Everyday life

Looking out the window and waving hello and goodbye to the cars

Our dog, hoping for some attention

The best (and easiest) bread ever:
New York Times No-Knead Bread
(short version of the instructions below, with some commentary from me)

This bread is amazing. It tastes and feels like a sourdough--a chewy inside and a fantastically thick, crunchy crust--but without the need to keep feeding a starter. Mine always die, sooner or later. The secret? A tiny amount of yeast and 15-18 hours of rising/fermenting.

Okay, here's the way I do the bread. Mix together:

• 1 1/2 cups warm water
• 1/4 tsp yeast
• 1 1/2 tsp salt
• 3 1/2 cups flour

The dough will be very, very sticky and almost runny. Cover the bowl with a plastic lid or saran wrap and let rise for 15-18 hours. Or more. It won't hurt it at all. I usually make mine some time in the afternoon or evening.

The next day, once the dough is full of bubbles on the top (it will look like bubbly pancake batter when it is being cooked), stir it a few times to deflate the bubbles. Grease a sheet of parchment paper and sprinkle a generous amount of cornmeal top. Put the dough on top of the paper and place in a shallow, wide bowl (this helps the ball of dough go up and not just out when it rises). Sprinkle the top of the dough with a little more cornmeal to keep it from sticking, and cover with a towel.

Then neglect it for a while: 2-3 hours. I like letting it rise a long time, more than the recommended 2 hours, for extra pouffy-ness.

Put a large cast iron or ceramic dish (one with sides at least 4" tall and that has an oven-proof lid) in the oven at 450. I use a square ceramic dish about 9x9" and 5" tall. Once the dish is nice and hot (give it 20 minutes in the oven), lift the parchment paper & dough up and carefully place it into the dish. Be as gentle as possible so you don't deflate it.

Bake with the cover on for 35 minutes. Take the cover off and bake another 10 minutes.

Why does the bread taste so good and have such an amazingly crunchy crust? The long fermentation gives the dough more flavor and texture. Because the dough is very wet, and because you bake it in a covered pot, it "steams" the bread, replicating very fancy steam ovens that professional bakeries use.

This is really a ridiculously easy way to make bread, once you've done it a few times. The best part is you can forget about it, leave it for way too many hour when it's rising, and it still turns out perfectly almost every time. And no kneading is required!

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First word

It's official! Zari has said her first word: papa. Eric claims it's because she loves him best. I think it's because she is with me most of the day, and I talk to her a lot. In any case, it's pretty cute.

Of course, she has been communicating for a while now via sign language. Her current vocabulary consists of: nurse, water, food/eat, ball, bye & hello, dog, cat, fish, bird, potty, papa, shower, and shoes.

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The perineum

The topic for today is perineums (perinea?). Let's start by reading Sara Wickham's classic articles Perineal pampering - before, during and after birth and Is prevention always the best cure?

There's a great visual example of an upright birth with no one messing around with the perineum from Sage Femme. (It begins after the 3rd or 4th slide and is definitely not work appropriate. Unless, of course, you are a midwife, doula, or childbirth educator!)

So, let's talk perineums!

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Need info on David & Lee Stewart

You know--the NAPSAC people (National Association of Parents and Professionals for Safe Alternatives in Childbirth), author of Five Standards for Safe Childbearing...

Here's what I need: I remember hearing that David & Lee Stewart had home births for their children and that some/all (not sure on this part) were unassisted due to a lack of midwives? Now, I have this really annoying problem of remembering arcane details, but not where I found them. I am trying to document if this actually happened. So far I've had no luck finding out whether or not they did have unassisted home births. I'm revising a chapter for my dissertation and discussing one of the strains of unassisted birth--home birth advocates who wanted to have a midwife but, when none were available, chose to do it alone rather than birth in a hospital. This was the case with Marion Sousa, author of Childbirth at Home. Also with Peggy O'Mara (editor of Mothering). Here's an excerpt from Pushed:

Unassisted birth isn’t new. In the 1960s and 1970s it was often the only alternative to a hospital birth—a strapped down, separated from husband, guaranteed episiotomy birth—and the women who did it also gave birth to organized midwifery. “That’s what we were doing in the 1970s before there were any midwives,” says Peggy O’Mara, editor of Mothering. “It was part of the whole back-to-land movement and commune movement.” It was also a natural extension of the early feminist, grab-a-speculum-and-mirror-and-reclaim-your-body ethos, she said. “And I consider it a really legitimate response to certain environments. Where I lived in southern New Mexico, for instance, the choices were so poor that we just wanted to figure it out ourselves.”...For O’Mara, unassisted birth was the best women could do under the circumstances.

If you think about it, Ina May Gaskin et al started out this way too: they wanted to birth on their own terms, so they just started having babies themselves and learned as they went along.

So...if you have any leads, please pass them my way.

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Anyone writing about UC?

I am working on a section in one of my dissertation chapters about other academics/writers/etc who are currently writing about unassisted birth. This could be a book, a chapter in a book, an article, a thesis or dissertation, etc. If this applies to you or someone you know, please contact me (homebirth.study at gmail.com) so I can mention it in my dissertation. Many thanks!

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Permission to Mother

Dr. Denise Punger, a family physician and IBCLC in Florida, recently published a book called Permission to Mother. She and her husband, an osteopathic physician, work together in a private practice. Her book is available on Amazon and Barnes & Noble, as well as an e-book (only $5!) on her publisher's website. This is definitely going on my wish list!

