn't eating pounds of them.

But guess what? It's the conservative approach, it's typical of hospitals across the nation, and a cup of ice can open up a practitioner to a nasty fight should mom end up with pneumonia from aspirating during surgery.

It's miserable being told you can't have ANYTHING by mouth for hours on end, *especially* if your surgery is delayed. But they'd rather you be miserable than take the miniscule risk of aspiration that 'might' have been prevented had they restricted mom to absolutely nothing by mouth.

That one little thing can be enough to raise questions as to whether or not mom received 'adequate' care, and like many other issues, there's no way to go back in time and answer the question of 'Would this have happened regardless?'

There are many such examples in anesthesia, and even more in obstetrics. And when they are paying $100-150K+ PER YEAR for malpractice insurance already, I can hardly blame them for practicing 'defensive' medicine. This didn't happen out of nowhere, and it won't go away on its own.
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#95 of 116 Old 09-11-2006, 06:15 PM
 
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I can hardly blame them for practicing 'defensive' medicine. This didn't happen out of nowhere, and it won't go away on its own.
Right. It will go away when practitioners, patients and/or gov't regulation changes the system as it exists. (Which is not in the best interest of patients, does not provide them with a higher standard of care, and which leads to our abysmal birth outcomes.) The lives of babies and mothers are not expendable -- we cannot just chalk it up to "Well, that's the current climate" and move on, defending medical providers as if they are blameless.
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#96 of 116 Old 09-11-2006, 06:38 PM
 
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Originally Posted by MsElle07
Right. It will go away when practitioners, patients and/or gov't regulation changes the system as it exists. (Which is not in the best interest of patients, does not provide them with a higher standard of care, and which leads to our abysmal birth outcomes.) The lives of babies and mothers are not expendable -- we cannot just chalk it up to "Well, that's the current climate" and move on, defending medical providers as if they are blameless.
Who ever suggested we should just 'move on' and accept things the way they are?

And who said medical providers are 'blameless'?

The only thing I've stated is that I don't blame them for practicing the way they do given the current climate. Heck, many OBs themselves don't agree with the way things are done, but they are stuck between the proverbial rock and hard place if they buck the system, something goes wrong, and mom decides to blame anyone but herself. It happens, and all you have to do is be around for one of your co-workers to face it to see the reality of what can happen to your entire career in an instant.

As an example, we personally know SEVERAL OB's who completely disagree with their inability to attend VBAC attempts, but there is NOTHING they can do about it. Their malpractice carrier refuses to cover them if they attend VBACs. It's not like they can just up and decide one day to say 'I think VBACs are fine and I'm not going to stop attending them, regardless of insurance coverage.' The hospitals won't allow them to do that, and realistically, do you honestly expect them to attend ANY birth with NO malpractice coverage? It's bad enough when your insurance carrier gets slammed for millions of dollars, but if it's YOU personally....yeah, I hope people aren't waiting for THAT day to come.

Do they share some of the blame for where things are today? You bet they do. In the end, though, it really doesn't matter. They have to practice within the realm of reality, not something that is very pretty unfortunately.

Anyhow, I'm really curious as to why a woman desiring a natural birth with no interventions would WANT an OB to deliver her in the first place. Even the most low intervention doc is going to do things you won't likely see in other settings. If you truly don't want an IV, continous monitoring, blah blah blah....why on earth would you go to the hospital in the first place? That makes no sense to me. Kind of like going to a Mexican restaraunt and demanding spaghetti, then being royally pi$$ed off when they tell you that's not what they serve.

Work to change the system...that would be an EXCELLENT plan, however in the meantime, you have to make your birthing choices based on the REALITY of today. And the REALITY is you are not very likely to have a natural, unmedicated, no intervention birth at most hospitals across this country. Right or wrong, it's the way it is, and stomping your feet, demanding instant change to all you disagree with is incredibly unlikely to work, not to mention VERY likely to stress mom out considerably.

Figure out what kind of birth you want, and do it in a place that is most likely to respect those wishes. Doesn't mean we shouldn't advocate for change within the current system, but don't expect instant results.

