A lot can happen in a week

This past week we...

Bought another multi-family property. We spent Saturday ripping out loads of old carpet, layers and layers of flooring, and trash left by previous tenants. It will be really nice when we're finished with it but I am having major buyer's remorse. Why do we do this???

Went on vacation to my parent's cabin in northern Wisconsin. It took 10 hours to drive there and 14 to drive back (you'll see why later).
 
Had our car break down on the way home. The alternator pulley and belt broke about 5 hours into our trip. Fortunately we were 5 minutes from a European auto repair shop. Fortunately the shop was still open at 4 pm on a Friday. Fortunately the shop was able to locate the hard-to-find parts at a local VW dealership, since none of the auto parts stores carried them.  $550 and a few  hours later we were on our way.

Classic Eric quote: "The noise stopped! We should just keep driving." This was right after the alternator belt broke and the screeching noise stopped. I insisted we go to the shop. A minute later, the A/C failed, the power steering failed, and the alternator light went on. He conceded we should have the car looked at.

Enjoyed wonderful weather while most of the country suffered through a heat wave. Today's high is 92 F (close to 34 C) and that's cooler than last week


Had no internet access for a week. I read 2 books and about 20 magazines. I took naps in the hammock.  And I realized that I probably don't need to check my email several times a day!

Human Rights in Childbirth: Panel 4

Panel 4:

Collaboration, Competition, Money and Monopoly:

The legal status of doctors, midwives, and hospitals in pregnancy and obstetric care

Panelists:

• Barbara Hewson: human rights attorney, UK
• Marlies Eggermont: healthcare lawyer and midwife, Belgium
• Becky Reed: midwife, UK
• Amali Lokugamage: obstetrician-gynecologist, UK
• Elke Heckel: independent midwife, UK
• Debra Pascali-Bonaro: doula and filmmaker, USA 
• Jill Arnold: blogger, USA
• Ina May Gaskin (moderator): midwife, USA

 Barbara Hewson spoke about independent midwives in the UK and their difficulty in obtaining malpractice insurance (also called professional indemnity insurance, or PII). Recent EU regulations concerning healthcare mandate that all health care providers carry PII, which might mean the extinction of independent midwives across Europe unless they are able to find a creative solution to the insurance mandate.

She also mentioned Mary Cronk, an experienced (and now retired) British midwife known for her pithy advice. Cronk was fond of saying that doctors and midwives are the servants of the women they look after, not the masters. Hewson also referred to Cronk's strategies for when you're told "you're not allowed to do that."

Marlies Eggermont, a midwife and lawyer in Belgium, referred to the Ternovszky case and examined whether Germany, France, the Netherlands, the UK, and Belgium are in compliance with Article 8 of the European Convention on Human Rights. She concluded that these five countries have legislation in place consistent with Article 8, but that real choices are often absent. Insurance is often an issue, either availability or cost. She also noted flaws with physicians' risk communication and detection.

Becky Reed highlighted the history and closure of the Albany Midwifery Practice, which I summarized in Panel 2.

 Amali Lokugamage, a UK OB/GYN, spoke about her journey to home birth as an obstetrician. She noted the monopoly of the medical model in understanding pregnancy and childbirth. Her own experience of pregnancy opened new ways of knowing and understanding the world around her, as her left-brained self discovered right-brained thought processes for the first time. She wrote a book about her own journey to choosing a home birth ("a peak experience in my life"), called The Heart in the Womb. She also mentioned that the grading of evidence in RCOG and ACOG documents gives patient more power in negotiating their care.

Elke Heckel also spoke about the difficulties for independent midwives to find PII.

Debra Pascali-Bonaro spoke about the important role of doulas in maternity care.

Jill Arnold told her own story: pregnant with a suspected big baby, her care providers urged her to have an elective cesarean. She began researching the medical literature, disocvered that those recommendations were not supported by evidence, and refused the procedure. She named the elephant in the room in her story: that an authority figure was encouraging her to make decisions that had no medical basis.

In the ensuing discussion--which, like all of the post-panel discussions, was quite lively--I remember that Betty-Anne Daviss made a comment about both horizontal (provider to provider) and vertical violence (provider to woman) in maternity care.  We also heard about the importance of pursuing mediation before pressing charges or going to hearings.
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What are the basic needs of women in labor?

After panel 3 of the Human Rights in Childbirth Conference, the moderator abandoned the usual audience Q&A in favor of small group discussions. She challenged us to discuss one of the issues raised in the panel, then report back to the larger group.

