Birth control / controlling birth

Yesterday I was musing on the idea of controlling birth. Along with accusations of being selfish, narcissistic, irresponsible, horribly misinformed, or tragically brainwashed, home birthers also are accused of wanting to control their birth. Women submitting hospital birth plans get accused of this, too. You can't control birth. Birth is [fill in the blank...dangerous, unpredictable, chaotic, messy, etc.] Thinking you can control birth is delusional. Labor & delivery nurses have a common lore that the longer and more detailed the birth plan, the more likely the woman will end up with a cesarean.

Being in control was very important to me. It was probably the primary reason I chose to have all four of my children at home.

But here's what I mean when I speak about being in control:

The control comes in setting up my birth environment and the people who will be with me so that once I am in labor, the only task I have to focus on is working with the contractions. Home birth gave me the freedom to let go entirely during labor and just be in the moment.

I didn't have to fight any battles over monitoring or what I was allowed to eat or drink. I didn't have to wonder if the nurse or doctor would understand, let alone allow, my style of birthing. I didn't have to worry about any strangers coming into my space. I didn't have to be constantly vigilant to be sure my wishes were respected.  I didn't have to argue, negotiate, compromise, refuse, or accept. I just labored in peace. Being in control let me give up control entirely once labor began.

Control => autonomy

Control => freedom of thought, movement, time, and space

Control => the ability to let go entirely and to allow labor to unfold spontaneously

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More on birth plans

I'm on a birth plan kick, if you hadn't noticed already.

First, I wanted to share this post about birth plans from Stephanie Soderblom's blog Vita Mutari. Stephanie is a CPM in Arizona. I met her once at a birth conference in Mesa, and a good friend of mine attends births with her. Stephanie's post actually inspired me to write up my own birth plan, especially the wording in the first part of the hospital version. Here are some excerpts:

I have heard some argue that a birth plan is trying to control the uncontrollable (the birth)…that it is almost guaranteeing that you will have problems because you are trying to dictate the way the birth will go.

First off…I can not disagree strongly enough...To me, a birth plan has nothing to do with controlling the birth or how the birth will unfold…it is ONLY about how you are treated throughout this journey. I haven’t read a birth plan yet that addressed the BIRTH (“I want to be in labor less than 10 hours” “I will feel it only in my hips and cervix, not in my thighs or back.” “My contractions shall not become closer than 5 minutes apart”)…..NO! The birth plan is addressing the choices and actions of those around you!

Most birth plans can be summarized thusly: “You will treat me with respect at all times and I will maintain the autonomy that I had before entering your hospital. Before you touch me or intervene in the normal course of my labor/delivery, you will discuss it with me and obtain informed consent.”

**stands back and looks at the birth plan**

Yep…that’s pretty much it in a nutshell. This in no way states anything about how the birth will unfold or trying to control events – it’s about how you are treated and the respect you are given in the process as an adult autonomous human with rights and freedoms....

My favorite birth plan I have ever been given was hand-written on an index card and said simply, “Don’t F*** with me!” I happily signed this birth plan, hole-punched it and put it front and center in her chart.

I also added birth plans to the "topics of interest" on the left sidebar. If you click on it, you'll open this window, which has links to all of my posts on that subject.

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My birth plan

Birth Plan
Go into labor
Push out a baby
Nurse the baby
End of story

Birth Plan, slightly longer version
Go into labor
Ignore it for as long as possible
Walk
Sway hips
Sit on the birth ball
Get in the tub
Repeat as necessary
Please take pictures and videos
Most likely will be kneeling
Push out a baby
Catch the baby myself
Nurse the baby
End of story

Birth Plan, hospital version
Before you touch me or do anything to me or the baby, you will discus it with me and obtain informed consent.

If I decline something, which is entirely possible, treat me with respect.

You might want to know...
When I am in labor, I like to be left alone. If I need something, I will ask. Otherwise don't bug me.

If you have a question, ask my husband or midwife first. I like to be left alone.

I usually give birth kneeling or Captain Morgan style. I probably won't be on the bed. Be prepared.

If you want to take heart tones, you'll need a handheld Doppler. I will be moving around. A lot.

I will be eating and drinking if I am hungry or thirsty.

Don't offer drugs or ask me to rate my pain. Make up a number if you need to.

I catch my own babies and support my own perineum. Really. No touching me or the baby as it is emerging.

When I am pushing, stay silent and calm. Feel free to prepare a soft landing surface for the baby.

Baby is born, goes immediately on my chest, latches on, stays there indefinitely.

Umbilical cord remains unclamped and uncut until I feel like cutting it. Usually an hour after the birth.

No routine Pitocin or cord traction unless I'm hemorrhaging. My placentas usually take 1-2 hours to be born. Don't freak out.

Feel free to take pictures or videos. That would be awesome.

copyright @ 2011 by Rixa Freeze

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Why birth plans exist

Two timely examples of why birth plans exist in our current maternity care system. Not necessarily that they guarantee anything--after all, the piece of paper itself has no magical powers.

A Normal Pregnancy is a Retrospective Diagnosis By J.D. Kleinke (thanks to Jill at The Unnecesarean)

The Feminist Breeder's description of Lifetime TV's "One Born Every Minute." 
  

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Additional thoughts on birth plans

I've never written a birth plan. My first baby was a planned unassisted birth, so there wasn't any need to write a list of what I did or did not want to happen. I would just do it! With my second baby, I saw a nurse-midwife in a solo homebirth practice. Several times during my pregnancy, we discussed what I wanted her role to be at the birth. I'm seeing the same midwife this time; the only difference is she has added another CNM to her practice. They almost always attend births together, so my original midwife will likely be there. I've talked through my wishes with the other midwife, so she also knows what I expect her to do (basically, not much at all unless I ask for something or an urgent situation arises).

Some women planning out-of-hospital births write up a birth plan in case of a hospital transfer. Because my midwife is legally recognized, she can accompany me to a hospital with no fear of arrest or imprisonment. She knows what I want, and I figure between the two of us, we will be able to make my wishes known.

If we didn't have such a fragmented maternity care system, written birth plans would be largely unnecessary. When a woman knows her care provider well and has continuity of care through prenatal visits, labor, and birth, a birth plan is redundant. But this scenario exists mostly in out-of-hospital births, where the people attending the woman already know her and her desires. Most women give birth in hospitals, where nursing staff they have never met before provide most of the labor care. Hence the rise of the birth plan. Birth plans also exist because hospital routines vary so widely from one institution to another. If, for example, all hospitals were Baby-Friendly, then there would be no need to have a birth plan mentioning skin-to-skin contact or not giving pacifiers or sugar water to breastfed babies.

