Saturday, May 30, 2009

Collaboration, transfers, and attitudes towards home birth

One of the blogs I follow, Midwife with a Knife, has a new post about her views on home births. She's a high-risk OB training to be a perinatologist. I enjoy hearing from physicians who can talk rationally and sensibly about home birth. I don't agree with her on every point. For example, I do think that HBAC is a reasonable choice. And in many places, it's one of the only ways to have a vaginal birth. It's refreshing to hear from someone within the obstetrical system who understands why some women make this choice and who doesn't resort to the typical scare tactics or accusations of maternal selfishness. Perhaps there is hope in bringing together obstetricians and home birth midwives in collaborative, respectful relationships. After all, better communication, respectful treatment during hospital transfers, and open, collaborative relationships would only enhance safety for home birth families.

This is something that two Oregon State University researchers have been examining, in fact: conflict between obstetricians and home birth midwives and possible ways to create collaborative relationships. Assistant professor Melissa Cheyney (who had a baby at home a few weeks ago) and doctoral student Courtney Everson found that in Jackson County, Oregon:
assisted homebirths did not appear to be contributing to the lower-than-average health outcomes and, in fact, that the homebirths documented all had successful outcomes. But even more importantly to Cheyney, discussions with doctors and midwives uncovered a deep mistrust between the two groups of birthing providers, with doctors expressing the firm belief that only hospital births are safe, while midwives felt marginalized, mocked and put on the defensive when in contact with physicians....

One of the biggest problems Cheyney sees is that physicians only come into contact with midwives when something has gone wrong with the homebirth, and the patient has been transported to the hospital for care. There are a number of reasons why this interaction often is tension-filled and unpleasant for both sides, she says.

First is the assumption that homebirth must be dangerous, because the patient they’re seeing has had to be transported to the hospital. Secondly, the physician is now taking on the risk of caring for a patient who is unknown to them, and who has a medical chart provided by a midwife which may not include the kind of information the physician is used to receiving.

And because the midwife is often feeling defensive and upset, Cheyney said, the contact between her and the physician can often be tense and unproductive. Meanwhile, the patient, whose intention was not to have a hospital birth, is already feeling upset at the change in birth plan, and is now watching her care provider come into conflict with the stranger who is about to deliver her baby.

“It’s an extremely tension-fraught encounter,” Cheyney said, “and something needs to be done to address it.” As homebirths increase in popularity, she added, these encounters are bound to increase and a plan needs to be in place so that doctors and midwives know what protocol to follow.

“We’re having a meeting in early May to propose a draft for a model of collaborative care that might be the first of its kind,” in the United States, Cheyney said.

Physician blogger KevinMD agrees that physicians and midwives need to cooperate more. He writes:
From the doctor’s side, the only times they interact with midwives is when trouble arises....Doctors should also see things from the midwife’s perspective, and collaborative programs where they can experience successful midwife cases can help resolve the conflict between the two camps.
Make sure you read the comments as well as KevinMD's original post.

Unfortunately, not all physicians or nurses are respectful or rational when working with homebirth transports, as the L& D nurse blogger at Stork Stories illustrates. In OB Docs and Nurses Scoff at Homebirth, she writes about the attitudes her OB and nurse colleagues have displayed when they encountered transports.
Often the OB’s didn’t handle themselves well...certainly not professionally. We had this one OB who would call for the OR to be opened before he even examined the patient or evaluated the situation...regardless of why they came in. And he often actually yelled at the mother, in the middle of her scary situation. “Your baby will die if we don’t do an emergency C/S right now, why did you let this happen!”

Most often the backlash was directed at the midwife who cowered in the hallway- uninvited by the staff, left alone detached from her patient. She never left the unit though until she was afforded the opportunity to visit and speak to her patient...