Maybe I'm too much of a realist.
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#97 of 116 Old 09-11-2006, 07:08 PM
 
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Originally Posted by wifeandmom
Work to change the system...that would be an EXCELLENT plan, however in the meantime, you have to make your birthing choices based on the REALITY of today. And the REALITY is you are not very likely to have a natural, unmedicated, no intervention birth at most hospitals across this country. Right or wrong, it's the way it is, and stomping your feet, demanding instant change to all you disagree with is incredibly unlikely to work, not to mention VERY likely to stress mom out considerably.
I concur. Hospitals are not the place to have intervention free births. I posed a question earlier: why are CNMs able to practice evidence-based medicine and retain their insurance coverage? And why can doctors not to the same?

I am completely sympathetic to the RIDICULOUS malpractice insurance system in this country that dictates how doctors practice in many cases. However, that does not change the bottom line -- that they should be providing the highest possible care for the mom and baby, and the stats are clear that that is not happening.
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#98 of 116 Old 09-11-2006, 09:39 PM
 
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Anyhow, I'm really curious as to why a woman desiring a natural birth with no interventions would WANT an OB to deliver her in the first place. Even the most low intervention doc is going to do things you won't likely see in other settings. If you truly don't want an IV, continous monitoring, blah blah blah....why on earth would you go to the hospital in the first place? That makes no sense to me.
I have to totally agree with you on this. Perhaps it has something to do with your insurance points above. It's what is "covered" or who is on the plan, or what the system dictates? I know from personal experience--I had NO idea what I was up against until after my tremendously interventive and horrible hospital birth. I honestly had NO idea women in the US gave birth outside of hospitals and birthing centers. Ten years ago was the first time I'd even heard of a midwife. For me, so much of it is cultural. We're taught birth is risky, unsafe, painful, horrible, etc....and who does one trust? Doctors! They'll fix it and make it all better.

For me, I think the consent thing has a lot to do with perceived trust. Ten years ago, I would have trusted that any doctor that I was receiving care for would provide me with any information that I would need. Now, I know this to be the most completely naive and potentially dangerous assumption I could have possibly held.

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#99 of 116 Old 09-12-2006, 06:27 PM
 
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I have worked for thirty years to change things; something has to change in the medical community. I was part of a community group that helped fund the first ABC in my town, and the hospital never used it. It was window dressing.

We had funding through B of A. The room was decorated with a rocking chair, a breakaway bed bought and paid for, and the hospital locked it up and threw the key away. This hospital is now the only medical center in the area. The others within 20 miles have closed.

It is so sad to work so very hard only to be totally ignored; what a pathetic statement on our birthing society. I am glad I voted with my feet for my four children's births by never placing them in stirrups and staying home.
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#100 of 116 Old 09-13-2006, 01:04 AM
 
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Originally Posted by MsElle07
I posed a question earlier: why are CNMs able to practice evidence-based medicine and retain their insurance coverage? And why can doctors not to the same?
In some areas, I think that's starting to change for the worse, causing CNMs to have to stop delivering completely. In my area, we used to have multiple CNMs delivering at hospitals, but then someone (not sure if it's the state or the insurance companies, but it seems to be a widespread thing) decided that CNMs needed an OB standing over them telling them what to do. So the CNMs were having to do more OB-like things, plus insurance companies were having to pay for two attendants instead of one (CNM *and* OB). There is now only one CNM still practicing in a hospital here (between 3 hospitals). One of the other ones was known to be pretty good (a friend of mine used her shortly before having a homebirth with my CPM), but the OBs in her practice said she cost too much, plus that last year before they took her off delivering, she wasn't allowed to really be a midwife anyway... she had to be more of an "OB-lite". Now she's still working with that OB practice, but can't do deliveries at all. This all happened around the same time that they started actively prosecuting homebirth midwives (for "practicing nurse midwifery without a license").

Oh, and CNMs can't do homebirths here. Having any trained attendant at a homebirth is illegal (for the attendant, not for the mom). We're working hard to change THAT law though. I'm going out of state to have my out-of-hospital birth. And no, my insurance won't be covering my birth, even though I'll be using a licensed midwife.

