Who has the right to speak for the baby?

Please welcome guest blogger Roanna Rosewood! I met her at the Human Rights in Childbirth Conference in the Netherlands. She spoke eloquently about her own experiences giving birth and about who has the right to speak for the baby. Below are her remarks from her presentation and letter to the conference. 

If you like Roanna's writing, keep an eye out for her upcoming book Cut, Stapled, and Mended: A Do-It-Yourself Birth. Forthcoming spring 2013.

I’ve been preparing for to the responsibility speak for my unborn baby since long before anyone else considered it. While my brother play-battled with swords, I sat next to my mother as she nursed, and I nursed my own “baby doll” imagining the day when the baby that I held in my arms would pulse sweet milk dreams and curl his toes around the touch of my fingertips as I rocked him.

Twenty some-odd years later, my belly as round as the moon, I could barely contain my excitement. “I love you.” I told him. I repeated it again and again, not out of doubt, but because I knew – even then, that I would fail him. I would make mistakes. “I love you” was the one thing that I could offer unconditionally. No matter what hardships he would face, he would never doubt my love.

Believing it was best, I willingly surrendered our bodies to the hospital. I was wrong. They coerced me into what I would later learn was an unnecessary cesarean.

I remember watching as they lifted him up over the operating curtain. I caught a glimpse of his black hair. I waited for them to hand him to me. They didn’t. They carried him away. He wailed loud, uncontrollable screams, one on top of the other. I wondered how he could breathe.

Every instinct in my body demanded that I get up and go to him, that I sooth him with the same simple words he had heard me repeat since his perfect ears had formed inside of me. I couldn’t. I was tied down. My womb was sitting outside of my body. There was vomit dripping down my cheek.

There was no reason for them to take him from me. My son was healthy. His distress was emotional, not physical. The doctors were so bloated with power that their routine more important than his well-being. While he screamed, they took his footprints, cleaned him, and measured him.

Why must a baby be measured at birth?

How much can he grow in an hour?

To them, the cesarean was routine. To us, it was everything. It cost fifteen-thousand dollars. I was forced to leave my newborn with others and returned to work early to make payments. Nightmares of being tied down and cut open that haunted my nights.  Where I used to rub and caress my belly with love, it is now cold and numb to the touch. Though it’s been twelve years, my eyes tear at the memory of failing my son. The sound of him screaming his first and simplest request of the world will forever echo through my body. I’ve tried to make it up to him. A million times I’ve told him that I love him. But there is no way to heal my son’s introduction to the world – his first breath, his first sight, and his first touch were filled with fear, pain, and disregard.

Pregnant again, the doctor I chose would have allowed a trial of labor but administration refused it. The decision was made by people who would never look into my eyes or see my baby’s entry to the world. Their business choices overruled both her medical expertise and my constitutional right to bodily integrity.

Why have others been given the power to deny me a basic bodily function? We are each of us, here right now, because a woman opened and bled for us so that we might live. The people and institutions managing birth have nothing to do with impregnating us. Our babies are a gift from something bigger, stronger, and more important than they are. The way that we choose to give birth is between us and the powers that entrusted us with this child.

I have deep respect and appreciation for birth professionals and the important work that they do in the world. But I would like to, not so humbly, remind everyone that women and babies are not products. We are consumers. Birth providers work for us. Their expertise in birth is no more important than our expertise in our bodies. Nobody can guarantee good outcomes. Medical errors continue to be a leading cause of death here and in other developed countries.

In spite of everyone’s best intentions, some mothers and babies will die surrounding childbirth. If there is a mistake to be made, let it be made by the one who has already proven her commitment to this child by willingly putting her very life on the line in choosing to give birth to him, let it be the one who will live with the resulting disability or death for the rest of her life. Let it be the one who will grieve and pray. Let it be the mother.