I feel that instead of the midwife or mother receiving hostility (or even the mother being whisked away to the OR without a trial of something if the baby was deemed stable...) the staff should have behaved in a compassionate professional manner, acting on any urgent situation with consideration that this mother is now experiencing not only labor but fear and grief over the loss of her beautiful planned birth.
I have written earlier about my issues with the ACOG's and AMA's official positions against home birth. Probably the most significant repercussion of these official position statements is that they strongly discourage physician-midwife collaboration. For example, the CNM who attended Dio's birth needs to have a signed collaboration agreement with a physician in order to administer certain emergency medications in our state (IV abx for GBS+, anti-hemorrhagic meds, lidocaine for suturing, etc). The agreement does not require the physician to take on a supervisory role, nor does physician assume any liability for the midwife's clients. She has contacted over 150 physicians in our state, and not one was willing or able to sign the agreement--including some of her own physician clients! This was often due to the physicians' malpractice insurance policies or hospital regulations, which of course are strongly influenced by ACOG and AMA recommendations.

Wouldn't it be fabulous if all medical students, especially those going into family practice or OB/GYN, did rotations with out-of-hospital providers? And if all home birth midwives were able to do hospital internships as part of their training? And if we had some kind of forum for OBs and nurses and midwives to meet and talk about how to improve maternity care, a dialogue where they really learned from each other. Imagine midwives sharing how they are able to achieve such low cesarean rates. Imagine physicians giving suggestions for how to make transports smoother (what kind of charting would be helpful for the hospital staff or having the midwife call the local L&D when a client is in labor so the staff is prepared in case a transport is needed).

What suggestions would you have--as a physician, a nurse, a midwife, a doula, or a birthing woman--to improve collaboration and communication and to make home birth transfers smoother and safer?


  1. I think if you called ahead and spoke to the on-call physician or charge nurse. Told them what you are doing and how long it would take you to get to the hospital in an emergency. The on-call Doc. Which is the Doc who assumes care of all patients who don't have a doctor, would then have a heads up.

    I think all the OBs are afraid of being sued. So they would then tell the midwife that they strongly urge her to bring her patient into the hospital. But they are saying that to save their own a$$ which I can't blame them for.

    I think the worst part is that we may be having a slow night and let some of our staff go home. If we knew someone nearby was having a homebirth, we could staff accordingly.

    I don't agree with the Doctor being an a$$hole but I have known NCB folks who come to the hospital and treat all the staff like sh1t. If you want respect, you need to give respect. It is a 2 way street.

  2. I agree that OBs and midwives need to work together and not against each other. It's not Team A and Team B, it's just one big team serving all pregnant women! I understand that there is a "turf" issue here but I don't get why there has to be such hostility. I think there are a lot of deep-seated grudges at play and many of us can't help ourselves when it comes to looking beyond that for the sake of the women (and babies). I even admit that I myself am guilty of making broad generalizations about a certain side of the "camp" just because I am still bitter about my own experiences. There is a lot of nastiness here that is going to take a lot of work to undo.

    Transfer was one of my biggest fears when I had my HBAC. If they treated me so badly when I was SUPPOSED to be birthing at the hospital, I was terrified to see how they would treat me when I showed up as one of those idiotic, selfish, treehugging homebirthers.

    I often wonder if there have been other moms, who might have been better off transferring and instead were so afraid of how the hospital would treat them that they stayed home, and might have had a bad outcome. This is not good. Hmmm, this might be a good talking point for the next time I go lobby in Richmond. The spike in unassisted births here in VA because women were too scared to go to the hospital led to CPMs being legalized a few years ago. Maybe the current state of ill will between midwives and OBs and how it is negatively affecting patients/clients can lead to a better attempt at collaboration instead of war.

    Man, I just want to keep talking about this. Maybe I should make my own blog post instead of rambling on your comment page! :P

  3. First, I think that there needs to be respect given by both sides of the fence. Without respect for the expertise that either a home birth midwife or obstetrician has, how can any interaction between the two between a hospital transfer go well?

    The other factor is education. I wish that the hospital staff who is anti-homebirth would look at the evidence. But it seems to me many (doctors and nurses) just don't want to, or immediately scoff at the evidence and are unwilling to review it with unbiased eyes.

    This goes for some homebirth midwives, as well. I was recently at a gathering of midwives, which turned out to be mostly CPMs, who tried to cover up their disgust at my upcoming role as a hospital based CNM.