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#101 of 116 Old 09-13-2006, 06:54 AM
 
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The situation you described is really sad, Vera. But it's not because CNMs are unable to get insurance coverage -- it's about OBs protecting their territory. In my area, we have a plethora of CNMs, and they deliver in hospitals, birth centers, and at home. However, the OBs have successfully lobbied hospitals to disallow family practice doctors OB admitting priveleges, unless they are under the supervision of an OB. My family practice doctor said that obstetrics was the best part of her practice until these regs went into place, and family docs were unwilling to acquiesce to the new demands. That's not about insurance coverage, though...
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#102 of 116 Old 09-13-2006, 03:05 PM
 
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To: wifeandmom,

Yes, the Mehl Study used low risk women. The point of the Mehl study was to show that women who deliver in the hospital could have better outcomes at home. Each and every one of the women who delivered at the hospital had a counterpart at home matched for age, parity, and other variants; the outcome at home in every situation was better for the mother, proving that women who allow unnecessary intervention into their labors suffer unnecessarily from the cascade of effects of the consequences.

As for women being induced, many women were induced in the 1970s. Most of my contemporaries had inductions. In the 1980s, the ACOG suggested that doctors let up on the number of labor inductions they did; however since we live in an age when everything is scheduled and no one can wait, we are again doing more and more inductions.

In Immaculate Deception, Suzanne Arms had pitocin wafers on her gums to stimulate labor in 1973. If you read her book, little has changed, particularly in the attitude of the medical profession against women.

There is nothing new in medicine. Everything comes and goes as styles and fashions, often with the same basis in fact and science.
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#103 of 116 Old 09-13-2006, 04:47 PM
 
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As for women being induced, many women were induced in the 1970s. Most of my contemporaries had inductions.
Yeah, my mom was induced in 1972 with my brother. She was a few days past her EDD, and she very firmly believes that her doctor wanted to go on vacation. : Thankfully, the labor/delivery was still quick and easy (2.5 hour labor, no pain meds, normal vaginal delivery). She probably would have spontaneously gone into labor in the next few days anyway, so the induction was quite pointless.

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#104 of 116 Old 09-13-2006, 05:01 PM
 
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I was never informed of the risks of a c/s but I knew them of course. I don't remember signing a form, neither does DH, but we did give them verbal permission, I think we said something to the affect "just save our baby" I even told them not to give me an spinal if there was no time just cut me open. But we had a crappy experience and when I was released was not even told how to care for my incision or not lift anything. I'm having a VBAC this time.
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#105 of 116 Old 09-13-2006, 05:42 PM
 
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[QUOTE=doctorjen][...]although I understand that the VBAC rate will no longer be considered as part of the quality measures used to assess hospitals, so probably we won't have to report them much longer. /QUOTE]

Oh my, this is interesting...why would a VBAC rate really not be considered in quality measures? (or am I being naive?) Is this JCAHO?
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#106 of 116 Old 09-13-2006, 06:19 PM
 
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Originally Posted by eilonwy
How is it possible that a doctor who is supposed to be a responsible party could advise/coerce a woman to have a c-section without once mentioning risk to her own health as well as her child's? I'm having a difficult time wrapping my head around it. I thought that our society was too lawsuit-happy to allow anything of the sort to happen; at the very least, wouldn't the doctors want to cover their asses?! They must be aware of the risks involved, why aren't they aware of potential lawsuits? That doesn't make any sense to me. :
With my homebirth transfer, no one discussed c/s risks at the hospital. But, even in active labor, I read the "consent" form. And no risks of c/s were addressed. How do I remember? Well, I took umbrage to "consenting" to students participating in my care, amongst other things, so I very clearly recall crossing the offensive language out. There was no c/s-specific language in it. I came awfully close to having a c/s; had I had one, it would not have been with a full discussion of c/s risks. So yes, it is possible that a doctor would not discuss the risks before surgery in an L&D situation. But I think that the problem is not with individual doctors necessarily acting with malice (I'm sure that there are bad apples--there are in every profession!). I think that the problem is systemic--it is a problem with how the medical/hospital system works. The fact is, it is very likely that when you sign the "consent" form at the hospital, there is no doctor present to ensure that you have been "informed".