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More about the Trust Birth Conference!

The Trust Birth Conference is less than a month away! Sagefemme recently wrote about what it means for her to trust birth. It is a powerful look at herself and how she relates to birth.

For those of you who wanted to come, but the cost of the conference was keeping you away, Carla Hartley created a Mommy Track that will allow you to attend many of the sessions at a greatly reduced rate!

If there is no way you can come in person, remember that you can purchase downloads of most of the sessions afterwards! Here is more detailed information from Carla about how to earn download "credits" and other ways to participate in the conference:

If you are absolutely sure you can't join us at The Trust Birth Conference...

...we are so sad that you won’t be with us. I am hoping for a miracle and that everyone who WANTs to come finds a way, as this will not ever ever ever happen again. And this is my last conference and probably my last chance ever to get to meet most of you. So I am still holding out that you can get here. When I was going back and forth and back and forth about going to The Gentle Birth Conference last fall, I kept arguing with myself about the cost and the time, but at the last minute I emailed Barbara and said I will register when I get there and started driving.

I had not been in the Convention Center 10 minutes when I felt my spirit jumping for joy. It was so great to see people I had not seen in years and to meet so many people (some of you) who I only knew by email. I did not get to stay for the whole thing but I can tell you it was one of the best decisions I ever made, even if it was so last minute. Yes, I am still paying that trip off on my credit card but it was SOOOOOOOOOOOOO worth every penny. And I ALMOST didn’t go. I would have hated to miss is. I learned things there I did not expect to learn. I was floating by Saturday night on collective birth wisdom. It was not political, as ours is not political. No one had an ax to grind or an agenda to push. It was just relaxing and invigorating at the same time, as the Trust Birth Conference will be. I am not trying to HOUND anyone. I just don’t want you to miss it is there is any way in the world you can come....

And it was ONE late email from someone about the Gentle Birth Conference that had me say WHY NOT? So I am so glad they sent out another round.

You may not be able to be here but I am SURE you will all be ordering downloads after the conference. We are giving you a way to earn some of those if you help us these last 3 weeks:
For every $100 in value you bring in for us, we will give you a voucher for a session download.

Send us a registration--that is, get a friend to register for the conference ($499) and have her email carla@trustbirth.com saying to give you credit, and we will give you a voucher for 5 downloads. If you get two registrations we will give you double for each subsequent registration. So send 2 registrations and we give you 15 downloads. Send us 3 and we give you 25 downloads...4 for 35 downloads! (This is only valid for those who pay $499 for registration, not retroactive or combinable with any other offers.)

Sell 2 half-page ads ($50 each) for the conference binder and we will give you a voucher for one download.

And get more downloads for other things: For example, if you send us one donor level donation for the Trust Birth Awards dinner at $99 you get one download. If the donor is not able to actually attend the dinner ,we will throw in one more as a compensation. Remember that the donor will have their name and website listed in the congratulatory ad on the back cover of Midwifery Today #86 so for $99 this is a phenomenal offer.

We want 100 Dinner Donors so the ad looks great. We are honoring 10 people; I want them to know that at least 100 people support that! (Right now it is just the Trust Birth Initiative and Lansinoh...don’t you want to be there too?) This is a value packed opportunity for your groups and organizations.

Here is my suggestion for local groups: Get 10 people to pitch in $10, then draw from those 10 names to see who gets the free download/s. This congratulatory back cover ad will be VERY EFFECTIVE for you. If you are a birth-related business or organization, you will never find a place where $99 will work so hard for you as this one. Lots of people will see it who might not ordinarily see Midwifery Today ads as we are framing it for our 10 recipients. This is a phenomenal opportunity to be part of something that will have significant meaning to a lot of people and give your group or business exposure for a long time.

About the dinner: some of the awards are surprises, and some of the honorees won’t be able to be there, but you do know we are honoring Ricki Lake, Dr. John Stevenson and Dr. Michel Odent who are all supposed to be there! Michel is also our keynote speaker: "Dispelling the Disempowering Birth Vocabulary."

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RGOC and RCM on Home Births

Compare the below statement (long but worth reading) from the Royal College of Obstetricians and Gynecologists and the Royal College of Midwives with ACOG's recent statement about home birth. I hope for the day when ACOG can produce a similar document that actually examines the evidence and listens to what women are saying. Imagine what we could achieve if ACOG were an ally to all birthing women!

Home BirthsRCOG and Royal College of Midwives Joint Statement No.2.April 2007

Summary

The Royal College of Midwives (RCM) and the Royal College of Obstetricians and Gynaecologists (RCOG) support home birth for women with uncomplicated pregnancies. There is no reason why home birth should not be offered to women at low risk of complications and it may confer considerable benefits for them and their families. There is ample evidence showing that labouring at home increases a woman’s likelihood of a birth that is both satisfying and safe, with implications for her health and that of her baby.^1–3

1. Introduction

1.1 The rate of home births within the UK remains low at approximately 2%,^4–6 but it is believed that if women had true choice the rate would be around 8–10%.7
1.2 The development of maternity polices over the last four decades, combined with frequent reorganisations of service structure, have impacted on the availability of home birth and have concentrated on births in hospitals.^8–10 Reasons for this appear to include:

• financial constraints
• the values and beliefs of organisations about maternity care
• lack of staff with the appropriate competencies.¹¹

1.3 Throughout this time, women and voluntary organisations have challenged the onedimensional approach to options for place of birth and have influenced the portfolio of evidence now available to support a return to a more diverse range of childbirth environments.^12–15

2. Review of the evidence: benefits and harms

2.1 The review of the diverse evidence available on home birth practice and service provision demonstrates that home birth is a safe option for many women.^2,16,17 However, this is not to define safety in its narrow interpretation as physical safety only but also to acknowledge and encompass issues surrounding emotional and psychological wellbeing. Birth for a woman is a rite of passage and a family life event, as well as being the start of a lifelong relationship with her baby. Home births will not be the choice for every woman.⁷
2.2 Randomised controlled trials to assess the safety of home births are not currently feasible. The observational data available show lower intervention rates and higher maternal satisfaction with planned home birth compared with hospital birth. Overall, the literature shows that women have less pain at home and use less pharmacological pain relief, have lower levels of intervention, more autonomy and increased satisfaction.^1,12,18–20 The studied interventions included induction, augmentation, perineal trauma and episiotomy, instrumental delivery and caesarean section. These are not insignificant interventions and may have considerable impact on a woman’s long-term health and emergent relationship with her baby, as well as her satisfaction with her birth experience.
2.3 Furthermore, the studies into women’s descriptions of home birth experiences have produced qualitative data on increased sense of control, empowerment and self esteem, and an overwhelming preference for home birth.^3,21–27
2.4 A distinction needs to be made between women who plan for a home birth and those who have an unintended home birth, as unintended home births or women who received no antenatal care are linked to a higher rate of both maternal and perinatal complications.²⁰
2.5 A proportion of women who plan a home birth are transferred to hospital,^9,13,14,19 most commonly for slow progress or needing pain relief not available at home, such as epidural anaesthesia. The most serious reasons for transfer are maternal haemorrhage, concerns about fetal wellbeing and the neonate born in an unexpectedly poor condition. Delay in transfer under these circumstances may have serious consequences. Owing to poor collection of maternity data, the comparative statistics for women being transferred in labour are unclear. Higher transfer rates are associated with nulliparity.^13,14,19,28 The discussion with women regarding their potential transfer in labour should include consideration of the distance between birth settings and of other local circumstances which may introduce delay in transfer.

3. Achieving best practice

3.1 Both the RCM and the RCOG believe that to achieve best practice within home birth services it is necessary that organisations’ systems and structures are built to fully support this service. These will include developing a shared philosophy, fostering a service culture of reciprocal valuing of all birth environments.
3.2 Comprehensive involvement by local multidisciplinary teams and users to underpin home birth practices within a clinical governance framework results in a quality service which demonstrates commitment to supporting women in their choices.^4–6 Equally, it supports the development of responsible and responsive practices that are maintained by effective clinical decision making.

4. Provision of information, informed choice and user involvement in planning the services

4.1 The key principles include providing unbiased information on birth environment options and being transparent about the potential advantages or disadvantages of home birth.^14,29–33 Written information regarding place of birth should be available for all women, all women should be encouraged to participate actively in the full range of antenatal care and women can make the choice for a particular place of birth at any stage in pregnancy.¹⁴
4.2 The support for women’s choices is linked to clinical assessments during pregnancy and labour, to update the care pathway.¹² It is acknowledged that there are no known risk assessment tools which have an effective predictive value concerning outcomes in the antenatal period and labour.^34,35
4.3 Home birth provision should take into account women’s individual needs, especially women from socially excluded, disadvantaged and minority backgrounds,^4,36–38 as they are less likely to access services or to ask for home births
4.4 The involvement of fathers/partners in planning and attending home birth is encouraged as pregnancy and birth are the first major opportunities to engage fathers/partners in the appropriate care and upbringing of their children.⁴

5. Continuity and communication

5.1 Continuing communication between health professionals, women and their families is requisite for continuity of care. ‘A midwife providing care to women, regardless of the setting, must take care to identify possible risk and pre plan to mitigate those risks through her approach to care, knowledge of local help systems and communication with colleagues and the woman and her family’.¹⁵ Planned referral pathways in pregnancy are designed to facilitate effective communication and feedback at all levels and with any agency involved in providing care.
5.2 UK maternity policies recognise that, for the majority of women, pregnancy and childbirth are normal life events and that promoting women’s experience of having choice and control in childbirth can have a significant effect on children’s healthy development.^4–6 The improved relationships built upon continuity of care and carer can lead to considerable advantages in the promotion of breastfeeding, reduction in smoking in pregnancy and improved nutrition for women.
5.3 Continuity of care is a complex concept as it can mean continuity of care from a team of midwives or continuity of carer by a single known midwife. Organisations need to explore ways of promoting home births within these care schemes, especially for socially excluded women.^36–39
5.4 Another aspect in ensuring effective communication is clear and detailed documentation of the care plan for home birth.^32,36