I was created to give life and speak for the interests of my baby. I cannot separate from it. It is who I am. It’s in the breadth of my hips that widened on their own volition to cradle them. It’s in the curve of my breasts, heavy with milk to sooth them. Every month, my womb aches in preparation to receive life because, as a woman, it is my responsibility, my honor, and my choice to bring new life into the world. I alone have earned the right to speak for my baby’s interests.

Read more ...

Human Rights in Childbirth: Panel 6

Panel 6:

Cases on the Edge: 
Controversial Birth Choices in the Netherlands

Panelists:

• Monique Severijns: mother, Netherlands
• Arie Franx: professors of obstetrics & gynecology, Netherlands
• Rebekka Visser: midwife, Netherlands
• Robert Kottenhagen: professor of law & ethics, Netherlands
• Wilma Duijst: forensic doctor and criminal law researcher, Netherlands
• Joke Meulmeester: Chairperson, VVAK, Netherlands
• Sandra Bruin (moderator): mother, Netherlands

The panel began with Monique Severijns telling the story of why she chose a (repeat) cesarean. From how she began her presentation, I expected this would be about choosing a primary elective cesarean with no medical indication. Instead, it was a story of a traumatic first birth that ended in cesarean and in her decision to choose a gentle, empowered cesarean the second time around. Her presentation spoke volumes about the normality of VBAC in the Netherlands, since she framed her choice as such a radical, controversial one in need of defending. Very different from the US, where most women in her situation a) would not see her choice as controversial at all and b) would not even have the choice not to have a repeat cesarean.

Next, Arie Franx spoke about controversies surrounding elective cesarean section (ECS) and "risky" home births. He noted that an OB who performs an ECS may be violating the Hippocratic Oath. He was the co-author of the 2011 Dutch obstetric guidelines, which noted that "term vaginal birth is a fact of nature and does not require consent." ECS is rare in the Netherlands; there were 69 performed in 2006 and 233 in 2011. Next, he addressed "risky" home births (twins, breeches, and VBAC). The Dutch maternity care system is based on a triage risk strategy, with 1st, 2nd, and 3rd lines of care based on the level of complication and complexity. The last of my notes reads, "He strongly disapproves of this." I think I was referring to his disapproval of "risky" home birth, but my notes aren't entirely clear.

Rebekka Visser, a Dutch midwife, explained why she attends breeches & VBACs at home. She gradually learned to respect and understand undisturbed birth. Over time, she started doing less and less during births. Now a primary interest of hers is understanding and promoting physiological birth. She argued that we shouldn't use the Dutch obstetric guidelines as the low or as a tool to coerce women. Rather, use them as a starting point for disucssion and keep care individualized. In her letter to the conference, she argued strongly that birth is a human rights issue and that "women themselves are the best advocates for their babies' interests. Period." During her time as a midwife, she has seen childbirth empower women, but she has also seen it inflict lifelong damage to a woman "if authority is taken away from her." 

Robert Kottenhagen, a law professor, addressed ethics & the legal status of the unborn. He noted that is most cases surrounding disagreements about home birth, "there is not a mother-fetus conflict at all, but a mother-doctor conflict." He examined the Dutch Civil code and the Abortion ACt of 1981 and concluded that under Dutch law, the unborn fetus does have some legal protection, but how far the fetus' rights may go when put into conflict with the mother's is unclear. Currently, "a doctor can act against the will of the mother to prevent severe damage or death of the unborn," according to the Royal Dutch Medical Association. However, these situations are fairly limited in scope. He concluded by noting that most often, there is not a mother-fetus conflict at all, but a mother-doctor conflict. "If the relationship between patient and doctor could be improved in such cases," he wrote in his letter to the conference, "the legal fight would probably be over."

Wilma Duijst, a forensic physician and law researcher, noted that her conclusions differ from Kottenhagen's. By law, a Dutch midwife cannot abandon a woman at home who refuses transfer or treatment. She advised against using coercion or threats on pregnant or laboring women.