One of the best tools you can take with you to the hospital is getting BRAINS/BRAINED*. Go through these simple steps whenever you're facing a decision about a procedure, medication, or intervention. This is definitely something to print out for your birth partner!

BRAINED
Trying to make a decision? Get BRAINED!
Ask yourself, and your caregivers, these questions:

Benefits - How could the recommended course of action help me or my baby?
Risks - How could the recommended course of action harm me or my baby?
Alternatives - Are there any other courses of action I could consider?
Intuition - What are my gut feelings about this?
Nothing - What happens if I do nothing?
Evaluate - Can you give me some time to consider my choices? Then...
Decide - Now that I have the information I need, I'm ready to make a decision.

BRAINS

Benefits- How will this procedure benefit me and my baby?
Risks - What are the risks to me and my baby?
Alternatives - What are some other things we might try instead?
Instinct/Intuition - What is your gut telling you?
Now/Never/Nothing - What if we don't do the procedure right now? What if we never do it? What if we do nothing?
Safety/Satisfaction - Will this procedure increase the safety and satisfaction of the birth for me and my baby?

Additional reading on birth plans:
A physician speaks about doulas and birth plans
Kingsdale Gynecologic Associates: doula ban and birth plan
Ghouls and doulahs
Midwifery model of care

*The BRAINED acronym comes from a handout that someone gave me from "Lucina Birth Services." The BRAINS acronym was passed around on a doula list serve.

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Thoughts on birth plans

Desiree of Hitting My Stride recently asked about birth plans--should she write one? If so, what to put in it? Is it too presumptuous to plan for an event that includes a lot of unknowns and uncontrollable factors? (She has two rare blood clotting factors that make hospital birth a necessity and induction fairly likely if the baby doesn't come by 38-40 weeks.)

I was thinking about what I'd say in response, and my first thought was: let's back up a bit first. Before even thinking of writing a birth plan, or list of birth preferences, or whatever else you want to call it, you need to know what is routine practice at your specific hospital. The last thing you want to do is write up a birth plan full of things that are totally irrelevant at your hospital. That will make the staff laugh or roll their eyes or label you as a control freak.

So first off, before you even think of writing up a birth plan, head to your hospital and talk specifics with the L&D nurses. For example, if you really want immediate, uninterrupted skin-to-skin contact after the birth, ask the nurses how likely it is to happen. What about skin-to-skin after a cesarean? If the mom or baby needs additional attention after the birth? If something is not routine practice, ask them what you need to say or do to make it happen. Go through all of the things that really matter to you. Ask the nurses which things won't be an issue and which you'll need to clearly communicate ahead of time.

Some things will need advance planning, such as wireless and/or waterproof telemetry. Some hospitals have telemetry, while others do not. If you know you'll be having constant monitoring (for example, for an induction) but want to have more freedom of movement, ask about wireless monitoring now, while you're still pregnant. If they don't have it, insist they order it! Ask to speak to the person who is in charge of ordering equipment and see what you can do to ensure they have the proper equipment in time for your birth. Or let's say you want to have access to nitrous oxide (aka gas & air or laughing gas) or TENS units for pain relief. These are both rare in the United States, although quite common in other countries such as Great Britain. You'd definitely need to inquire about them in advance.

My next advice--which Desiree seems to have down already--is don't worry about including any of the little things that you shouldn't even be asking permission for. The don't ask, just do kind of things. Eating and drinking if you're hungry, moving and changing positions, music, lighting, unhooking yourself from the monitors to move/go to the bathroom/etc (especially if, like most women, you have no specific reason to be on constant monitoring). Just do these things and don't take any flak from the nursing staff. Make sure your birth partner knows about these things and can buffer you from the nursing staff if you deviate from their policies or routines.

A third suggestion would be having two separate plans: one for the hospital staff with your most important preferences, and a longer, more detailed one for your partner, husband, or support person. Write down all of the things you want your support person to remember for you, so you don't have to remind them when you're in the middle of labor. Things like keeping the room lighting low, keeping you hydrated, helping you into different positions, asking you if you've had enough time to make X or Y decision, reminding both you and the staff of your preferences.

Now let's get back to the birth plan for hospital staff. Once you've eliminated all of the things that are irrelevant to your specific hospital and/or provider, write down the most important things in the briefest possible way. Keep it short and easy to read. Use lots of bulleted points, rather than long, wordy sentences. Don't go into any long-winded preambles. When I say short, I mean short. If you can make it fit onto an index card, all the better. Here's an example of how to communicate your pain relief preferences:

Pain relief:
~ Do not offer or suggest pain medications. If I want something, I will ask.
~ Do not ask me to rate my level of pain; please make up a number if required for your charting.
~ Please offer or assist with non-pharmaceutical comfort measures (showers, warm baths, birth balls, movement, changing positions, etc).

Instead of going into detail over every separate procedure, think of writing a general directive to ensure you are giving full informed consent. Something like this:

Please ask for my permission before every procedure, examination, medication, or intervention (including vaginal exams, AROM, episiotomy, routine infant procedures, etc).  If it is not an emergency situation, ask if I have had enough time to consider my options and review the alternatives before consenting to the procedure. 

When you arrive at the hospital, you can request a nurse who has experience with unmedicated labors (if, like Desiree, this is important to you). Have your birth partner talk to the admitting nurse and say something like "She really wants to labor without pain medications and labor and push in upright positions. Could you assign us a nurse who would be excited to help make this happen?" They might be too overstaffed to meet your request, but they might also be able to arrange nursing assignments to give you a nurse who loves working with unmedicated moms. This doesn't mean you are locked into having a "natural birth," just that you'll have more support for your initial desire to labor without pain medications.

My final thought is that planning for birth is like preparing proactively for breastfeeding. There are the individual choices you make and have control over during pregnancy, such as provider or place of birth. There are the institutional protocols and provider preferences that will influence what happens to you during labor and birth. And then there are the unpredictable, uncontrollable events that may throw you a curveball during labor. Birth plans are primarily for the second category of events--navigating institutional routines and employee protocols that may or may not be what you want, and may or not be beneficial for your or your baby.