6. Service structure support

6.1 The recent recruitment and retention problems of midwives within the maternity services have led to some NHS trusts withdrawing home birth services or informing women at the last minute that staff are not available. For women to believe throughout their pregnancy that they will have a home birth and for this option to be withdrawn late in pregnancy or in labour is not acceptable and will lead to further pressure on labour wards and midwives, as they have to manage women who are disaffected by the service at the start of their labour. Any possibility of not being able to provide the service should be highlighted in early pregnancy.
6.2 It is essential that formal local multidisciplinary arrangements are in place for emergency situations, including transfer in labour and midwives referring directly to the most senior obstetrician on the labour ward and/or to the paediatrician. The midwife is responsible for transfer and must remain to care both for the woman and the baby during transfer and, where possible, continuing on in the transferred unit. These protocols need to encompass the independent practitioners providing home birth service. The use of ‘flying squads’ is no longer supported and in the event of an emergency, transfer in is the only option.
6.3 Other agencies have an integral role in the collaborative management of home birth services, particularly the regional ambulance service. Therefore, developing a service agreement with these agencies will provide an improved risk management framework; for example, in the event of emergency transfer ambulances should take women to the consultant obstetric unit rather than the accident and emergency department. Babies need to be transferred to maternity units where there are appropriate neonatal services.
6.4 The clinical and personal safety of the midwife practitioner at home birth requires extra resources. For example, it is the employer’s responsibility to set minimum agreed levels of equipment for carrying out the role, including equipment for communication.^33,40 In addition, midwives working alone in the community should have appropriate lone-worker arrangements provided by their local NHS trust or employer.
6.5 Midwifery supervision is integral to any midwifery practice and all organisations must ensure that there are adequate numbers of supervisors of midwives to ensure 24-hour access.⁴¹ Where a woman has a risk factor which may deem her unsuitable for a home birth it is advisable that the midwife involves a manager and supervisor of midwives.

7. Skills and competencies

7.1 Midwife practitioners must be competent within the home birth environment and may require enhancement or updating of their existing midwifery skills prior to providing home birth services.¹⁵ Midwives’ personal accountability for only undertaking duties for which they have competencies, is governed by Midwives’ Rules and Standards.⁴¹ The organisation’s responsibility is to provide resources for acquiring new or maintaining existing skills associated with home birth practices, both linked to facilitating and observing physiological labour, as well as acting on emergencies. The mandatory ‘drills and skills’ training must include environments outside labour ward and simulation models should be available to encourage practising of skills. Up-to-date registers should be kept of those participating in skills drills to ensure that all staff participate regularly in a rolling programme.⁴²
7.2 The advanced courses in obstetric emergencies and neonatal resuscitation require adequate funding for further training.
7.3 Risk assessment must take place with what limited tools are available. Careful selection of low-risk maternities is important to minimise complications. Ideally, this should be by senior midwifery and obstetric staff.

8. Record keeping, audit and user surveys

8.1 Contemporary and accurate record keeping is vital; as for all aspects of health care.^33,41,43 The health records maintained on various sites need to be stored as a complete set and most organisations now require computer input for the birth records and obtaining the baby’s NHS number. These computer programmes aid auditing practices, both personal and organisational. Areas of service or practice for audit should include home birth, transfer and intervention rates as a minimum. User satisfaction surveys and focus groups need to be linked with home birth services. There should be robust clinical governance systems for monitoring the quality of home birth services. These should include both qualitative and quantitative audit data. Consideration should be given to women’s experiences, stories, transfer rates, ambulance response times and emergency scenarios. In the case of serious adverse outcome a detailed root cause analysis should be undertaken.⁴²

9. Conclusion

9.1 The RCM and RCOG support the provision of home birth services for women at low risk of complications. If the service is provided by midwives committed to this type of practice within continuity of care schemes and appropriately supported, outcomes are likely to be optimal. Services need evidence-based guidelines, where possible. Good communications, adequate training and emergency transfer policies are vital.