Joke Meulmeester, who works at the Advice and Reporting Center for Child Abuse (AMK) and is chairperson of the VVAK (Association for Child Abuse Counselors), noted that controversial birth choices rarely initiate investigations within her agency. She can think of only 1 case in his agency's history. In her letter to the conference, she commented, "Most reported cases around birth are the outcome of a multi-problem situation, with either serious medical and social problems." She noted that respect and communication are important. (As a side note, she had a home birth in the US in 1980).

Joke noted that the Dutch Obstetric Indication List or VIL (Verloskundige Indicatielijst) is a guideline, not a law. The VIL is a list of obstetric indications for risk selection to the appropriate care provider & birth location. The Netherlands has contradictory Supreme Court decisions about how binding medical guidelines are. In one legal case, medical guidelines were enforced, but in another they were not.

Some notes from the post-panel discussion:

• Raymond de Vries noted how a "society makes you desire the very things it limits you to." Fascinating. 
• We have created a culture of blame by dichotomizing choices and by standardizing choices and care.
• Why, if we grant rights to the fetus, does it make us so flippant about the rights of the mother? In other situations we'd never imagine doing such things to other (non-pregnant) people.

If you were present at Panel 6 and have anything else to add, please share in the comments section!
.

Read more ...

Cochrane Review: "all countries should consider establishing home birth services"

A new Cochrane review of home birth has concluded that that "that all countries should consider establishing home birth services with collaborative medical back up and offer low-risk pregnant women information about the available evidence and the possible choices."

Besides examining the evidence, the reviewers also address the interplay of autonomy and concern for fetal rights. Having recently participated in similar discussions at the Human Rights in Childbirth Conference, I was excited to see the following commentary:

This review shows that there is no strong evidence to favour either planned hospital or planned home birth for selected, low risk pregnant women. From an autonomy-based ethical perspective the only justification for practices that restrict a woman’s autonomy and her freedom of choice, would be clear evidence that these restrictive practices do more good than harm (Enkin 1995), as we stated in the previous version of this review (Olsen 1998). A decade later, the European Court of Human Rights in Strasbourg handed down a judgment stating that “the right to respect for private life includes the right to choose the circumstances of birth”. Thus, no matter what the level of evidence is, European governments are not allowed to impose, e.g. “fines on midwives assisting at home births” as it “constitutes an interference in the exercise of the rights ... of pregnant mothers” (Registrar 2010). On the other hand, the ethical concept of the fetus as a patient (Chervenak 1992) may lead some to state that “Obstetricians have an ethical obligation to disclose the increased risks of perinatal and neonatal mortality and morbidity from planned home birth in the context of American healthcare and should recommend against it” (Chervenak 2011) and that “In clinical practice it involves recommending … aggressive management (interventions such as fetal surveillance, tocolysis, Caesarean delivery)” (Chervenak 1992). In this ethical perspective recommendations about interventions are acceptable even when they are not supported by randomised controlled trial (RCT) data. The lack of strong evidence from RCTs and an autonomy-based ethical perspective lead to the conclusion that all countries should consider establishing home birth services with collaborative medical back up and offer low-risk pregnant women information about the available evidence and the possible choices.

One of the limitations of a Cochrane Review of home birth is the very small number of RCTs on home birth. I highly recommend reading the chapter on home birth in Amy Romano and Henci Goer's new book Optimal Care in Childbirth. They examine a large number of high-quality studies that the Cochrane Review does not include. (My review of this book is forthcoming.)