Birth plans also help ensure that you remain more in control over your individual, personal choices. Because if you really want an unmedicated birth, but the hospital staff and routines all push you towards having an epidural, you're going to have a hard time accomplishing your goal. Or if you want lots of uninterrupted skin-to-skin contact, but the hospital routinely takes babies to the warmer and only returns them after examining, weighing, bathing and swaddling, you'll probably find your arms empty after the birth. The birth plan itself does not ensure that your wishes will be followed. But it is a starting point for communicating what is most important to you. 

Labor and birth have unpredictable, uncontrollable elements. We cannot make these magically disappear simply by waving a birth plan around. But a lot of what happens to women during labor doesn't occur because of Mother Nature, but rather because of hospital routines, employee protocols, liability protection, and providers' preferences and training. This is where planning and preparation can make a difference.

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A physician speaks about doulas and birth plans

This comment just came in from Kingsdale Gynecologic Associates: Doula Ban and Birth Plan.

So I am actually a physician. Doula's may be beneficial in some situations, but you all must remember that the role of a physician is to provide good medical knowledge and advice based on evidence. Where Doula's may be thought of as positive most have zero training and often times may give inaccurate medical advice which is out of their scope of practice. If people want Doula's there should be a government agency licensing those individuals. As you wouldn't want just any person playing your doctor the same gaves for those helping. If they obstruct what we are trying to do they are not beneficial and can ultimately hurt you. Further, they do not have any medical liability. If you want a Doula they should accept medical liability for the 18 years that OB gyns do. In regards to birth plans. They are all nonsense. When it comes to the delivery room most if not all mean nothing. Your in pain you said I don't want drugs you change your mind you get drugs. Happens everywhere all the time. Look the most important thing is not extra personnel in the delivery room. The important thing is a safe and healthy delivery for both the infant and mother. Any mother or father for that matter that thinks anything else is more important should not have children till they get their priorities straight.

Let's discuss this comment from multiple angles--research evidence for/against doulas, personal experience as a doula/birthing woman/nurse/physician/midwife, role and usefulness of birth plans, desirability of licensing and malpractice insurance for doulas, etc.

Here are a few links to get the discussion started:

• Read another doctor's birth plan from WomanCarePC, a Chicagoland OB practice, at The Feminist Breeder (scroll down a bit to get to it).
• A Texas OB's birth plan, mentioned at The Unnecesarean
• At Your Cervix speaks about birth plans from an L&D nurses' point of view
• Navelgazing Midwife's series on birth plans:
• Let's critique a birth plan
• Birth Plan--Lemme Fix It
• Birth Plan--Revised (With OB approval)
• Homebirth birth plan
• Updated birth plan
• What happened to...?

Have at it.

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Kingsdale Gynecologic Associates: Doula Ban and Birth Plan

Remember back when  the Aspen Women's Center banned "doulahs"? There's another obstetrical practice that has not only banned doulas, but also written up a one-size-fits-all birth plan.

Yes, despite the very strong evidence that doulas have significant positive effects on the course of labor, on intervention rates, and on women's experiences, Kingsdale Gynecologic Associates has banned doulas "because of concerns for increased risk to you or your baby." Their "thoughtful, unanimous decision" to ban doulas comes down to this: "It has been our experience that they may serve to create a state of confusion and tension in the delivery room, which may compromise our ability to provide the safest delivery situation possible for you and your baby."

Not only does the pregnant woman no longer have access to a companion of her choice during labor, she has to sign the physicians' birth plan. Among other things, this birth plan notes that IVs are necessary for a safe labor, that you will only be allowed ice chips and popsicles, that you'll probably want drugs, that they will cut episiotomies to avoid bad tears, and that continuous fetal monitoring provides the "safest possible delivery."
Evidence-based medicine has been tossed out the window.

But this one takes the cake:

The labor and delivery nurses and doctors together act as “doulas” in a sense that we will be your advocate to provide positioning options, pain control and pushing techniques to make the process as easy as possible.

Yes, the physician who arrives when the baby is crowning and the nurses who are tending to several laboring women and spending almost no time doing direct labor support are somehow the equivalent of a doula--a person who knows the woman well, whose entire task is to provide continuous support and information and encouragement, and who never leaves the woman's side.

I'm sure a lot of us could come up with snarky/sarcastic/witty remarks to the doula ban and the birth plan (hey, it rhymes!). But better yet, I'd love to see someone edit the documents purely from an evidence-based medicine point of view, complete with up-to-date references. Perhaps we could create a wiki and work on this together? I'd be more than happy to send the completed documents back to Kingsdate Gynecologic Practice.

You're also free to write directly to the physician group and voice your thoughts:

Kingsdale Gynecologic Associates
1315 West Lane Avenue
Columbus, Ohio 43221
Click here for Directions

Phone: (614) 457-4827
Fax: (614) 326-0250

Still, the best reaction is if pregnant women leave Kingsdale Gynecologic Associates in favor of a provider who respects women's wishes and supports evidence-based care. For example, CNM Emily Neiman wrote that her midwife/physician practice, Women's Contemporary Health Care, would be "happy, thrilled, ecstatic to have these women transfer to our practice. We have no issues with doulas, 'allow' you to write your OWN birth plan, and provide continuous labor support."

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Totally freakin' amazing birth stories

I've come across a few great birth stories that make me want to have a baby again. Which is looking a lot more possible since my period just started, right after my 32nd birthday. It's a birthday present that I have mixed feelings about. I like being period-free. Since January 2006 I have had 4 periods, total. But I am also happy to know my fertility is returning, to know that another baby is now possible.

So first off, Amy of Life in Slow Motion just had her second baby, another girl. I first started reading her blog when Zari was a tiny baby. I wish I lived closer to her, because she takes amazing photographs and I'd love to have our portraits and family pictures done by her. Her first baby was a fairly traumatic hospital birth, so she chose to give birth at home the next time. First, read Baby Ada's Birthday (and watch the video, too--it's amazing to see her literally deliver her own baby so calmly and naturally). Then you can read more about the birth at Welcoming Baby Ada.

The other stories are all on Birthing Beautiful Ideas--a blog I just discovered and wish I'd found much earlier!

Story #1: Birth and the Big Baby: An Unnecesarean Avoided. BBI was the doula for this woman, who was under considerable pressure to schedule a cesarean and/or induction for "suspected fetal macrosomia." Her client had already given birth vaginally to a 9-lb baby and didn't want surgery unless it was really necessary. She finally decided to consent to an induction, but her baby had other plans....