I was sitting next to Jill Arnold, Chantal Gill'ard, and Britt Somebody (if it was you, please leave your full name in the comments!). Anna Verwaal's film had been the last item on the panel, and we first discussed why we resisted some of its emotional appeals. Then we turned to answering Michel Odent's question:

Now that we have discovered that newborn babies need their mothers, can we (re)discover the basic needs of women in labor?

I vounteered to be the spokeswoman. Here's what I reported back to the large group:

~~~~~

The four of us attempted to answer Michel Odent's question about the basic needs of women in labor. We enjoyed watching the film, but we found ourselves resisting some of its emotional appeals and its implicit assumptions that there's a right and a wrong way to give birth. We are searching for a series of truths or standards that hold true in all settings, that don't prescribe a certain way to give birth, yet that aren't so weak as to be totally useless.

Even if all women are given the most ideal, supportive birth setting possible, some women will still need medical intervention. So it's not solely about having a spontaneous, unmedicated labor. In addition, not all women desire or enjoy a "natural" birth or even a vaginal birth. Can we identify the basic needs of women in labor in ways that allow for a variety of birth experiences and a diversity of journeys?

We think we can. For those of you who like to think more left-brained, we came up with four key needs of all laboring women:

First, a right to autonomy.

 Second, a right to informed consent and refusal and the necessary information to make those decisions.

Third, real options to choose from. Autonomy and informed consent/refusal cannot exist without choice.
 
Fourth, being treated with respect & dignity.

If you're more of a right-brained thinker, these four principles can be boiled down even further into one simple question. This is the litmus test for what every woman deserves when she gives birth:

Was there love in the room?

Home again

We flew back from France a week ago. I had the kids on my own again. It went something like this the whole way home:

Me: okay kids let's go. no running the wrong way on the moving sidewalks. Inga, wrong way! who needs to go pee? look, airplanes! I'm sorry that your ears hurt. try some gum to see if they will pop. no Dio you can't climb over the seat. watch out so your drink doesn't spill. Zari can you watch Inga while I use the bathroom? uh oh, Inga just ripped the magazine. look, Inga, a picture of a dog! yes, we're way up high in the sky, higher than the clouds. Dio please don't kick Zari. Could we get some more water please? (x 21 hours)

Eric: sleep. watch a movie. sleep. watch another movie. read a book. sleep. (x 21 hours)

The kids did okay on the first two flights, but by the third flight they were a mess. Zari's ears wouldn't pop and she was sobbing the whole time. Dio was shrieking because I made him stay buckled in when the light went on. Inga was screaming because 5 minutes after she finally fell asleep, Dio had to go to the bathroom and she woke when I got up to help him.

We traveled for 21 hours from start to finish, starting at 4 am. Eric got bumped on the way home--on purpose, so he could get vouchers--but that meant I was on my own the first night home. So you'd think we would all sleep like the dead after being awake for so long. But no. Dio woke up at 1:30 am (7:30 am French time) and was convinced it was time to be awake. Oh, and Zari and Inga both woke up multiple times that night, too. Thankfully we're all back on schedule now.

I've been working my way through 4 weeks of weeds in my gardens. It's hot hot hot here and unusually dry. I'm actually watering my plants, which you never do in this part of the country.

Coming up:

• Notes on the rest of the Human Rights in Childbirth Conference
• A set of book reviews about food, France, and raising children
• Reviews of some new DVDs, from documentaries to prenatal bellydancing

Human Rights in Childbirth: Panel 3

Panel 3:

The Rights of the Baby:

The interests of the unborn child and the power to speak for those interests

Panelists:

• Farah Diaz-Tello: civil/human rights lawyer, USA 
• Roanna Rosewood: mother, USA
• Barbara Harper: nurse and birth activist, USA
• Susan Bewley: obstetrician-gynecologist, UK
• Noam Zohar: professor of philosophy and ethics, Israel
• Michel Odent: obstetrician, France
• Anna Verwaal (moderator): maternal child health nurse, birth consultant, USA

Farah Diaz-Tello, an attorney for National Advocates for Pregnant Women, opened the panel by commenting on the legal implications of separating the mother & fetus. Pregnant women become second-class citizens when the fetus-mother are are separated, giving the fetus equal or greater rights than the woman. Pregnant women have been--and are continuing to be--punished for their health-care problems and addictions. She referred to a case in Norway where a pregnant woman terminated her pregnancy rather than face imprisonment for the duration of her pregnancy. She commented on the need for treating pregnant women with dignity and respect and ended with the question: "At what point in pregnancy does a woman start to lose her human rights?"

Roanna Rosewood, a mother of 3 children, told a moving story about her first two births via cesarean section. When she was pregnant with her third, her hospital had changed its policies and made VBAC practically impossible. Her doctor wanted to help, but her hands were tied. So Roanna chose to give birth to her third child at home. An excerpt from her presentation:

Women were created to give life and protect the interests of our children. We cannot separate from it. It is who we are. It's in the breadth of our hips that widen of their own volition to cradle them. It's in the curve of our breasts, heavy with milk to soothe them. Every month, our wombs ache in preparation to receive life because, as women, it is our responsibility, honor, and choice to bring new life into the world. We alone have earned the right to speak for our unborn babies' interests.

Roanna is currently working on a book Cut, Stapled and Mended: A Do-It-Yourself Birth  , forthcoming in 2013.

Barbara Harper, founder of WaterBirth International, first reviewed the UNICEF Convention on the Rights of the Child. In her presentation and in her letter to the conference, she touched on the growing field of epigenetics that examines how perinatal experiences affect a human years, even decades, later. A few comments for her conference letter worth mentioning:

Fear is omnipresent in modern birth rooms throughout the world. Fear of outcome, fear of litigation, fear of not following the rules and regulations set by the institution. When women were surveyed, they do not want to be in an environment that is unfriendly, non-supportive or not accommodating....

The place of birth is not as important as the cooperative effort and respectful attitude that is show to mother/baby....How we care for pregnant women, assist birthing mothers and what we do immediately after birth with mother/baby creates sequelae that influence the core of our existence as human beings. Instead of looking at a "right place" or a "wrong place" to care for women and their babies, we must look at a "cooperative best way," with complete honesty. 

Dr. Bewley, a UK OB/GYN, examined laws or regulations that currently limit pregnant women's freedom. She noted that pregnant women's liberty is constrained in several different ways: by laws that restrict work or exposure to occupational hazards, by airline travel rules, by incarceration in prison or mental health institutions, and by cultural or social stigma. In all of these cases, these limitations require sound justification. She next turned to examples of limiting pregnant women's autonomy in favor of avoiding harm to the fetus. She highlighted several real-life examples that might provoke medical professionals to limit a pregnant woman's autonomy in order to help the baby:

• Women who are HIV+ but decline anti-retrovirals, 
• Substance misusers
• Jehovah's witnesses who refuse in-utero blood transfusion for hydrops
• Woman with a personality disorder inserting tools into her uterus at 28 weeks gestation
• Women with severe pre-eclampsia refusing hospital admission
• Women who decline cervical cerclage in the second trimester 
• Women who refuse to consent to a CS and whose babies are stillborn or sustained brain damage
• Women who decline routine blood tests due to needle phobia

In these cases, actions to prevent "real and avoidable harm" were not universally beneficial: some babies were helped, others were harmed.

Dr. Bewley next addressed the differences between treating the mother as a patient versus the fetus as a patient. She highlighted the tools ("obstetric armamentarium") that obstetricians can use when counseling their patients:

• appealing to their training, skills, and expertise
• having a trusting relationship with the patient based on confidentiality and consent
• listening to the patient's story
• formulating a diagnosis, prognosis, and agreeing on a plan
• Advising, monitoring, prescribing, operating, negotiating, and referring
• Using friends, family, religious and community advisers
• Heavy-duty moral persuasion (she noted that while she personally doesn't like to use this one, it *does* get used by other physicians)

She suggested abandoning the the use of force, threats, or fear.

Last, Dr. Bewley examined the possible effects of proposed "fetal rights" laws and reiterated her main point--that laws limiting pregnant women's autonomy in the name of safety will never have a universally beneficial effect. Some babies will be helped, but others will be harmed. What Dr. Bewley was implying, I think, is that certainty is elusive in medical decision-making. This makes the ethics of doctor-patient interactions all the more complicated.

Noam Zohar, a philosopher of bioethics, discussed how risk is always culturally processed. Every day, parents take much more elevated risks with their existing children than they do when they choose to give birth at home. Being a parent means weighing one marginal risk against another. He commented: "Even if the there is some increase in negative outcomes due to home birth, the absolute magnitude is so small that it is absurd to base any policy on it."

Michel Odent reminded us that we need to think long-term about what is best for babies. He expressed satisfaction that science and medicine have finally (re)discovered a core truth: that newborn babies need their mothers. The challenge for the 21st century is to find the answer to another core question: can we (re)discover the basic needs of pregnant & laboring women? 

Anna Verwaal showed a short video posing questions about the impact of birth experiences on the baby. While the images were beautiful and arresting and most of the commentary was spot-on, I (and Jill Arnold, who was sitting next to me) resisted some of the more heavy-handed rhetoric that the right kind of birth has the potential to cure the ills of the human race and that we're scarred for life if our own birth was difficult or traumatic. I turned to Jill and said, "Hey, I was born while my mother was hanging upside-down by her ankles and I think I turned out just fine!" She agreed.

I don't feel like I am somehow still processing or struggling against the circumstances of my less-than-ideal birth. This doesn't negate the need for gentleness and love and respect during the birth process; however, we need to be careful about some of the inflated claims we might make in our efforts to improve the birth experiences of mothers and babies.

Dutch bikes

Some tourists in the Netherlands take pictures of canals or old buildings. I take pictures of bikes.

a typical street, full of parked bikes

bikes parked in front of a theater building

old street & canal in Amsterdam, with bikes parked all over of course

lots of people doubled/tripled up on bikes (usually a parent with 2 kids, but occasionally adults would ride too!)

 Now my favorite part...all of the cool bikes & bike seats. I loved these front-end cargo bikes.

 Inside there is a seat with 2 seatbelts.

 I also saw some serious cargo bikes! You'll never get wet inside these.

Tandem bike, plus a child seat on the back

A family with 3 children lives here! You can see the parent's bike with 2 child's seats and saddlebags, and a kid's bike chained up behind it. I love the little windscreen in front of the baby seat. 

 

"No biking" signs

Okay, I did take one houseboat picture!

Homebirth in Australia: more marginalized and less safe

Homebirth Australia just issued a statement responding to the SA Deputy Coroner's recommendations to require health care workers to reported planned "high-risk" home births (more details available at the end of this post). The statement is included in full below.

Also worth reading is Hannah Dahlen's article Pushing home birth underground raises safety concerns. Dahlen is an associate professor of midwifery at University of Western Sydney.