    I have been finding myself shaking my head and throwing my hands up. I find myself becoming much too frustrated on this topic because as a beginning CNM, I'm overwhelmed with the arguments on both sides. I can't imagine anyone not wishing safe and happy births for all mothers and babies- but it's the attitude that "my way is the only way" that frustrates me!

  4. Rixa, you said it all in the second last paragraph! All of those are great suggestions that would do wonders to improve the relationships and understanding between midwives, maternity nurses and ob-gyns.

    Each side would have more respect for each other if they saw where their differing skills are an asset to producing the end result of a healthy and happy mother and child/ren. For example, ob-gyns should be exposed to normal, natural uncomplicated birth in a home setting. They can see that low-risk women can have amazing birth experiences that leave them and the baby in much better shape than those low-risk women birthing in hospitals with the usual interventions. The midwives should see and appreciate the skill of ob-gyns who can care well for those women who become high-risk and need medical interventions in their births. There is a place for both kinds of practitioners and the hand-over of care of a low-risk changed to high-risk mother should be natural and respectful. In the end, the focus should be on the mother and baby, not on egos and blaming each other.

    The one complicating factor seems to be the legal liability issue. There are so many things that happen to mothers and babies in labour and birth that are influenced more by fear of being sued than the reality of what is happening and the true risk levels. This seems to be one major divide, with midwives trusting in the natural birth process and ob-gyns and nurses looking for something to go wrong or preempting what they think could go wrong in order to cover their butts legally. Maybe this taints the views of each kind of practitioner about how each conducts themselves and what they do with their clients.

    Parents should also be more educated about birth issues and take more responsibility for their birth choices. In the end it is unrealistic to think there could be a zero infant mortality rate or even zero disability/complications rate when it comes to birth. Parents need to understand and accept that not all babies and mothers survive, and it isn't always justified to blame/sue the practitioners.

  5. Midwives in Washington State have a Home to Hospital Transport Protocol pilot program happening in a couple of hospitals currently.
    This document is designed to establish a set of expectations on both sides, and ideally to finesse smooth and efficient transports from everyone's perspective, and optimize outcomes.

    At our local hospital where we sometimes have great transports and sometimes have iffy ones, the MW's are planning a visit to a nursing staff meeting (with help from a HB friendly MW/RN) to talk to everyone, introduce ourselves properly and make sure they know that we're committed to working toward the same goals. Our clients who wind up in their care may not *want* to be there, but we all want the same things once we're there. Healthy, happy mom, and healthy, happy baby.

    The other piece of this which I think some MW's omit is good, thorough discussion about transport in prenatal care. Clients who come to care saying 'I'm not going to hospital under ANY circumstances" give me the willies. I even tend to think that could be a client who may not be well suited to homebirth. It's necessary to unpack where that animosity/fear is coming from because Homebirth is awesome, but there are instances when we NEED what the hospital offers. If we transport for fetal distress, we're not going to be able to do away with the continuous EFM. If we transport for mec, baby's probably going to get suctioned (I know, it blows when you have a vigorous baby who gets suctioned for the heck of it). When we avail ourselves of the hospital tools, we can expect hospital protocol to come into play. But to a large extent thats what we're *there* for. Client's must be well prepared for this eventuality. In my experience docs and nurses are happy to receive well prepared clients who understand well why the're there, and are ready to work with whatever curveball their labor has thrown them. A hospital birth can be brilliant, even if it wasn't what you wanted at the outset.

    As a providers the MW's I work with(and I will do the same) DO call ahead to brief the L&D staff of what's on the way, regardless of if it's a leisurely, relaxed transport for labor dystocia and pain relief, or if it's a quick, emergent transport for whatever (usually fetal distress). If mom's in an ambulance I call to let them know I'm right behind with all charts/records etc. I'm also a huge believer in MW remaining with the client for the duration of the transport. I want the hospital staff to have me there (with all PN records, labor charts, transport forms outlining reasons for transport, maternal/fetal status at time of transport etc) to be able to ask whatever questions they need. I want them to see me as part of the team, even if they think I'm MAD to be a homebirth midwife.