Story #2 part I: the written account of Beautiful Birthing Ideas' own VBAC waterbirth in a hospital-that-does-not-do-waterbirths. Notice the transformation in the nurse. Before: nurse keeps trying to get BBI out of the tub and onto the bed, and the sneaky doctor keeps thwarting her plans. After: nurse raves about how amazing the waterbirth was. Here's the doctor re-educating the nurse as BBI is pushing:

After a couple of pushes, Dr. N and Chris helped me to get into a hands-and-knees position so that I could gain the assistance of gravity in my pushing. And then Dr. N turned to my nurse to tell her the following: “Look at how beautifully she’s doing. Look at how natural and normal this is. She’s pushing on her own, and no one is yelling ‘PUSH’ in her face, no one is counting for her.” And you know what? My nurse started to get excited about this birth. In fact, about twenty minutes into my active pushing, she came into the room to remind me of my birth plan and of my initial intention to push in a side-lying position. Although I told her that I felt much more comfortable pushing on my hands and knees, I was so grateful that she had taken my birth plan seriously enough to remind me when I wasn’t following it!

And then the nurse almost cannot restrain herself with excitement:

A and I snuggled in the water for another ten minutes, and then we moved out to the main room. And my nurse—the one who wanted me the heck out of the tub—was nearly jumping up and down saying, “That was the most amazing thing I’ve ever seen! You are awesome!” ... Later, I learned that about five other nurses rushed into the room to see the woman who had the hospital’s first water birth.

Story #2 part II: Not Too Posh to Push (Upright and Spontaneously): A’s Birth Video. BBI shares videos from her VBAC as part of the Lamaze Healthy Birth Practices Carnival on upright and spontaneous pushing.

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Ghouls and Doulahs

Halloween is just a few hours away. Are you scared yet? If not, here's something to shiver your timbers.

This sign is from a clinic in a town where I went to university. I am SO glad I didn't get pregnant when I was living there. It was before I knew anything about birth and I could easily have gone to such a place and not known any better. Anyway, the internet has been buzzing about this sign. Here's just a few pieces to whet your appetite:

• Dou-la-la in Signs, Signs, everywhere there's signs asks what's next--forbidding women to look at certain websites, books, or movies?
• Radical Doula wrote about Signs you don't want to see at your ob-gyn's office
• Organic Birth asks What's next?
  
• Bellies and Babies commented on this in Posted Refusal and Black Lists, and corresponded with a CNM who uses one of the clinic's doctors for their backup physician. This midwife explained that the sign isn't quite as bad as it seems.

Still, even if there's a back story and the docs aren't really that bad, they certainly could have come up with a better sign! Like actually spell "doula" right for starters..

If you're not already scared by the "no doulah" sign, then read this OB's Birth Plan. It's so bad that I wonder if it could possibly be real. I read through the original thread and it does seem legit--as legit as something can be on the internet! 

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Home birth news and articles

The blog has been quieter than usual--not from a lack of things to write about, but from an overwhelming number of ideas spinning around in my mind. So it's time to condense. In this post, I'm including links and some brief excerpts from several articles and posts and news about home birth.

Judith Lothian's guest post at Science & Sensibility: “Being Safe”: Making the Decision to Have a Planned Home Birth discusses, among other things, her recent research on women's experiences of home birth in the US. She will present her findings at the 2009 Lamaze Conference in Orlando:

Many of the findings of the research surprised me. Women made their decision to have a planned home birth before becoming pregnant, early in the pregnancy, or sometimes as late as 30 weeks into the pregnancy. I was surprised that all of the women described themselves as “mainstream”. They all wanted a natural birth. All the women came to believe that “intervention intensive” maternity care increased risk for them and their babies. They valued the personal relationship with their midwife and believed that this relationship increased safety. They believed they could manage the work of labor more easily and more safely in their own homes. They all expressed confidence that a hospital and skilled physician care were available if needed. ‘Being Safe’ emerged as the theme that captured the essence of women’s decision to plan a home birth. In stark contrast to the current thinking, that birth is safer in hospitals under the care of an obstetrician, these women believe that giving birth at home is safer for them and their babies.

In a powerful way, the findings suggest that we need to look closely at the meaning of safety for women, and whether women and their babies are indeed safe in the current system.

Her findings are remarkably similar to the ones I and my coauthors found in our article Staying Home to Give Birth: Why Women in the United States Choose Home Birth. From the article's abstract:

The most common reasons given for wanting to birth at home were: 1) safety (n = 38); 2) avoidance of unnecessary medical interventions common in hospital births (n = 38); 3) previous negative hospital experience (n = 37); 4) more control (n = 35); and 5) comfortable, familiar environment (n = 30). Another dominant theme was women's trust in the birth process (n = 25). Women equated medical intervention with reduced safety and trusted their bodies' inherent ability to give birth without interference.

Jennifer Block wrote a fascinating and sometimes quite funny article about The Birth Wars: Who's Really Winning the Homebirth Debate? She argues that beyond the vitriolic insults that each side often hurls at each other (home birth is putting your baby at risk and is a selfish choice the mother makes just for "the experience" coming from one side and doctors and hospitals are evil places that injure mothers and babies just to make money coming from the other). She includes more about Melissa Cheyney's research and an example of birth telephone that Cheyney investigated that turned out to be totally fabricated. Cheyney commented:

What we found is that the animosity is so high between midwives and obstetricians that all kinds of rumors spread that are unsubstantiated. A woman and her midwife would transport for something relatively benign, and three or fourOBs away, the story was that the baby came in half-dead. You know that game Telephone? That's the folklore, that's what becomes the institutional memory.

Jennifer Block dedicated several paragraphs to explaining the Dr. Amy phenomenon. Sorry all you conspiracy theorists out there--Dr. Amy is in fact a real person, not an online avatar paid for by theACOG. Block explains Dr. Amy's mission and talks about her face-to-face meeting with her:

"The most important piece of information that every woman should know about homebirth is that all the existing scientific evidence to date shows that it has an increased risk of preventable neonatal death," she wrote on Slate.com. "Even the studies that claim to show thathomebirth is as safe as hospital birth, actually show the opposite." This is a typical Tuteur declarative. She has read the data and done her own calculations, and she believes a different number than the one that was peer-reviewed. This is usually challenged by several readers or activists, some of whom have been summoned like a volunteer fire department to respond. A "debate" then ensues, in whichTuteur charges that the study's authors are, simply, wrong. Then there's the name-calling. The researchers, which she often names, are "biased," pulling a "bait-and-switch," and women are falling for it. "I have written repeatedly about the fact that whilehomebirth advocates claim to be educated . . . they are easily duped because they lack the most basic knowledge about science, statistics and childbirth itself," she writes.