~~~~~

Coroner’s Recommendations:  

Short sighted and misses the point on homebirth
7 June 2012

Following an inquest in to the death of three babies, recommendations about the provision of homebirth services have been made by South Australian Deputy Coroner Anthony Schapel.

Homebirth Australia has concerns about the recommendations made by the Coroner. It is our view that, if implemented, the recommendations will lead to homebirth becoming more marginalised and less safe.

What was missing from the Coroner’s findings was any real consideration of the reasons why women choose homebirth. Lack of access to quality maternity care options and sensitive providers forces many women to turn their back on hospital care.

Listening to women, respecting their autonomy and developing services that genuinely meet their needs we will do far more to ensure the safety of mothers and babies than punitive short-sighted responses that remove options and marginalise certain choices.

Women make the choice to give birth outside a hospital with identified risk factors due to their profound dissatisfaction with the current maternity care system and in some cases because of previous hospital experiences that have left them deeply traumatised.

When our hospitals leave women so damaged after a birth that they refuse to return no matter what the risk, then we need to look at why.

Any law reform around homebirth must recognise that all women (including pregnant women) have a fundamental right to bodily autonomy and a legal right to refuse medical care.

The right of women to make decisions around the circumstances of their births and to choose homebirth has been recognised by the European Court of Human Rights.

The ability of women to make decisions about their maternity care is recognised at common law and by the Australian College of Midwives, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists and the Australian Medical Association.

Women will continue to choose homebirth regardless of the legal or regulatory framework surrounding midwifery practice and other women will heed their call for support if the maternity care system fails to support them to give birth at home.

Contact: Michelle Meares – 0439 645 372

Human Rights in Childbirth: Panel 2

Panel 2:

Safety, Risk, Costs & Benefits:

Weighing Choices in childbirth

Panelists:

• Peter Brocklehurst: doctor, Director of National Perinatal Epidemiology Unit, UK
• Soo Downe: professor of midwifery sciences, UK
• Elitsa Golab: civil and constitutional rights lawyer, USA
• Hélène Vadeboncoeur: public health researcher, Canada
• Jennie Joseph: midwife, USA
• Jo Murphy-Lawless: sociologist and historian, Ireland
• Marieke de Haas: mother, Netherlands
• Robbie Davis-Floyd (moderator): medical anthropologist, USA

Peter Brocklehurst, head researcher of the Birth Place study, began the panel by presenting results from his research. This study followed women in the NHS in four birth locations: home, freestanding midwifery units, alongside midwifery units, and obstetric units.