Seems that the medical profession is so firmly of the (anecdotal) belief that they won't get sued for the unnecessary c/s that they do not have a healthy fear of litigation over the consequences of those unnecessary c/s. Once women start holding them legally accountable for those unnecessary c/s that cause harm, things might start looking up.
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#107 of 116 Old 09-13-2006, 06:59 PM
 
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Originally Posted by jcchirib
With my homebirth transfer, no one discussed c/s risks at the hospital. But, even in active labor, I read the "consent" form. And no risks of c/s were addressed.
I still have my consent forms here somewhere. I had a vaginal birth, but upon entering the hospital, I was handed vaginal birth consent form and C-section consent form. I didn't sign either one, because I read the forms and it says that the risks had been explained to me, yadda yadda yadda. Well, no one had explained the risks, so I didn't sign until they explained them. The staff apparently forgot about the forms, so that's why I still have them, unsigned. No one ever did explain risks of either type of birth. I did have a vaginal birth, but never consented to it. And this wasn't even a matter of "there's no time". I was there for 4 days before the birth occurred. There was plenty of time to explain risks and get the consent forms from me.

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#108 of 116 Old 09-13-2006, 07:50 PM
 
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Originally Posted by jcchirib
Seems that the medical profession is so firmly of the (anecdotal) belief that they won't get sued for the unnecessary c/s that they do not have a healthy fear of litigation over the consequences of those unnecessary c/s. Once women start holding them legally accountable for those unnecessary c/s that cause harm, things might start looking up.
One of the many problems with this is that it's hard to prove damages if you're okay from a medical standpoint. I can't imagine having to prove I was damaged if somebody on the street cut me open, no matter how well I recovered! But, if it's a doctor, it's different.

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#109 of 116 Old 09-13-2006, 10:12 PM
 
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Doctors consider themselves priests or gods even of the religion of modern medicine, as the late great medical heretic used to say, so how could they be wrong, ever?
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#110 of 116 Old 09-14-2006, 02:59 AM
 
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I signed a consent form for my c/s, but it certainly did not list any risks of the procedure. It was a very general surgery type form. It didn't list any of the risks that I now know today.

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Originally Posted by wifeandmom
Anyhow, I'm really curious as to why a woman desiring a natural birth with no interventions would WANT an OB to deliver her in the first place. Even the most low intervention doc is going to do things you won't likely see in other settings. If you truly don't want an IV, continous monitoring, blah blah blah....why on earth would you go to the hospital in the first place? That makes no sense to me. Kind of like going to a Mexican restaraunt and demanding spaghetti, then being royally pi$$ed off when they tell you that's not what they serve.
Because it's the only option fiscally available to her? There are lots of women out there that do not have health coverage for midwives (CNM or otherwise) or birth centers AND do not have the resources available to be able to go out of that network. How about the underserved areas of the country where midwife/birth center options are not available? How about in states where DEM licensure has been heavily lobbied against by the AMA or the ACOG?

How about the simple fact that the EVERY WOMAN has the LEGAL RIGHT to refuse any procedure (IV, CEFM, etc) and that the EMTLA states that hospitals have to "treat" her.

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Work to change the system...that would be an EXCELLENT plan, however in the meantime, you have to make your birthing choices based on the REALITY of today. And the REALITY is you are not very likely to have a natural, unmedicated, no intervention birth at most hospitals across this country. Right or wrong, it's the way it is, and stomping your feet, demanding instant change to all you disagree with is incredibly unlikely to work, not to mention VERY likely to stress mom out considerably.
It is not the pregnant or laboring woman's job to make the hospitals/nurses/doctors/anesthesiologists job easier. Nor is it her job to "work within the system" or the "reality" of today. Seriously...she is the one paying here, it's her body, and she has the right to demand whatever she wants regardless of a hospital's policy - again, that's her LEGAL RIGHT!

That doesn't mean that women shouldn't be well informed about the birth climate - it certainly will ease any stress she may have when faced with a difficult birthing situation, but she can't wait for the legislature to figure it out or the hospital administration (every doctor's and nurse's favorite scapegoat) to change. She has to work with her particular situation. I for one am not going to say that the only way women can have low-interventive births is by avoiding the hospital - that has got to be the WORST suggestion I have ever seen someone give regarding this issue.

Quote:
Figure out what kind of birth you want, and do it in a place that is most likely to respect those wishes. Doesn't mean we shouldn't advocate for change within the current system, but don't expect instant results.
Why not expect results in your situation? It's YOUR body, it's YOUR baby, and it's YOUR birth - no one should be able to tell you what to do, plain and simple. As individuals we have got to stand up and say ENOUGH!