References

1. Wiegers TA, Keirse MJ, Van der Zee J, Berghs GA. Outcome of planned home birth and planned hospital births in low risk pregnancies: prospective study in midwifery practices in the Netherlands. BMJ 1996;313:1309–13.
2. Olsen O. Meta-analysis of the safety of the home birth. Birth 1997;24:4–13.
3. Ogden J, Shaw A, Zander L. Deciding on a home birth: help and hindrances. Br J Midwifery 1997;5:212–15.
4. Department of Health. The National Service Framework for Children and Young People. Maternity Services. Standard 11. London: Department of Health; 2004 [www.dh.gov.uk/assetRoot/04/09/05/23/04090523.pdf].
5. Welsh Assembly Children’s Health and Social Care Directorate. National Service Framework for Children, Young People and Maternity Services in Wales. Cardiff: Welsh Assembly Government; 2005 [www.wales.nhs.uk/sites/documents/441/ACFD1F6.pdf].
6. 6. Scottish Executive. A Framework for Maternity Services in Scotland. Edinburgh: Scottish Executive; 2001 [www.scotland.gov.uk/library3/health/ffms–00.asp].
7. Department of Health. Changing Childbirth: Report of the Expert Maternity Group. London: HMSO; 2003.
8. Department of Health and Social Security. Standing Maternity and Midwifery Advisory Committee (Chairman J. Peel). Domiciliary midwifery and maternity bed needs. London: HMSO; 1970.
9. Campbell R, Macfarlane A. Where to be Born: the Debate and the Evidence. Oxford: National Perinatal Epidemiology Unit; 1987.
10. Tew M. Safer Childbirth? A Critical History of Maternity Care. 2nd ed. London: Chapman and Hall; 1998.
11. Demilew J. Homebirth in urban UK. MIDIRS Midwifery Digest 2005;15:4(Suppl 2).
12. Edwards N. Choosing a Home Birth. London: Association for Improvements in the Maternity Services; 1994.
13. Chamberlain G, Wraight A, Crowley P. Home Births: The Report of the 1994 Confidential Enquiry by the National Birthday Trust Fund. Carnforth: Parthenon; 1997.
14. National Childbirth Trust. NCT Home Birth In the United Kingdom. London: NCT; 2001.
15. Nursing and Midwifery Council. Midwives and Home Birth. NMC Circular 8–2006. London: NMC;2006 [www.nmc-uk.org/aFrameDisplay.aspx?DocumentID=1472].
16. Springer NP, Van Weel C. Home birth. BMJ 1996;313:1276–7.
17. Olsen O, Jewell MD. Home versus hospital births. Cochrane Database Syst Rev 1998;(3):CD000352.
18. Northern Region Perinatal Mortality Survey Coordinating Group. Collaborative survey of perinatal loss in planned and unplanned home births. BMJ 1996;3:371–5.
19. Davies J. The Midwife in the Northern Regions Home Birth Study. Br J Midwifery 1997;5:219–24.
20. Confidential Enquiry into Stillbirths and Deaths in Infancy. 5th Annual Report. Focus group place of delivery. London: Maternal and Child Health Research Consortium; 1998.
21. Viisainen K. Negotiating control and meaning: home birth as a self-constructed choice in Finland. Soc Sci Med 2002;52:1109–21.
22. Andrews A. Home birth experience 2:births/postnatal reflections. Br J Midwifery 2004;12:552–7.
23. Munday R. Women's experience of the postnatal period following a planned home birth; a phenomenological study. MIDIRS Midwifery Digest 2004;13:371–5.
24. O’Brien M. Home and hospital: a comparison of the experiences of mothers having home and hospital confinements. J R Coll Gen Pract 1978;28:460–6.
25. Goldthorp WO, Richman J. Maternal attitudes to unintended home confinements: a case study of the effects of the hospital strike upon domiciliary confinement. Practitioner 1974;212:818–53. Royal College of Obstetricians and Gynaecologists and Royal College of Midwives Joint Statement No.2 5 of 6
26. Alment EA, Barr A, Reid M, Reid JJ. Normal confinement: home or hospital? The mother’s preference. BMJ 1967;I:52–53.<>
27. Paddison J. Home Birth a Family Affair: A Qualitative Research Case Study of Home Birth and Social Boundaries. Wigtownshire: Impart Publishing; 2005.
28. Campbell R, Macfarlane A. Where to be Born? The Debate and the Evidence. 2nd ed. Oxford: National Perinatal Epidemiology Unit, 1994.
29. Emslie MJ, Campbell MK, Walker KA, Robertson S, Campbell A. Developing consumer-led maternity services: a survey of women’s views in a local healthcare setting. Health Expectations 1999;2:195–207.
30. Hundley V, Rennie AM, Fitzmaurice A, Graham W, Van Teijlingen E, Penney G. A national survey of women’s views of their maternity care in Scotland. Midwifery 2000;16:303–13.
31. Singh D, Newburn M. Access to Maternity Information and Support: the needs and experiences of pregnant women and new mothers. London: National Childbirth Trust; 2000.
32. Royal College of Midwives. Home Birth Hand Book: Volume 1: Promoting Home Birth. London: RCM; 2002.
33. Royal College of Midwives. Home Birth Hand Book: Volume 2: Practising Home Birth. London: RCM; 2003.
34. Enkin MW, Keirse MJ, Renfrew MJ, Neilson JP. A Guide to Effective Care in Pregnancy and Childbirth. 2nd ed. Oxford: Oxford University Press;2000. p. 52.
35. Campbell R. Review and assessment of selection criteria used when booking pregnant women at different places of birth. Br J Obstet Gynaecol 1999;550–6.
36. Hutchings J, Henty, D. Caseload practice in partnership with Sure Start: changing the culture of birth. MIDIRS Midwifery Digest 2002;(Suppl 1):538–40.
37. Sandall J, Davis J, Warwick C. Evaluation of the Albany Midwifery Final Report. London: Florence Nightingale School of Midwifery, King’s College; 2001.
38. Royal College of Midwives. Making Maternity Services Work for Black and Minority Ethnic Women: A Resource Guide for midwives. London: RCM; 2004.
39. Hodnett ED. Continuity of caregivers for care during pregnancy and childbirth. Cochrane Database Syst Rev 2000;(2):CD000062.
40. Royal College of Midwives. Safety for Midwives Working in Community. Position Paper 12. London: RCM; 1996.
41. Nursing and Midwifery Council. Midwives Rules and Standards. London: NMC; 2004 [www.nmc–uk.org/aFrameDisplay.aspx?DocumentID=169].
42. National Health Service Litigation Authority. Clinical Negligence Scheme for Trusts, Maternity. Clinical Risk Management Standards. London: NHSLA; 2007 [www.nhsla.com/NR/rdonlyres/F8184718–3AF9–400E–A3F3–5D9309E2 AA72/0/CNSTMaternityClinicalRiskManagementStandardsApril2007website.pdf].
43. Royal College of Midwives. Litigation: A Risk Management Guide for Midwives. 2nd ed. London: RCM Trust; 2005

Valid until April 2010 unless otherwise indicated.
This statement was produced on behalf of the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives by: Miss JL Cresswell FRCOG, Chesterfield, and Ms E Stephens RM and peer reviewed by: Ms J Demilew, Ms C Dowling, Dr MCM Macintosh MRCOG, Ms P McConn, Dr MP Mohajer FRCOG, Mr RJ Porter FRCOG and Mr PJ Thompson FRCOG.