Soo Downe spoke about how women in the UK are influenced to make choices, from newspapers to television shows (including One Born Every Minute and Call The Midwife. Although we have the data about birth outcomes, she argued, we don't have the belief in the data. She argued that we need to frame birth choices not in terms of home/hospital, but in terms of consequences.

She also mentioned a book chapter that she authored in 2010 called Towards Salutogenic Birth in the 21st Century--the book is now on my to-read list.

Hélène Vadeboncoeur spoke about VBAC. Do pregnant women have VBAC rights? She reviewed the situation in the United States, where expecting women have had to resort to legal means to gain access to VBAC. She mentioned some maternity organizations that have made significant contributions, including the White Ribbon Alliance work to ensure Respectful Maternity Care via its elaboration of the Universal Rights of Childbearing Women (PDF) and the International MotherBaby Childbirth Initiative. She concluded by discussing how evidence-based medicine has an unexpected negative consequences of leaving less space for individualization of care.

Elitsa Golab, an attorney who is involved with ICAN, spoke about the concept and historical development of informed consent in the United States. How a society upholds a person's right to informed consent reflects the values that a society places on a person's autonomy. One of the earliest important legal decisions was Schloendorff v. Society of New York Hospital, in which Justice Cardozo wrote:

Every human being of adult years and sound mind has a right to determine what shall be done with his own body; and a surgeon who performs an operation without his patient's consent commits an assault for which he is liable in damages. This is true except in cases of emergency where the patient is unconscious and where it is necessary to operate before consent can be obtained.

We currently have two standards of informed consent: a patient-based standard, and a physician-based standard. She called for moving away from a physician-based and towards a patient-based standard.

Golab also discussed what a pregnant woman can do if her informed consent is violated--does she have any legal recourse? She called for a cultural recognition that birth is an important process and that women need actual choices to be able to give informed consent.

Jennie Joseph, a British-trained midwife who currently works in Florida, argued that poor women are left disenfranchised in our maternity care system. Her statement that "capitalism, racism, classism, and sexist will kill your baby, will kill you" received a standing ovation. The basic premise of her practice is that every woman wants a healthy baby. She provides access to every woman who wants care, no matter her ability to pay. She has witnessed incredible results in birth outcomes when women--many of who were high-risk because of poverty or race--receive supportive care.

Jo Murphy-Lawless posed the question "Who are the people/groups benefiting from our current maternity care system?" (Let me give you a hint: it certainly didn't have pregnant women at the top of the list!) She discussed the evolution of a health care system to a health care industry. With ever-tightening schedules of risk, the insurance industry profits from these constraints. Another by-product of the health care industry is increased centralization of maternity care.

She suggested borrowing from the environmental movement and using the process of "positional analysis" to make the necessary connections between trends in health care and women's needs in maternity care. We also need to be sure not to focus only on women's individual experiences of birth--which are very important--but on a collective approach that examines the values we transmit to the next generation.

Marieke de Haas, an anesthesiology resident, spoke about her choice to have a vaginal breech birth at home. Just last week, her resident colleagues laughed at her when she told them she loved giving birth and wanted to do it again a week after she had her baby. When she was pregnant with her breech baby, she didn't feel safe enough to explain her wishes to her hospital-based care providers, let alone try for a physiological birth--hence her choice to birth at home. She hopes for open dialogue between women and their care providers so women feel supported enough to be really open about their hopes and wishes.

At the end of the panel presentations, Robbie Davis-Floyd spoke how health care models that are too successful often get shut down. She presented the case of the Albany Practice in London, an all-risk NHS midwifery practice with fantastic outcomes--perinatal mortality rates were 4.9/1000 in the practice, compared to 11.4/1000 in the overall borough and 7.9/1000 nationwide. Remember, this group took on women from all risk factors in an underprivileged area; these were not cherry-picked wealthy white women by any means. The Albany Midwifery model also had a much lower cesarean rate and a very high home birth rate. Despite--perhaps because of--these excellent outcomes, the practice was shut down in 2009 by King's College Hospital.

Now a few of my notes from the very lively discussion and Q&A:

• A physiologist/pharmacologist commented about the need to study the long-term effects of drugs used in labor, especially oxytocic drugs. 
• Karen Guilliland, a midwife from New Zealand, mentioned that they're doing a study similar to the Birth Place study and haven't seen a rise in adverse perinatal outcomes among nulliparous women. She posited that cultural/social context matters in birth outcomes, since she comes from a culture that supports midwives, women's choice, and place of birth.
• Soo Downe referenced a report finding that where women and midwives are respected in the culture, maternal mortality is at its lowest. (Trying to find the name of the report--can anyone help?)