Then there's the name-calling. So omnipresent has Dr. Amy been on the boards that she began to take on a mythical status among the home birth community. Some activists believed she wasn't real, that her picture and bio were fake, that she was a mere avatar for some sort of undergroundACOG propaganda machine (rumors live on all sides).

But "Dr. Amy" is real. I sat with her, face to face, for nearly three hours at a Starbucks off Route 1 south of Boston a couple years ago. She is not a researcher, not an epidemiologist, and probably not onanyone's payroll; she is an obstetrician-gynecologist who left private practice more than a decade ago because, she told me, she'd had it withHMOs and wanted to spend more time with her four kids (she let her license lapse in 2003, according to the Massachusetts Board of Medicine). And for some reason, which I never quite got to the bottom of, she believes in every cell that Home Birth Kills Babies (that's in fact the title of her most recent post on her new site, The Skeptical OB), and no amount of research evidence will convince her otherwise.

And then there's the problem with the research. Because randomize controlled trials do not, and will not ever, exist for home birth vs. hospital birth, those opposed to home birth will continue to insist that the practice is not safe, despite the many observational studies that indicate it is likely a reasonable choice with many benefits for both mothers and babies:

...if the only research that will satisfy those with authority and power is research that is unfeasible, the controversy will never be resolved. There could be 20 more large, observational studies that come to the same conclusion as those that already exist, but they still wouldn't be randomized controlled trials. The home birth advocates would continue to say "The research proves it's safe!" and the American medical establishment would continue to say "The research isn't good enough!"

Jennifer Block also wrote another article Where's the Birth Plan? for RH Reality Check, arguing that incorporating midwifery care into the proposed national health care scheme would have both financial and health benefits.

Compared to healthy women who get standard obstetric care and deliver on high-tech labor and delivery wards, women with low-risk pregnancies who get care with a midwife and deliver in birth centers or even in their own homes, benefit from a five-fold decrease in the chance of a cesarean delivery, more success with breastfeeding, and less likelihood that their baby will be born too early or end up in intensive care. And all of this for a fraction of the cost of the statusquo.

A new economic analysis forecasts savings of $9.1 billion per year if 10 percent of women planned to deliver out of hospital with midwives. (Right now, just one percent do). If America is serious about reform, midwifery advocates are saying, "Hey, how about us?"

Childbirth has been compared to various other life experiences and situations, from running a marathon to having sex to going to the bathroom. In Restaurant Wars and Birth Wars, Sheridan of Enjoybirth analogizes birth choices, and the ACOG's opposition to home birth specifically, to the choice between eating out or cooking at home. I suspect her post is a response to Jennifer Block's article The Birth Wars. An excerpt:

Imagine the year is 2035. People rarely cook at home anymore for a few different reasons. They have gotten too busy and because of subsidies from the food industry eating at a restaurant is less expensive. They actually pay more out of pocket to eat at home. Many people look back and remember, “People actually prepared meals AT HOME! It is amazing that they were willing to go through all that time and energy and that so many survived.”

There are of course a few “natural” people who still eat at home. There is a renewed interest in examining this practice, when a celebrity makes a movie called The Business of Eating Out, examining the risks of doing so and reminding parents about the option of eating at home.

This next one isn't exactly news, but a Medline/Reuters recap of the recent Dutch home birth study. From Home Births Can Be as Safe as Hospital Births in Low-Risk Women:

Intrapartum death:
Home: 0.03% vs. Hospital: 0.04%
Intrapartum and neonatal death within 24 hours of birth:
Home: 0.05% vs. Hospital: 0.05%
Intrapartum and neonatal death within 7 days:
Home: 0.06% vs. Hospital: 0.07%
Neonatal admission to an intensive care unit:
Home: 0.17% vs. Hospital: 0.20%

Jill of Keyboard Revolutionary argues that we shouldn't have to say no when giving birth:

We have to write out a detailed birth plan, make our doctors read it, and then cross our fingers that they will actually listen to our wishes. We have to bring a "support person" or five to the hospital who are also well-versed in our birth plan to help us fight off the marauding staff....I often hear this in response to women who relate their tales of hospital birth trauma. "You can always say no. You should have said no." YOU SHOULDN'T HAVE TO. If you are in the "care" of someone that you need to threaten with lawsuits in order to make them listen, you need to take a step back and do some serious reevaluating.

Briefly noted:
Read about Cindy Crawford, Christy Turlington And Other Celebrity Homebirths
Sazz argues that outlawing home birth will hurt hospital birthers too and features a comment about losing normal birth skills

State & local home birth news:
Cleveland.com reports about Home delivery: Families opt to have children at home
Fort Wayne Journal Gazette: For some, life begins at home
News OK: Giving birth at home remains popular with many Oklahoma mothers
WCCO: Home Births On The Rise, But Are They Safe?
Colorado's 9News: Woman gives birth in her home - alone

From the UK
For the BBC, Cathy Warwick of the Royal College of Midwives recommends: 'Don't tell women how to give birth'
Also by Cathy Warwick for the Tribune: Seismic shift needed on homebirths
London Financial Times: Baby Talk

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What if you never saw a birth like this?

One of my readers, doctorjen, submitted this birth story for the book giveaway. I am reposting it here with her permission. She is a family practice physician who works in a small rural hospital. I always enjoy reading stories of the births she attends.

Sometimes I attend a birth that reminds me how different my experience is than many hospital providers. This birth was very powerful and beautiful, and reminds me again how awesomely powerful women's bodies are. It was not an easy birth, but the hard parts were still handled by the mama and her baby with amazing power and just a little help. I know that most hospital practitioners have never seen a birth like this - and I wonder how my view of birth would be different if I never had either.

B. is another one of my teenage clients. Unlike many of my teen moms that come of difficult backgrounds, B. was an excellent student, with loving, supportive parents. B.'s pregnancy was a huge shock to her family, and to her large circle of loving family friends. The circle of friends includes the family that are executive directors of the maternity home I often do prenatal care for. This family had known B. since birth, and despite their career being focused on caring for women with unintended pregnancies, B.'s was still a big shock. Family and friends both recovered well from the initial shock, and B.'s mom especially was very supportive and wonderful throughout the pregnancy, attending all her visits and being happy about the baby, even though she was disappointed about the timing.

