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?