Some final questions that were raised:

• How can we restore women's autonomy here and now in the world?
• Is the legal route the only one, or the best one, to ensuring women's autonomy in childbirth?
• What happens when women are denied autonomy in childbirth?
• What about ethnicity and racial outcomes?

If you've made it through my summary of Panel 2, congrats to you! I'm glad you took the time, because these matters are pressing and relevant. Just today, I read that Australia might further restrict and regulate home birth women and their midwives, especially those who choose "high risk" home births. South Australia deputy coroner has recommended regulations requiring health care workers to report intended "high risk" home births. He has also proposed requiring these parents to have a consultation with a senior obstetrician about their home birth plans. See this article and this article for more details.

Rixa op-ed begins here: I strongly object to any approach that further penalizes, ostracizes, or coerces women and their midwives. It's the wrong strategy. Women who are already "obstetric refugees" because of a lack of options, previous traumatic birth experiences, or negative treatment by hospital staff, are not going to suddenly choose hospital birth if their home birth choices are further restricted. If anything, it will push these women further underground, further outside the system. It will definitely increase the rate of unassisted births.

Obstetricians have created a Pandora's box by creating an environment for childbirth that some women find unacceptably unsafe and hostile. Then, when women choose to birth outside that environment, obstetricians seek to punish the very women they were driving away. Talk about a double bind. It's like raping a woman and then punishing her for being raped.

Australian midwives are in agreement that a punitive approach is misguided. From Adelaide Now:

Australian College of Midwives' Dr Hannah Dahlen said the recommendation was concerning.

"What I think that will do is push birthing underground as some mothers will now not go near a hospital for blood tests or scans (as they did previously)," she said. "The ramifications will make the system less safe, not more safe."

Dr Dahlen said the inquest was a lost opportunity to improve the health system to provide more options to pregnant women and many felt like "refugees" who avoided hospitals after negative experiences.

If health care workers object to women choosing home births, they must realize that they have created the very conditions that drive women away from hospitals. One-third of all births ending in cesarean? Almost no chance of avoiding synthetic oxytocin at some point during labor or birth? Having to fight and negotiate for what you want, instead of simply letting go and laboring? Not "allowed" to have a VBAC or a vaginal breech birth? With these scenarios, home birth seems like a no-brainer.

15 months old!

Where has my baby gone? I have a crazy active toddler now who won't sit still for more than 2 seconds. How am I going to manage through the 3 plane rides home from France? (I'll be on my own again, since Eric wasn't able to get the same flight home.)

Inga's hair is growing in nicely...and it's curly! Who would have thought?

She often sleeps like this.

She loves to go on the playground equipment all by herself.

 

 

Inga says just a few words: mama, papa/dada, uh-oh, eew, & fish (last one learned yesterday when we were at the aquarium in Monaco)

She signs a lot more words: more, please, dog, cat, bird, fish, car, airplane, train, milk, nurse, papa, eat, shoes 
 
She just started sleeping all the way through the night, a good 12-13 hours. We were down to one 6 am waking but now she's cut that one out too. Hooray!

splashing in the "dragon pool" on the way up to the parc du chateau in Nice

aquarium in Monaco

nursing on top of the Monaco aquarium

Human Rights in Childbirth: Panel 1

Panel 1:

Ternovszky s. Hungary:

Context and Consequences of the ECHR Decision

Panelists:

• Anna Ternovszky: mother, Hungary
• Stephanie Kapronczay: human rights attorney, Hungary
• Istvan Marton: OB/GYN and professor, Hungary
• Imre Szebik: bioethicist, Hungary
• Elizabeth Prochaska: human rights attorney, UK
• Karen Guilliland: midwife, New Zealand
• Barbara Katz Rothman (moderator): sociologist, USA

Each panelist had 5 minutes to speak. After the panel presentations, a 30-45 minute discussion/Q&A with the audience followed.

The panel opened with an acknowledgement of the presence of the Hungarian ambassador to The Hague, Gyula Sümeghy.