    I have a huge amount of respect and gratitude for the physicians and nurses I transport my clients to. I totally understand how frustrating it must be to have someone you don't know coming through the door in unknown shape and then have to manage it. I'm there to bridge that gap as best I can. Without them I couldn't provide safe homebirth options. I'm crystal clear with my clients about that and Clients need to be on board with this too. Everyone's gotta keep talking about making every transport as good as it can be.

    Excellent post Rixa!

    1. I am an RN working on a project to develop a similar protocol in California. Do you have info of where I can get a copy of the Washington state protocol you mentioned?

  6. Washington State is a GREAT place to birth! I have had two of my five births here (kiddo number two and kiddo number five) and got excellent care from the HB midwives. The hospitals around here don't seem to be rabidly against it, either, they tend to know the HB midwives by name. Not saying there aren't any dissenters, but there is definitely less hostility to midwifery/natural/holistic medical care here than in other parts of the country.

  7. I consider myself to be incredibly lucky to be a med student planning on going into ob/gyn after two midwife deliveries of my own boys and training as a midwife for two years. I am going to look into doing a rotation at The Farm.

    I am interested into what sort of flexibility I may have as a practicing ob/gyn to attend out of hospital births. I definitely plan on backing up midwives, but sometimes I want to be able to attend one of the cool births, too.

  8. The government should get involved, fund midwifery education, and have an international symposium on evidence-based pregnancy, labor and postpartum care. We should look at countries which already have strong obstetrics and midwifery cooperatives, bring their experts in as speakers at the symposium.

    If somehow, at the same time, we could revise the legal system to reward positive care instead of punish EVERYONE (making doctors afraid to care for their patients based on insurance premiums), perhaps midwifery would have chance in this country.

    Oh, and I LOVE the idea of med students doing a round of at-home job shadowing. If every doctor had to follow a midwife around and witness a few home births, that would be GREAT.

    Wasn't there an article about a South American country starting to embrace upright birth again in which they mentioned that all their OB's had to do a round with a traditional midwife out of the hospital?

  9. I'm in Ontario, Canada, where midwifery is regulated and covered under universal health care. We don't have a perfect system, but it is certainly more collaborative than what you've described.

    Midwives have hospital privileges, and so regularly work with and consult with the OBs. This creates a situation where the OBs and midwives know each other. They don't always get along, but there is a formally established relationship, as well as formally established guidelines for when midwives need to consult or transfer care.

    Home birth transfers are never trauma-free, but the system is set up so as to reduce that trauma. A midwife rides in the ambulance with the mother and is technically responsible for her care until she sees the OB. The midwives call ahead to the hospital and a room and OB are ready when they arrive. Also, where I am, the midwives use the hospital charting forms for homebirth as well, so in the event of a transfer there's an easy exchange of info.

    If all is well with mom and baby after birth, care is immediately transfered back to the midwife. In some cases, the midwife still catches the baby (this depends on the OB and what is going on, of course). The woman is never left alone- in the event of a c-section, the midwife is in the OR.

    I know there are some OBs who feel like they are "cleaning up the midwives' mess" but on the whole it seems to work.

    I have heard that doctors in British Columbia are required to attend a homebirth as part of their training. Hopefully the rest of Canada catches on to that idea!

  10. I am speaking as an HBAC-transport mother.

    I think first and foremost the OB *must* have a healthy respect for normal birth in general, and home birth specifically. When I was pregnant I saw my midwife's "back-up OB" for a VBAC consult. He was so bold as to tell me that my best chance at a VBAC was in an OOH setting.

    This OB and my midwife have a wonderful collaborative relationship and I think that's so important! He respects what she does and she respects what he does.

    I was never treated as a "failure" or a "freak" or an "irresponsible" mom for choosing a home birth. When my son was born, the OB even called out to my midwife to give the 1 and 5 minute APGARs.

    It was a wonderful, seamless, stress-free (as much as possible, anyway) transfer.