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Write to ACOG

If you have a response you would like to communicate to ACOG about their recent statement on home birth, please write or call:

ACOG Office of Communications
202.484.3321
communications@acog.org

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MO midwifery legislation

Midwifery legislation is currently in the works in several states, including Missouri. Here's an update from the most recent efforts in Missouri: Push for midwives strengthening.

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Responses to ACOG (updated!)

Responses are rolling in! Let me know if you see any others and I will post them:

• ICAN's response to ACOG and the AABC.
• The Big Push for Midwives asserts that ACOG is out of touch with the needs of childbearing families.
• Permission to Mother (a family doctor blogger): Time to deal with ACOG
• The Mommy Blowg talks about the latest from ACOG
• Midwifery World says it's a shocker (sarcasm intended)
• Friends of Missouri Midwives asks its readers what they think of the statement
• TrueBirth responds
• House of Harris points out the contradictions
• VBAC Warrior responds with a drawing
• Jill says ACOG makes her laugh
• Jennifer Block (author of Pushed) examines the notion of a cause célèbre
• Sagefemme briefly shares her thoughts
• Tina Cassidy (author of Birth: The Surprising History of How We Are Born) responds
• A new midwife shares her thoughts.
• Descent takes a somewhat earthy approach to ACOG
• BlogHer discusses the research
• A MDC mama writes a parody of the ACOG statement
• Hathor the Cow Goddess is drawing cartoons: Your choice and Protect our, um...women

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10 responses to ACOG's statement on home birth

On the heels of ACOG's newest statement on home birth, I wanted to share my responses.

1) For the first time, ACOG has suddenly started supporting freestanding birth centers, a drastic shift from its long-standing opposition to out-of-hospital births. The research on birth centers has not changed—in fact, the outcomes from the National Birth Center Study are similar to those of the CPM 2000 study for things such as cesarean rates (4.4% vs 3.7%), hospital transfers (15.8 % vs 12.1%; urgent transfers were 2.4% vs 3.4%) and intrapartum/neonatal mortality (1.3 vs 1.7/1000). Although the data on out-of-hospital births has not changed in the past year and a half, compare ACOG’s 2006 statement with its recent position on home birth:

November 2006: "American College of Obstetricians and Gynecologists (ACOG) believes that the hospital, including a birthing center within a hospital complex...is the safest setting for labor, delivery, and the immediate postpartum period....Although ACOG acknowledges a woman’s right to make informed decisions regarding her delivery, ACOG does not support programs or individuals that advocate for or who provide out-of-hospital births."

February 2008: "ACOG acknowledges a woman's right to make informed decisions regarding her delivery and to have a choice in choosing her health care provider, but ACOG does not support programs that advocate for, or individuals who provide, home births....ACOG believes that the safest setting for labor, delivery, and the immediate postpartum period is in the hospital, or a birthing center within a hospital complex...or in a freestanding birthing center."

2) ACOG claims that “Childbirth decisions should not be dictated or influenced by what's fashionable, trendy, or the latest cause célèbre.” Ricki Lake’s documentary and The Big Push for Midwives, among other recent developments, are evidently unsettling to ACOG. The rate of home birth has remained relatively stable for the past several decades; I would argue that it is hardly fashionable or trendy in that sense. Women choosing home birth face significant social stigma. It is not an easy or socially acceptable path. Instead, it is a choice that some women will always make out of deeply held philosophical or religious beliefs. This statement also implies that women choose home birth for frivolous reasons without serious thought or carefully weighing the risks and benefits of various options.

On the other hand, one recent trend in childbirth—elective cesareans with no medical indication—is supported by ACOG as ethically justifiable “if the physician believes that cesarean delivery promotes the overall health and welfare of the woman and her fetus more than does vaginal birth.”

3) ACOG yet again pays lip service to “a woman’s right to make informed decisions regarding her delivery and to have a choice in choosing her health care provider” while working to undermine women’s ability to make those very decisions. Vaginal birth after cesarean (VBAC), for example, is increasingly difficult to arrange in the United States as a direct result of an ACOG recommendation. Hundreds of hospitals have banned VBACs since 1999, when ACOG revised its recommendations on VBAC and stated that VBAC “should be attempted in institutions equipped to respond to emergencies with physicians immediately available to provide emergency care.”[1] In practice, this translated into 24-hour in-house anesthesia and OB coverage, a requirement that often only large, tertiary hospitals can guarantee.