Anna Ternovszky spoke first about her two children's births, attended by Dr. Agnes Gereb. When she was pregnant with her second, Dr. Gereb was already under investigation and Anna was uncertain if she would lose her birth attendant. Anna and human rights attorney Stephanie Kraponczay decided to bring Anna's case before the European Court of Human Rights. As I noted in an earlier post, they won the case. The ECHR decision found that Anna's human rights had been violated in regards to both the right to privacy and the right to be free from discrimination. Although Anna won the case, Hungary's new home birth regulations are extremely restrictive and make HB nearly unattainable for both parents and midwives. Anna urged that we must continue to fight discrimination against midwives when there's a bad outcome. She noted that Hungary's regulations still give OBs the ultimate power in who can have a home birth. In addition, only OBs are allowed to provide prenatal care, further limiting access to midwives and eliminating the benefits that come from well-developed relationships between a midwife and the woman she cares for.

Next, attorney Stephanie Kapronczay, who works for a human rights NGO in Hungary, spoke about how she became interested in the case. She was horrified to learn that in Hungary, the doctrines of informed consent/refusal did not apply to pregnant women and that midwifery was not recognized as a profession. Now that she has won the case, she continues to be concerned about over-regulation of home birth since government decrees, rather than professional protocols, house home birth regulations. She mention the plight of Dr. Agnes Gereb, who is still under house arrest awaiting her 2-year prison sentence.

Dr. Istvan Marton, a Hungarian OB/GYN and professor, spoke about how he helped introduce family-friendly obstetric care in what used to be a totalitarian state. He published a book about family-friendly childbirth that sold 100,000 copies--remarkable for a relatively small country. His book is titled Terheskönyv: gyakorlati útmutató kismamáknak by Marton István. (Publication information: fényképezte Fekete Zsuzsa, 3rd ed., Budapest : Novotrade, 1990.). The record also says the book is based on Pregnancy and Birth Book by Dr. Miriam Stoppard.

In Hungary's health care act, doctors can treat pregnant women without their consent after 24 weeks of pregnancy. (See the slides below.) In other words, Hungarian medical practitioners have to uphold the fetus against the mother's interests--this goes against EU law that upholds a person's right to informed consent. The only way to get outside this legal-medical system was through home birth. Dr. Marton mentioned that he is working hard to obtain a presidential pardon for Dr. Gereb.

 

Hungarian bioethicist Imre Szebik spoke next. He argued that there is a war going on in Hungary over childbearing women's rights, and one tool in that war is providing false information. Underlying motives include financial gain and securing professional dominance for obstetricians. He noted that all testimonies in Dr. Gereb's trial came from OBs who openly stated that they were opposed to home birth. He feels that her trial was strongly biased. The underlying assumption at the trial was that whatever a midwife said, it was wrong. Scientific evidence was totally neglected by the experts testifying, and a double standard was evident. Szebik also explained the Hungarian obstetric system; most OBs' income comes from "informal" payments (bribes) to supplement their meager state salaries. However, home birth providers in Hungary accepted payments on a voluntary sliding scale. He argued that home birth outcomes in Hungary implicitly criticized hospital practices, and that the existence of home birth questions the dominance and hegemony of doctors and hospitals.

Elizabeth Prochaska, a UK human rights attorney, examined how the Ternovszky case is law and what impact is may have. All EU member countries have agreed to the human rights convention. So if a human rights complaint is upheld by the ECHR, the government has to follow the court's decision or face a large fine. Of course, the ECHR cannot do anything more than impose fines, so theoretically a state can ignore ECHR rulings as long as they have deep enough pockets. Prochaska explained that the more exciting and promising thing to do, now that the Ternovszky case exists, is to bring your case domestically, since EU law is domestic law.

She gave a recent example of a hospital in the UK that was going to suspend its home birth service over the Christmas holiday period. She represented the plaintiffs (pregnant women due in that period who had planned home births) and threatened legal action against the hospital if they withdrew their home birth services, based on Article 8 of the Human Rights convention. The hospital immediately backed down and contracted with independent midwives to cover these mothers' needs. So, take the EU human rights law to your domestic courts--it's the best way to show the power of this ruling.

Prochaska also noted that EU law is "absolutely clear" that a woman can only receive medical treatment without her consent when she has a documented inability to comprehend the situation (such as a documented mental illness). 

Karen Guilliland, a midwife from New Zealand, next spoke about the NZ maternity care system. She noted that New Zealand's progressive system can not through the law, but through the power of the women's vote and women's groups. In New Zealand, the courts have upheld pregnant women's and midwives' right to make decisions about their health care. She painted a very rosy picture of birth choices and rights in New Zealand, noting that 80% of women use midwives, that women have free access to choose home births or birth centers, and that both midwives and pregnant women have the right to access and collaborate with doctors. However, she noted that New Zealand is becoming more fetus-centric. She noted the importance of consumer power and the need for strong male involvement in ensuring that pregnant women and midwives continue to have rights.