  11. As I said to midwife with a knife, I don't know how physicians can spend so many years of education and residency honing their skills, just in order to attend mostly uncomplicated births that don't require the majority of their skills. It's like training to be an intensivist or critical care physician, and then spending most of your time in family practice. Doctors have already divided those two specialties: high-skills adult medical care, versus low-skills normal adult care.

    If obstetrics was the practice of high-skills high-risk labor and birth, rather than the medical management of all births regardless of medical necessity, then midwifery would fit quite nicely into our healthcare system. But I don't know if collaberation between midwives and obstetricians is ever going to be smooth as long as they remain competitors for the same market.

  12. I'm a pregnant mother who is planning a home birth for my second. My first was a natural hospital birth with an OB. I live in NC, where CNMs must work under a physician and CPMs are not licensed.

    I agree that education and exposure is the key. Why would OBs realize how competent midwives are when they have never seen a successful home birth and have only seen those who have such significant problems that they must be transferred? Studies can easily be dismissed, but first-hand experience is powerful.

    My back-up OB did some of his training in New Zealand, and so has a healthy respect for midwives. In fact, he founded an organization called NC Physicians for Midwives. Organizations like that might also help to start bridging the gap between the professions.

    I hope, of course, that I do not have to transfer. But if I do, I want everything to go as smoothly as possible. For me, a supportive back-up OB is a key part of that, as is already having the required blood work, etc. beforehand. I may even "pre-register" so the hospital isn't surprised to see me. My (illegal in NC) midwife would attend a transfer as a relative. Why jump through all those hoops for something that isn't likely? So I don't end up being mistreated by doctors or staff who do not understand my choices.

    Great post! I read and enjoy your blog regularly. Thanks!

  13. I'm going for my 2nd HBAC in roughly 5 weeks. I'm a Canadian ex-pat living in the UK, and the system here is quite different. Births are midwife-led anyway (hospital or home), and OBs are generally only called in if there's a problem. Women don't routinely see an OB antenatally, and wouldn't normally be attended by one in birth.

    In terms of hospital transfers, it can vary depending on the type of midwife being used. An NHS (our national healthcare system) midwife would ring the hospital to let you know that you're transferring in, probably having rung them earlier when you went into labour (i.e. advising that they are attending a home birth so that the hospital can prepare in the event of a transfer.) Some hospitals will put an ambulence on standby for home births.

    If you employ an independent midwife (i.e. a "private" midwife you pay for yourself, and isn't employed by the NHS), she will usually call the hospital at some point in your pregnancy to introduce herself, and advise them of your home birth. If you do transfer (protocol would be the same), she usually won't be able to continue acting as your midwife and will be more like a doula. Some hospitals do allow independent midwives to work under contract in the event of a transfer, but it's not that common.

    Thankfully, the process - both home births and transfers - are fairly common here and staff are prepared.

  14. As a hospital based provider, I most wish for a truly collaborative system, where providers at each level of care respect each others area of expertise and can seamlessly transfer to another level of care if needed. There is so much distrust and fear in our current system - between client and provider, and different types of providers. It would be great if clients could be assured that if they needed a more complex type of care, that they would still be receiving evidence based and compassionate care in which they were kept fully informed and still retained all decision making. The hostility between midwives and docs, family docs and OBs, regular OBs and MFMs, etc helps no one. It would be great if our maternity care system in the US switched to being primarily midwifery or general practioner based - so that most women received care from a provider that knows them, that can see them over the long haul, and who provides evidence based care. OBs can be surgical and high risk specialists but also continue to provide evidence based care. It'd be great, too, if you needed one intervention you didn't have to accept everything they can think of because it's a package deal.

  15. Great thoughts in this post.

    I've birthed all four of my children at home, including twins. While home birthing has put me in a "weirdo" category with some people, having twins at home as put me on the planet Mars. But I don't mind.

    My twins came at 40 weeks and 3 days. They were born naturally, without incident. I had a 4 hour labor. They were born into my hands and the hands of my sweet husband. They weighed 9 lbs, 1 oz and 7 lbs 14 oz (and I'm an avg sized person). They were beautiful and healthy in every way and exclusively nursed 19 months.

    Home birthing has taught me that **anything** is possible in life.


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