B. was sort of a high maintenance pregnant client. She'd obviously been the petted baby of her family, and reacted strongly to all the discomforts of pregnancy. She had quite a number of unscheduled visits for belly pain, back pain, nasal congestion, pelvic pressure - you name it. She had multiple visits to labor and delivery for pre-term contractions (never true pre-term labor.) Her family, and even her boyfriend, always responded to her with loving concern, and attempts to make her feel better. I have to admit to getting a little frustrated with her - but did my best to keep it to myself.

During the third trimester, B. "studied" childbirth with a couple of family friends. Both of them had taken a Bradley class, and they went over their work book and notes with her. She also borrowed several books from me, and wrote a term paper in her junior English class on the risks of epidurals. She wrote a birth plan that looked very Bradleyish, and included not wanting to be induced and not wanting any pain medicines. Having at this point seen her in tears so often due to back pain, or Braxton Hicks contractions, I privately wondered about this birth plan - was it hers, or the friends? The one friend had a lovely unmedicated VBAC with me 3 years ago and she and her mother (who is the executive director of the maternity home) planned to be at the birth as support people.

As B. approached her due date, she stopped complaining about contractions. She joked about how ironic it was that she'd had them for months and now they were gone when she wanted them. Her due date passed, with no interest on her part in induction - she never even mentioned it, despite mentioning often how much she wanted to see her baby. At 41 weeks, she was scheduled for a biophysical profile. B. called on the way to the ultrasound to say she was having a little bit of pink tinged mucus when she wiped. By the time the ultrasound was done and she went up to labor and delivery for the NST portion, she was still having a little bloody show, and now having some irregular contractions as well. She asked a labor nurse to check her. The nurse called (my favorite nurse again) and said she thought B. was trying to start laboring. She was 1 cm dilated and 60% effaced, with irregular contractions (about 10 o'clock in the morning.) The ultrasound, however, showed a decent sized straight posterior baby. The nurse told me she'd suggested that B. go home and spend as much time on hands and knees as she could stand, and try to get this baby to turn around. She had appointment with me later in the afternoon, and planned to keep it.

Around 3 pm, B. came for her appointment. She told me the contractions had slowly been getting stronger and a little closer together all day long. She also told me she'd been crawling around as much as she could, and had her mom rubbing her back and was feeling contractions mostly in her back. She asked me if I'd check her again. During the visit, she had 3 strong contractions, and during the 3rd one, she started to cry, and when her mom asked her what was wrong she said "This just hurts so much!" I checked her a few minutes later, and she was now 3 cms and 80% effaced. B. was cheered up that she was actually making change. To my surprise, she said she wasn't ready to go to the hospital yet. I suggested she go home, eat supper, take a soak in the tub, a nap if she could manage it, and that I guessed she'd be back to the hospital later this evening. Her boyfriend was due to give a speech in a college class that evening, and decided to try to still get there to give it, while her mom planned to stay with her.

Around 8 pm, B. arrived back to the hospital. At this point, her contractions were every 3 minutes, and she was breathing hard with them and having a lot of pain and pressure in her back. Her whole support team arrived with her - boyfriend (who'd gotten an A on the speech), mom, dad, family friends (the mom and daughter who were to be her designated labor support) The nurse called me and said B. was now 4 cms dilated and 90% effaced, and contracting regularly. I came in to see her at this point. B. was bouncing on the birth ball when I got there, and one of the friends was kneeling on the floor pushing on her back. B. was obviously working hard now, but excited that she might soon see her baby. Although she mentioned that she was hurting, she also seemed calm and determined, and although she asked for the support she needed ("Rub my back!" "Where's my drink?" "I'm hot!") she didn't talk about pain medicine.

For the next few hours, B. got in and out of the tub (we were having issues getting it hot enough, so she'd stay in until she was cool, then get out while we drained and refilled it) walked in the halls, bounced on the ball, drank juice, and leaned on her support team. For a long while, the contractions seemed to stay about the same, and then, they started to become less frequent instead of more frequent. B. started to be tired, and crabby, and struggled to stay on top of contractions. She'd not wanted a lot of cervical exams, so we kept trying to help her be comfortable. Finally, around 2 am, when B.'s contractions were only about every 7-8 minutes now, and she was falling asleep between them and waking up struggling to cope with them, I asked her if she wanted a cervical exam, and she said she did. I checked, and she was still 4 cms dilated, and 90% effaced. B. was really discouraged at this point. She'd now been laboring since about 7 in the morning, and had had absolutely no change since arriving to the hospital 6 hours ago.

We discussed options at this point. First of all, I told B. that her baby was fine, she was fine, she was coping beautifully and keeping up her hydration, peeing well, and overall doing great - so there was no medical need to do anything at this point. We could just wait and see what happened. I suggested if she wanted to wait, that we try dimming the lights, and tucking her up on her side in bed with all kinds of pillows for support, and she see if she could rest. She was exhausted at this point, and sometimes dozing off between contractions. Second, if she didn't feel like resting was an option, and she didn't want to just continue waiting, we could try something to augment her labor - either AROM or Pitocin. She asked a lot about what either intervention would mean. (Pitocin would mean continuous monitoring, and being stuck to the IV pole - AROM would commit her to delivery, might make contractions more painful, and might encourage the baby to stay in a poor position - but would leave her with the freedom to still move and be off the monitor,) She cried a little at this point, and said she was just so tired, and scared, and not wanting to hurt anymore. Her mom, who is very emotional, cried too, and said she felt so helpless to help her daughter feel better. Her dad, the boyfriend, and the family friends were all for AROM, wanting to get this show on the road. Seeing her distress, I suggested that she try just resting for a while, that there was no need to make a decision right now, and she calmed down and said she'd try that.

A few minutes later, at about 2:15 am, we had her tucked as comfortably as we could on her side, with pillows under her leg and arm, and mom rubbing her lower back still. We turned off the lights, and the nurse and I told her we'd be right outside the door if she wanted us. For 30 minutes or so, she was quiet, and we hoped she was able to sleep a little. Then, we started to hear her moaning through contractions and breathing hard again, although the contractions were still 7-8 minutes apart. Finally, around 3:15 am, her dad came out of the room and said B. would like to talk to me.