One point that really struck me was that New Zealand's maternity care laws and regulations mirror its core social/cultural beliefs. It made me realize that changing laws won't do enough; we also need to change attitudes and values about maternity care.

The Hungarian ambassador spoke next, noting that a presidential pardon for Dr. Gereb is at the sole discretion of the president. He found this issue very important and interesting and feels that the Ternovszky case has contributed significantly to both international and domestic dialogue.

Human Rights in Childbirth Conference, Introduction

I can't possibly describe in full the complex discussions at the Human Rights in Childbirth Conference. So let me share the highlights, taken from my notes and from my memory.

We arrived at the Hague University of Applied Sciences on a windy, rainy morning. If Amsterdam is old and scenic, then The Hague is IKEA on steroids. Everything is modern and geometrical, glass and stainless steel and blond wood. Close to 300 participants filled this auditorium, with another several hundred listening in via webcast. A large number of attendees were from Holland; the remaining came from all over the world. The audience was a majority female. Participant occupations ranged from midwives, OBs, pediatricians, and neonatologists; to doulas, mothers, and birth activists; to bioethicists, attorneys, and health care CEOs.

Hermine Hayes-Klein, the brainchild behind the conference, opened the conference. An American attorney who moved to Holland and had her two children under the care of Dutch midwives, Hermine was intrigued by how the care she received contrasted to her American friends' back home. After the European Court of Human Rights ruled in 2010 (Ternovszky vs. Hungary) that pregnant women have the "right of choosing the circumstances of becoming a parent." The ruling stated that EU member countries must ensure that pregnant women have access to home birth and that home birth providers should not be persecuted. This landmark ruling has wide implications for childbearing women and midwives across Europe, although the details of how this decision will be implemented in each country are still unclear.

The ECHR decision made two important points: First, that women have the right to be the chooser in how and where to give birth. Second, that women need options to choose from. The Human Rights in Childbirth Conference explored the extent that women do or do not have birth choices in various countries around the world. Presenters and participants examined how a lack of birth options might be considered a fundamental human rights violation.

Ina May Gaskin gave a brief keynote address, noting that the conference would attempt to address the following topics:
1. Pregnant women in many countries are learning that they have fewer rights than other people.
2. Strategies to address the above situation.
3. Low- and high-income countries face opposing challenges regarding childbirth (too little access to medical care versus too much medical care).
 She reviewed trends in maternity care around the world--deskilling of midwives and obstetricians, increase in cesarean rates and inductions, closure of community hospitals and centralization of maternity care in large tertiary centers, changes in infertility medicine, rise in medical malpractice suits. Ina May ended her presentation with a call for more localized, decentralized maternity care and an end to the double standard in treatment of home and hospital providers after a bad outcome.

Four panel discussions filled the rest of the two conference days: Day 1 took a global perspective on human rights and childbirth issues:

• Panel 1: Ternovszky v. Hungary: Context and Consequences of the ECHR Decision
• Panel 2: Safety, Risk, Costs and Benefits: Weighing Choices in Childbirth
• Panel 3: The Rights of the Baby: The interests of the unborn child and the power to speak for those interests
• Panel 4: Collaboration, Competition, Money and Monopoly: The legal status of doctors, midwives, and hospitals in pregnancy and obstetric care

Day 2 examined issues of human rights within the Dutch maternity care system. 

• Panel 5: Perinatal Mortality in the Netherlands: Facts, Myths, and Policy
• Panel 6: Cases on the Edge: Controversial Birth Choices in the Netherlands
• Panel 7: Financial Pressures in the Dutch Obstetric System
• Panel 8: Ternovszky in Holland: The Future of Choice in the Dutch Obstetric System

My next series of posts will summarize these panel discussions.

Back from the conference

Wow, what an intense 2 days at the Human Rights in Childbirth Conference! I am so glad I didn't bring Inga. She did great, by the way--no problems at all with me being gone. I was super engorged the day after I left her and had to pump 3 times :)

The conference had an outstanding group of speakers and participants. My brain was firing at top speed, and I took nonstop notes during each conference session. More details to come soon.

Me & Jill of The Unnecesarean and CesareanRates

Jill with the conference organizer and two amazing US attorneys. We had great conversations about the boundaries of personhood and the murky legal status of pregnant women. 

If you attended the conference or viewed the webinar, please drop by and share your thoughts!
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