Dr. Marsden Wagner has noted that ACOG “has no data to support it [the 1999 VBAC recommendations], no studies showing improvements in maternal mortality or perinatal mortality related to the characteristics of institutions or availability of physicians.” In fact, the studies that do exist show no elevated mortality rates among VBACs in smaller hospitals compared to large tertiary hospitals.[2] When the American Academy of Family Physicians reviewed all of the evidence on VBAC and the necessity of 24-hour OB and anesthesia, it recommended that "TOLAC should not be restricted only to facilities with available surgical teams present throughout labor since there is no evidence that these additional resources result in improved outcomes." (Read the full report here).

Despite the fact that ACOG’s 1999 recommendation was not evidence-based, obstetricians and hospital administrators are under heavy pressure to comply with the recommendations. As a result of ACOG’s new position on VBAC, hundreds of smaller hospitals have instituted a no-VBAC policy, requiring women to have mandatory repeat cesareans or to travel elsewhere—sometimes very long distances—to give birth. ACOG’s active opposition to home birth and to non-nurse midwives also undermines a woman’s ability to choose her health care provider. It is akin to saying “We support your right to chose any color of car you want. But since we believe that only blue cars are safe, we will oppose any attempts to legalize the manufacture, sale, or distribution of non-blue cars.” In sum, ACOG’s supposed support of a woman’s right to autonomy is nothing more than thinly veiled paternalism.

4) ACOG claims that a woman “attempting” a VBAC at home “puts herself and her baby’s health and life at unnecessary risk.” This shows ACOG’s distrust in a woman’s ability to make her own decisions. Whether or not a HBAC—or a hospital VBAC or an elective cesarean—is unnecessarily risky is for each individual woman to decide, based on a complex set of factors, values, and life experiences. Again, this is an example of paternalism. Instead of respecting a woman’s ability and right to make her own decisions, ACOG has made a sweeping pronouncement that attempts to speak for women.

5) ACOG claims to be concerned about the rising cesarean rate and states that it “remains committed to reducing it.” However, several of ACOG’s actions actively promote higher cesarean rates, including its support of patient choice cesareans as ethically justifiable and its 1999 VBAC recommendation.

6) When all else fails, blame the woman: After stating its concern with rising cesarean rates, ACOG then places the blame back on women themselves: “Multiple factors are responsible for the current cesarean rate, but emerging contributors include maternal choice and the rising tide of high-risk pregnancies due to maternal age, overweight, obesity and diabetes.”

7) ACOG repeats its claim that “studies comparing the safety and outcome of births in hospitals with those occurring in other settings in the US are limited and have not been scientifically rigorous.” It claimed this about out-of-hospital births (including freestanding birth centers) in 2006. Yet with no new research on birth centers in the past year and a half, ACOG has recently reversed its stance. ACOG also ignores the CPM 2000 study about midwife-attended home birth, a large, prospective study of all CPM-attended births in the year 2000.

8) ACOG states: “The availability of an obstetrician-gynecologist to provide expertise and intervention in an emergency during labor and/or delivery may be life-saving for the mother or newborn and lower the likelihood of a bad outcome.” I agree that access to emergency services when needed is essential, and unfortunately continued opposition to home births only makes that access more difficult. In states where midwifery is illegal, many midwives are forced to abandon their clients if they transfer to a hospital out of fear of being arrested. Midwives in many states cannot openly refer clients or consult with backup physicians. Surely these situations do nothing to improve safety for the birthing woman. Decriminalization of midwifery (and removing sanctions from collaborating physicians) would help remedy this situation.

9) ACOG states that “lay or other midwives attending to home births are unable to perform live-saving emergency cesarean deliveries and other surgical and medical procedures that would best safeguard the mother and child.” Yes, this is true for all midwives and many family practice physicians, in and out of hospitals: a CNM or family doctor working in a hospital cannot perform a cesarean (unless the family doctor has done additional training in obstetrics). They must transfer care to an obstetrician if the need for surgery arises. Nurse-midwives cannot do forceps deliveries or vacuum extractions.

10) ACOG labels women who choose home birth as selfish and narcissistic. ACOG writes: “The main goal should be a healthy and safe outcome for both mother and baby. Choosing to deliver a baby at home, however, is to place the process of giving birth over the goal of having a healthy baby.” This statement as insulting as it is misinformed, and it shows ACOG’s inability to recognize that women choosing home birth do it to safeguard their baby’s well-being. Accusing women of being “bad mothers” is both unprofessional and paternalistic.

This statement also reveals a fundamental rift in belief systems between obstetrics and midwifery. In the obstetric worldview, women’s emotional needs are often portrayed as pitted against the fetus’ physical well-being. In the midwifery paradigm, however, safety isn’t a matter of either/or. (Either you have an emotionally satisfying but dangerous home birth or you have a safe hospital birth where you sacrifice your own comfort and emotional needs for the good of the baby). It is an and/and situation where the well-being of mother and baby are inextricably intertwined.

[1] ACOG Practice Bulletin No. 5, July 1999, “Vaginal Birth After Previous Cesarean Section.” According to the International Cesarean Awareness Network (ICAN), over 300 hospitals have banned VBACs since 1999. ICAN is currently compiling a comprehensive list of the status of VBAC in every U.S. hospital.
[2] Marsden Wagner. What Every Midwife Should Know About ACOG and VBAC. Midwifery Today. McMahon, M. (1996). Comparison of a trial of labor with an elective second cesarean section. New Eng J Med 335 (10): 689-695.