(Side note: I take issue with a couple of places where you state that the OB "allowed" a mom to do something. If anything, it's the mom who's allowing the doctor to assist her with the birth of her baby.)
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#111 of 116 Old 09-14-2006, 12:15 PM
 
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Originally Posted by pamered_mom
(Side note: I take issue with a couple of places where you state that the OB "allowed" a mom to do something. If anything, it's the mom who's allowing the doctor to assist her with the birth of her baby.)
Amen to that!!!
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#112 of 116 Old 09-14-2006, 02:12 PM
 
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Why would a low risk woman choose an ob?
Here is my situation.
My husband and I got pregnant by accident, we were not planning on having another kid, mostly because we don't have insurance. I managed to qualify (barely) for medicaid. I would like to pay a midwife to deliver me here in KY but they aren't licensed in this state. We also don't have a free standing birth center in my area. So, I can't afford to pay for a home birth MW, there are no CNM's covered in my state, my only option is an OB in a hospital, or UC at home. I don't feel comfortable with that because all of my 3 previous kids have had pretty tight nuchal cords at birth. I even told my OB that if it was up to me I would be at home with a MW and want to be treated that way. Of course she isn't completely on board with that. I have agreed to sign waivers for all the medical procedures I am refusing.

Informed consent is a joke. I told my previous ob's at all three births not to cut me as they picked up the knife to do the episiotomy. All three did it anyway.

Jennifer, mom to Joel , Duncan, Celia, and Aidan. Wife to Nathan.
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#113 of 116 Old 09-15-2006, 04:30 AM
 
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Originally Posted by MsElle07
Right. It will go away when practitioners, patients and/or gov't regulation changes the system as it exists. (Which is not in the best interest of patients, does not provide them with a higher standard of care, and which leads to our abysmal birth outcomes.) The lives of babies and mothers are not expendable -- we cannot just chalk it up to "Well, that's the current climate" and move on, defending medical providers as if they are blameless.




I was so depressed and disheartened by my birthing experience (unwanted unneccessary csection). I am still suffering today. I am enfuriated that my empowerment was stripped from me, that everything that I asked to be done or not done throughout the birth process was ignored. I am not exaggerating when I say my birth plan might as well have been toilet paper.

I think the current birth atmosphere in most hospitals today is absolutely atrocious.

We need OBs who can stand up for what is right.

Mama to my spirited J, and L, my homebirth: baby especially DTaP, MMR (family vax injuries)
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#114 of 116 Old 09-15-2006, 05:21 PM
 
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One change that some hospitals have made is to require women to sign consent forms before her labor begins. This makes sense to me. Another is to have women take an epidural class, which (hopefully, though certainly not always, I'm no fool) can explain the benefits and risks of the epidural procedure. Some hospitals require you to take the class or you don't receive an epidural, which I'm not sure I agree with, but I can understand in theory.

The point is to educate women as much as possible before she's writhing in pain on the bed.

Women have a responsibility to educate themselves, ask questions and figure out what hospital procedure is. Doctors have the responsibility to educate their patients, explain things in plain English and practice according to evidence.

When I work with mothers as a doula, I explain that their parenting responsibilities begin when they find out they're pregnant, NOT when the baby is born. With the Internet and countless books out there, there's a lot of resources available to them, and ignorance is a very poor excuse.

I also agree that our medical culture is not always friendly to informed women and partners, but that's slowly changing. My husband is in med school, and a lot of the students actually LIKE when their patients know what's up. They're genuinely frustrated when their patients don't care, or surrender their power to the physician.

Alison
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#115 of 116 Old 09-24-2006, 10:35 PM
 
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Originally Posted by jennkraig View Post
WI would like to pay a midwife to deliver me here in KY but they aren't licensed in this state.
Are you absolutely sure there are no midwives in KY?

That is amazing because Kentucky was the home of the Frontier Nursing Service http://www.midwives.org/whoweare/fnshistory.shtm. They never lost a mother or baby despite the fact that they were serving an impoverished, malnurished segment of society. What a record!
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#116 of 116 Old 09-24-2006, 10:50 PM
 
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I'm in Louisville, there are CNM's here but no liscenced homebirth midwives. There are homebirth midwives, but they operate kind of extralegally.
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