B. said again that she was so tired, and just so worried that doing anything would make her hurt more. I told her honestly that it may well make her hurt more - but I was also a little worried that she was so tired now, that if we waited a few more hours and she was still unable to rest that she would just be that much more tired and still in the same position. I assured her again that she didn't have to make any decision urgently, because she and the baby were fine. She thought for a moment and said she thought she'd like to try having her water broken. I checked her again - still 4 cms, 90% effaced, 0 station - and hooked her membranes with an amnihook, and clear fluid spilled out. B. had been lying in bed at this point, but the very next contraction, she sat straight upright, called for her friend to rub her back, and rocked back and forth. "That was much stronger!" she said, "I can't do this lying down!" We encouraged her to get up, and the next few contractions, which came faster and faster, she walked in the room, and leaned over her mother during a contraction. Soon, she was breathing harder, moaning through contractions, and saying this laboring stuff was not much fun. She wondered if getting in the tub would still help, and we decided to find out.

Once B. was soaking in the tub again, she was smiling some more. Contractions continued to come every 3 minutes or so, but she felt less pressure and less and less discomfort in her back. Since she was more comfortable, and anyway had such good support, I decided to lie down for a bit. By 4:15, I was snuggled in a recliner with some blankets from the blanket warmer and was able to doze. I slept fitfully off and on until the nurse woke me at 5:45. "B. is pushing a little with contractions, and she wants you" she said.

Back in B.'s room, the scene had taken on a much more intense feel. Somewhere along the line B. had shed all her clothes. She had the external fetal monitor strap on, and not one other thing. She was standing up, and during a contraction leaned forward holding up hanging from her mom's shoulders, and the friend was rubbing hard on her back (the friend later told me she was sure she'd left bruises since B. wanted such hard rubbing!) B. was sweating, and breathing hard. "Please, can't I just push?" she wanted to know, and I asked her if she felt like pushing. She said not really, but she just wanted it to be over. I suggested she just wait until her body started pushing. She reached out and grabbed my arm and said "Then please, won't you give me some pain medicine?" This was the first I'd heard her mention it since she walked in the door. I tried to talk to her about it - saying I thought she was close to having her baby, but she just kept saying "oh please, please do something!" Her support people (who've attended many births) both suggested that she was in transition, and tried to remind her what that is like. Her mom started to cry again, and said it was just so hard for her to see B. in pain. I had to agree it was hard to see her hurting and wished there was something to do for her. I told her we'd have to do an exam if she truly wanted pain medicine, and she willingly flopped down on the bed and said "Just check me then!" I did - but she was 8 cms or so dilated, with the cervix just stretching away during the exam, and the baby's head descending through it. Too late for IV pain meds, and even an epidural might not make it in time. Hearing this news, B. said again she did not want an epidural, so just forget it!

B. hopped back out of bed immediately, and went back to leaning on her mom. She was still working hard, but looked determined again. She'd snap at whoever was rubbing her back "Harder! Don't stop!" and snap at the boyfriend to bring her drink right now. After 10 minutes or so, she suddenly plopped down on the floor - completely naked, leaking amniotic fluid all over, sweating, breathing hard - flat on her rear end on the floor. Her mom sat down behind her, and soon she flopped backwards into her mom's lap. Mom sat cross legged, and B. laid with her upper body in mom's lap, curled her arms around mom's arms, and rolled back and forth with contractions. We could easily see each contraction build across her belly, and almost the outline of the baby since she was thin to begin with. After just a few contractions, she said she was having more pressure in her butt, but still no real urge to push, but couldn't I just check her again and couldn't she try to push the baby out anyway. And furthermore, she was not getting off this floor, couldn't I just get down here on the floor and check her anyway?

I can get on the floor of course, and after convincing her to at least slide a clean bed pad between her rear end and the (possibly yucky) hospital floor, I did a quick exam. Tiny anterior lip, with the baby pretty much through the cervix. B. said she just wanted to try to push, and I encourage her to wait for a true urge, but didn't think she'd hurt anything by pushing. Lying in her mom's lap with her arms curled under and gripping mom's arms, B. pushed with the next contraction. For the first couple contractions, she pushed in short bursts, or just grunted a little. Even so, we could soon see the outline of the baby's head bulging the perineum. B.'s mom's leg fell asleep, and she asked B. if she could move, and B. snapped "Don't you dare move!" The mom took a deep breath and held as still as she could. After a couple more contractions, B. said her tailbone hurt, and I asked her if she wanted to move. "I am NOT getting in that bed!" she said with a serious glare. I meekly replied that I just meant maybe she could try squatting or kneeling and get off her tailbone. She thought for a moment and said she'd try that.

B. slowly turned over - it taking quite a bit of effort to get off the ground at this point. She made it over to her knees, and I suggested she hold on to the bed. Her boyfriend lay down across the bed with his head at the side of the bed, and she knelt at the bedside, holding his forearms for support, and resting her head on his shoulder. He whispered encouragement to her - and told her he was sorry for doing this to her - and she held on to him for dear life. The poor mom finally made it to her feet with her asleep leg, and the support people moved to supporting the mom, who was just overwhelmed at the intensity of it all at this point. B.'s dad had been in and out of the room, and now was back in, but in the corner of the room. He could see B.'s head over the bed, but not the rest of her. The mom and the 2 friends stayed behind B., wanting to see the baby. Shift change happened just then, and the 3 new nurses joined the 2 I already had in the room. I knelt on the floor next to B. Although it sounds like a huge crowd, it was very quiet and intense in the room. The only sounds were B. working hard, and her boyfriend encouraging her, and the nurse or I telling her how wonderful she was doing. Within just a couple pushes, baby's head was staying visible even between pushes.

With the next contraction, B. slowly pushed her baby's head out, and mom started to cry, dad across the room started to cry, the friends cheered, the boyfriend started to cry. Even though B. was kneeling on the floor, I could see the baby's head emerge, and then almost look sucked back against the perineum - a turtle sign that immediately made me think of a shoulder dystocia. Baby was LOA, having turned I think somewhere late in labor. I waited for B. to take a few breaths, and asked her if she could push again, and she started to push. The baby didn't move at all and her face suffused with purple while B. pushed. I reached for the head and pushed up gently to see if the anterior shoulder would be freed - but it didn't budge. While B. pushed, I switched directions and tried to free the posterior shoulder - but it didn't budge. B. took a few more breaths, and when she started to push again, I lifted the head up again, and with a slight popping sensation, the baby's anterior shoulder came free, and almost immediately the whole baby slid out into my hands. There were 2 tight wraps of cord around the neck, but baby splashed right out. B. heaved a huge sob of relief and dropped her head and shoulders down on the bed. One of the nurses squatted on the floor with me and unwound the cord, and dried the baby's face as she coughed a couple times, and then started to cry. With the first cry the whole room erupted into laughter and tears and whoops of joy.