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ICAN's new website

Advocacy Group Unveils New Web site

Site features easy navigation, community resources

REDONDO BEACH, CA, February 7, 2008 – The International Cesarean Awareness Network launches a new, user-friendly Web site today in an effort to further the group's outreach efforts.

"The new Web site will make an impact in the battle against the growing cesarean statistics by providing information to moms, challenging them to take responsibility for their births and will give women the tools they need to make educated decisions about their births – because this isn't about statistics. It's about every mom and every baby getting the safest birth possible."

Easy navigation is a key feature of this Web site, which has been in the works since July when ICAN Board Members recognized the need for a more user-friendly Web site. (The Web site can be found at www.ican-online.org) Site viewers will find information separated into five categories: Pregnancy, Recovery, VBAC, Advocacy and Community.

"In our daily advocacy work, we saw a clear mandate for a site that as simple to navigate, simple to understand and full of easy-to-access information for the woman avoiding a cesarean, recovering from a cesarean or on her journey to VBAC (vaginal birth after cesarean)," Laureen Hudson, ICAN Publications Director said. "ICAN interacts with women on very different journeys -- the messages a pregnant woman needs to hear to avoid a cesarean are not the same
messages a woman on the journey to VBAC needs to hear. We like to think that this site addresses those two complimentary, yet divergent, needs."

The Web site lets women research the VBAC policies of hospitals near them; learn how to correct problems (such as malposition or pre-eclampsia) that commonly lead to cesareans; get quick physical recovery tips to help after a cesarean; and stay up-to-date on medical research on pregnancy and birth. New community features include user birth blogs, videos and images; and the capability for users to create their own homepage on the ICAN site to share with friends and family. ICAN leadership also can connect more easily via the Web site with the women ICAN serves. Further, the Web site features a new logo – the logo, and all of the Web work, were completed entirely by volunteers.

"We wanted our site to be easy for the average woman recovering from surgery and caring for a newborn to find the info they needed quickly and easily," Webmaster Melissa Collins said. "One of my favorite features is the online social community that is safe for moms planning a VBAC or just wanting to avoid. I'm really excited to watch this new community grow."

This new Web site comes after research in 2007 by the National Center for Health Statistics showed the cesarean rate reaching a record high of 31.1 percent. Further, a CDC report indicated the maternal death rate rose for the first time in decades and Consumer Reports includes a cesarean in its list of "10 overused tests and treatments." Other research from 2007 cites a VBAC continues to be a reasonably safe birthing choice for mothers. And while studies indicate a VBAC is a viable option, women often have difficulty finding a health care provider who encourages a VBAC – which is where one of the site's new features comes into play.

"The most useful tool for women is probably the Hospital VBAC Ban information," Collins said. "Women can look up the hospitals near them and find out their VBAC policy and if any doctors are actually available to attend them. It is getting difficult for so many women to find a VBAC supportive provider and this is one way to make that a little easier for them."

Mission statement: ICAN is a nonprofit organization whose mission is to improve maternal-child health by preventing unnecessary cesareans through education, providing support for cesarean recovery and promoting vaginal birth after cesarean. There are more than 94 ICAN Chapters across North America, which hold educational and support meetings for people interested in cesarean prevention and recovery.

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Carrie Ann Moss on midwives

Carrie Ann Moss talks about her experiences with her two midwife-attended births, one in hospital and one at home:

I have had two babies using the care of a midwife, the first was delivered (by the midwife) in a hospital setting. The second baby was delivered in our home. With both experiences, the midwife made the pregnancy experience and birth so honored and beautiful.

The Midwives Model of Care is unlike using traditional obstetric care, in that it is family-centered and focuses strongly on the mother's wellbeing as an important factor in a good birth outcome. I still treasure memories of the meetings I had throughout both pregnancies, where the midwife would take whatever time was needed to accurately and sensitively monitor my babies' growth. I have no such memories about my Obstetrician appointments, thorough as they were. And in the case of our home-birth, the Obstetrician was not involved at all in the end.

I believe midwifery care is an important healthcare option for families to have access to. Whether they attend a birth at home or in a hospital, midwives bring a special and unique tradition of family-centered care to the experience of having a baby and it would be wrong to stop them from helping American families.

Yours sincerely,
Carrie-Anne Moss

From The Big Push for Midwives

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Celebrity home birth!

Scrubs star John McGinley and his wife Nichole recently had a waterbirth at home with a midwife in attendance. McGinley had these comments about the birth: "Nichole was a mountain lion, a warrior in the birthing process. The birth was astonishing!" Read more here.

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Documentary on wet nursing

Please forward this information to anyone who might be interested in participating:

Ever thought of hiring a wet nurse?

Channel 4 is making a documentary called Wet Nurse. It's a fascinating subject and we aim to make an informative, compassionate and fair documentary exploring the need of a wet nurse in today’s modern society.

Wet nursing is back in fashion and this is because of health scares about formula milk, increase in plastic surgery and women making a lifestyle choice: they don’t want to breastfeed nor want to use formula milk. This added with gay couples – especially since the law changed allowing them to adopt – could a wet nurse make a comeback? I’m particularly keen to speak to women who want to hire or are currently using a wet nurse or women who are cross feeding for this documentary. We want to know as much as possible about this complicated issue so get in touch and tell us your thoughts!

You can email anna.edwinson@granadamedia.com or call directly on 0044 - 20 7261 3375.

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