The updated Cochrane Review is significant for those working to reform American maternity care policies. Notice the language supporting autonomy, accurate information, integrated home birth services, and professional collaboration from last year's Home Birth Consensus Summit. The new Cochrane recommendations should make it easier to translate these consensus statements into action:

• We uphold the autonomy of all childbearing women....Shared decision making includes mutual sharing of information about benefits and harms of the range of care options, respect for the woman’s autonomy to make decisions in accordance with her values and preferences, and freedom from coercion or punishment for her choices. (Statement 1)
• We believe that collaboration within an integrated maternity care system is essential for optimal mother-baby outcomes. All women and families planning a home or birth center birth have a right to respectful, safe, and seamless consultation, referral, transport and transfer of care when necessary. When ongoing inter-professional dialogue and cooperation occur, everyone benefits. (Statement 2)
• Effective communication and collaboration across all disciplines caring for mothers and babies are essential for optimal outcomes across all settings. (from Statement 6)

For more information on the Cochrane Review on home birth:

• University of Copenhagen: Birth is no reason to go to hospital
• Full text (PDF) of the review

Read more ...

Human Rights in Childbirth: Panel 5

Panel 5:

Perinatal Mortality in the Netherlands: 
Facts, Myths, and Policy

Panelists:

• Anna Myrte Korteweg: mother and author, Netherlands 
• Elselijn Kingma: philosopher and bioethicist, UK and Netherlands
• Ank de Jonge: midwife and researcher, Netherlands
• Manon Benders: pediatrician-neonatologist, Netherlands
• Mariel Croon: journalist and midwife, Netherlands
• Raymond de Vries (moderator): sociologist, Professor of Midwifery Science, USA/Netherlands

The morning began with a keynote speech by Raymond de Vries about having a baby in the Netherlands. I missed the first half (I slept in on purpose--I was exhausted). I listened to the rest of his presentation in the balcony while I pumped. I had been away from Inga for 48 hours at that point and was probably a full cup size larger, even after pumping a few times.

Panel 5 opened with Anna Myrte Korteweg, a mother who wrote a book about birth choices in Holland after her traumatic first birth. Her book is called Vrije Geboorte (Freedom of Birth), and she blogs here. She had planned a home birth but had to transfer to a hospital during labor. 
 

Elselijn Kingma, a philosopher and bioethicist from the UK and the Netherlands, addressed the relationhsip between science and policy. How we interpret the numbers from scientific studies isn't a given and is highly subject to variation. Our narrow focuson perinatal mortality shows that we don't equally value all members of society (i.e., we tend to gloss over mothers who are subjected to massive harms in the process of hospital births). Where people feel safe isn't objective or fact-based, ut determined by both policy and rhetoric.

Manon Benders, a pediatrician and neonatologist, presented her experiences with perinatal mortality. She works in a NICU and sees struggling babies on a daily basis. This, of course, influences her perspective on place of birth. I found a disconnect between her message--which was quite well-intentioned--and her audience. She called for what she saw as an innovative way to meet the needs of mothers who wanted to birth at home, while providing immediate access to medical and surgical care for mothers or babies who need it: a "multi-disciplinary birth center." I don't think she realized that this is exactly what a hospital is--a place where all providers are in one location--but that that very system fails to meet the needs of all pregnant women. I sensed some frustration among the audience that she didn't really get the main messages of the conference. 

Next, Ank de Jonge, first author of the large Dutch home birth study, spoke about perinatal mortality in the Netherlands. We should avoid jumping to hasty conclusions, she advised. She also noted that the intense focus on Dutch perinatal mortality is not mirrored in others coutnries with similarly high numbers. For example, Denmark has a higher term PNMR than the Netherlands, yet they don't question their maternity care system. However, because the Dutch maternity care system is different from most of Europe's, it is home birth that gets questioned and too often blamed.

Mariel Croon, a Dutch midwife and journalist, examined how money and the media in influencing attitudes towards home birth and midwifery in the Netherlands. The media has a very powerful role in this country, and midwives have been forced into a defensive role due to media reporting of recent studies. She recommended that midwives should use the media strategically and should take an offensive role the conversations about maternity care, much as Dutch obstetricians have already done. She also called for more women's voices in these debates, which are too often overwhelmed by professionals.

Read more ...

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.
.

Read more ...

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?

Read more ...

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.

Read more ...

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.

Read more ...

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.

Read more ...

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.

Read more ...

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!
.

Read more ...