Within a minute or so, B. was looking around for her baby. A nurse threw a clean pad down on the bed, and B. stood up, lifted her leg up while I passed the baby under to her hands, crawled onto the bed holding the baby, and sat cross legged on the bed holding her baby to her chest. (Only teenagers are that athletic in the minute after birth!) Her boyfriend wrapped his arms around them both, and we put a couple warm blankets around them all, and everyone sort of stepped back and breathed some sighs of relief ourselves. Baby was born at 7:17 am, about 24 hours after labor started, 11 hours or so after she'd come to the hospital, but just 4 hours after she'd been 4 cms and had her water broken.

After a while of sitting and holding her baby, B. started to feel more cramping and more uncomfortable and wanted to get the placenta out. She lay back on a few pillows, still holding her baby to her bare chest. We clamped the cord, and the boyfriend cut it with shaking hands, while everyone else took pictures. B. pushed once, and the placenta was out. While B. was pushing the baby's head out, since she was kneeling and leaning forward, I could easily see her perineum. The head had slid out slowly and atraumatically and I didn't think she'd had any tears at that point. However, as the shoulders came, there'd been a sudden little gush of blood, and I worried that the popping sensation as the shoulder came was a perineal tear. Sure enough, I could see a midline tear. At first, I though it was just the skin, but as I tried to follow it downward, I couldn't quite see the base of it. Worried about the extent of this tear, I decided to take apart the bed and put B.'s legs in the foot pedals and get decent light to see what was what.

Unfortunately, the tear turned out to be a partial 3rd degree laceration. The sphincter capsule and muscle fibers hung loose in the middle. I explained to B. that she would need some local anesthesia and stitches. This sounded like a just terrible idea to her at this point, but I was able to inject the local pretty much without her feeling much (sometimes the vagina and perineum are numbish from the stretching of the baby and overload of the nerves.) While B. snuggled her baby, and drank a Sprite lying down, I repaired the sphincter, then the perineal muscle layer, then the skin. The tear didn't go quite all the way through the sphincter, and the rectal mucosa was all intact.

Soon, we were done, and B. wanted to have the baby weighed. This skinny 17 rd old had managed to push out an 8 lb 13 oz baby girl - in less than 30 minutes! I asked B. if she was upset about not getting pain medicine and she said "Heck, no!" and that she'd have been very disappointed if she'd gotten pain medicine that close to the baby's birth after getting through all that labor on her own. We helped B. put the baby to breast, and cleaned up the room. B.'s baby mostly did not leave her arms for the next 24 hours, but snuggled with her mama, and nursed, and was loved. The next morning, the nurse who came on in the morning did her assessment exam - and was shocked to find crepitus over the right clavicle, and the baby wincing whenever she touched it. An xray showed that her right clavicle was broken. Looking back, I'm sure that was actually the pop I felt as the shoulder came free. Fortunately, babies' clavicles heal easily, and she has no nerve damage or other problems and just needs to have no one pull on her arm while she's healing. B. felt great, despite the long labor, the extensive perineal repair, and the lack of sleep. She positively glowed while describing her birth - and was so in love with the baby.

See, the thing about this kind of birth is that this mama had it in her to do it. All she needed was the space to do it in. She just needed folks around her to believe she could. It was not an easy birth, or a short birth, or an uncomplicated birth. It was ordinary and yet sacred, moving and extraordinary. Mostly, we just encouraged this young mama to do what felt right to her, and she took the powerful, primal energy of birth and used every bit of it to make it hers. Watching her, who'd seemed so young and vulnerable and needy, turn instead into someone powerful, and strong, and even commanding was an amazing thing. When she was hurting, she didn't need me to rescue her or feel sympathetic, she just needed me to trust her and give her the space to keep going.

So: What if you attended births, but you never saw a birth like this? What if instead your system encouraged, or even coerced, needy, opinionated teenagers like this into lying in bed, strapped to a monitor, until they were overwhelmed? And then you talked them into an epidural to make them comfortable? What if their birth plan was treated as the hubris of an inexperienced child and laughed at? What if her request for limited exams was seen as childish and responded to with "You were able to open your legs to get this baby in there!" type comments? What if she'd pushed and pushed, but her baby had been wedged posterior by the epidural, and her sacrum couldn't move squashed against the bed and the baby never came out? Or she did come out, but the sticky shoulders in hands and knees was a full blown shoulder dystocia in semi-sitting and she'd had a huge episiotomy and a brachial nerve palsy, or worse brain damage from lack of oxygen? Then you'd say "Those damn teenagers think they know what they're doing. Can you believe she thought she could do this? Thank God we saved her baby!" And knowing you were right about it all, you'd treat the next client just the same. Occasionally, you'd see some quick birth happen before you could intervene much, but those would be chalked up to luck, and the rest would have the full gamut of technology you can provide.

I've seen that alternate birth story during my training. I've heard it told to me by friends and clients who birthed elsewhere. I'm always so grateful when I get to witness a birth like this, a birth that took a woman to the limits of her abilities, but she stretched herself and did it. These are the births that keep me going, that I remember in middle of night awakenings, that remind how strong women are, that I wish every birth attendant would be required to witness.

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Midwifery model of care

I enjoyed Jill's recent post about her thoughts on the midwifery model of care. She contrasts her two very different birth experiences and the types of care she received. I especially agree with her take on birth plans:

I'll never sit back and put 100% of my trust in any physician ever again. Even with my home midwives, the majority of the learning, research, and general work I did was fueled by my own desire, not by what they told me to do. It is so incredibly important for women to educate themselves on what's going on with their bodies, especially if they are using a model of care that doesn't take a personalized approach.

It's been said that if you need a birth plan to tell your provider what you want, then you've got the wrong provider. I think this is very true. I didn't even need to think about writing a birth plan with my home midwives, because not only had we already discussed in depth what I wanted and expected during labor, but it was assumed that, barring any medical necessity or danger, I would be getting what I wanted anyway.

She saw midwives for both of her pregnancies, so it's not simply the provider's initials or location that determines the quality of care a woman will receive.

I also wanted to urge any of you living in Virginia to contact your local representatives about some restrictive midwifery legislation recently introduced to the House of Representatives. Jill has more about it on her blog.

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