Category Archives: women’s healthcare

Your Epidural is Against the Law: What Alabama Women and Doctors Need to Know


We have one more day of Alabama’s 2013 legislative session, when it is still possible to ward off the ghastly specter of Foreign Law from being forced upon us.  Colorado, that means you—stand back, with your Rocky Mountain High and your happy newly-weds.  Meanwhile, our beloved state Supreme Court has brought pregnancy and childbirth back to what they think God meant it to be—drug free.  No epidurals.  That can work well, especially if you have a midwife or a doctor skilled in normal unmedicated birth, but do women want to give up that option?  How about no spinal blocks for c-sections?  Girlfriends, better practice your breathing!  Obstetricians, addiction specialists and anesthesiologists, do I have your attention?

 

Our story begins back in 2006, when Alabama passed a Chemical Endangerment statute meant to protect children from harm in meth houses.  Although it said nothing whatsoever about pregnant women and was never intended to apply to women who become pregnant while addicted or who use a drug during pregnancy, that didn’t stop prosecutors from jumping right in.

 

I first learned of the problem when National Advocates for Pregnant Women (NAPW) contacted me about efforts to challenge the prosecutions of two Alabama women jailed under such misuse of the law. I decided to add my name to amici curiae briefs that explained to the court how dangerous these prosecutions are for maternal, fetal, and child health.  I’m proud to be listed right there with the 47 groups and individuals who co-signed, including ACOG (The American College of Obstetricians and Gynecologists), the American Medical Women’s Association, the National Perinatal Association, and NOW-Alabama.  Y’all know I’m a good progressive, but ACOG has never been accused of such.  What gives?

 

I know my obstetrician friends are truly concerned about the well-being of pregnant women and babies, and I’m sure that’s part of ACOG’s reason to sign on.  They must know the law puts these women in an impossible position—abort, or deliver and go to jail.  Stopping drug use before delivery is often not a safe option.  ACOG also had to be aware of risks to their professional membership.  The law as it was originally enacted and intended by the legislature says a prescription of a controlled substance is only legally given to a child if directly prescribed for the child.   If revised to include prosecution of pregnant women who take a drug, there is no exception within the statute for the many situations when physicians prescribe controlled substances to pregnant women.  A controlled substance given partly to protect a fetus (such as methadone, if a woman with addiction wants to safely continue pregnancy) is not prescribed to the fetus.  An epidural used during labor or a spinal block for a c-section contains opiates as a way to reduce the need for toxic anesthetics, but it is prescribed to the woman.  General anesthetic protocols include several types of controlled substances, again dosed for the woman.  What’s left, supposing you need your appendix out while pregnant?  Bite hard on that stick and it’ll be over soon.

 

Despite a well-done court challenge, Alabama’s Supreme Court couldn’t resist the chance to get back-door personhood.  In January, they decided the word “child” included fetuses and went a giant step further by adding non-viable fetuses, embryos, and fertilized eggs.  Talk about judicial activism!  We are informed that “outside the right to abortion created in Roe and upheld in Planned Parenthood, the viability distinction has no place in the laws of this State.”

 

You really ought to read the ruling to get the full contortionist flavor.   I’ll wait while you go wash your mouth out.  If you didn’t make it to the end, here it is:  “We conclude that Court of Criminal Appeals correctly held that the plain meaning of the word “child” in the chemical-endangerment statute includes an unborn child or fetus.  However, we expressly reject the Court of Criminal Appeals’ reasoning insofar as it limits the application of the chemical-endangerment statute to a viable unborn child.”

 

Applause came quickly on the anti-choice sites, such as this one quoting Liberty Council founder Mathew Staver: “The U.S. Supreme Court’s abortion cases are an aberration to law and stand on an island by themselves, and that island will one day disappear.”  We know that is the underlying intention of these prosecutions and of the Alabama Court’s decision.   What a nice bonus for them that women also get to experience pain of Biblical quality while undergoing surgery without medication!

A Senate Resolution is in the works which would affirm the Court’s interpretation of the statute as correct.  If passed, will Governor Bentley sign it?  Does he understand the consequences to his physician friends?

 

Here’s an interesting scenario:  let’s suppose a pregnant woman is pressured or forced to undergo c-section against her wishes and is given spinal anesthesia.  She is royally outraged, as she should be, and requests charges pressed against the obstetrician and hospital for chemically endangering the fetus.  Can the prosecutor refuse to do so?

 

There are two paths I can see for prosecutors to travel.  They could comply with their duty to enforce the law as interpreted, in which case physicians who care for pregnant women ought to look a mite more nervous—if not sweating and trembling or packing their bags—when I pass them in the hallway.  Or we could continue to see this law used selectively, for low-income women who are addicted.  I can tell you that at least where I practice, no one is arresting well-off mothers taking prescribed opiates during pregnancy.  Much as I’d like to, I sure haven’t seen a slow-down in c-sections either.  The law is broken many times a day, without so much as a raised eyebrow.  Huntsville, Alabama, living on the edge. . .

 

Without even a token effort to apply the law equitably, it seems to me the law is unconstitutional as applied.  The state must be aware it is violating Equal Protection by not defending all fetuses, only poor ones.  If so, we ought to expect at least a few arrests of women taking prescribed pain medications or methadone, and perhaps their physicians.  Who will that be? Are you quite certain it won’t be you?

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Filed under addiction, Alabama Legislative Session 2013, women's healthcare

A Woman’s Body is Her Own– Including in Pregnancy and Birth, Part 5


Here we are, at the end!  You might want to read Part 1 (overall explanation of this series on home birth legislation), Part 2 (safety data), Part 3 (training and considerations for rural/ poor families) and Part 4 (the duty of the state) if you haven’t already.

 

My Birth Stories

 

No matter how much we may try to be objective, it cannot happen.  We are all prone to bias of some sort.  Have you ever noticed how often a group of women at a social gathering will eventually come around to sharing their birth stories?  These are crucial events in our lives.  I know my birth stories likely have some influence on how I have understood the home birth movement, so I’m going to tell them—and this, believe it or not, is the short version.

 

I married at 21 and got pregnant after 3 years of trying at age 25, in the middle of my MD, PhD program.  We had just about decided we were going to have to adopt.  When I called my husband to tell him the test results, he was shaking so hard he had to get a friend to pick up the receiver.  We were ecstatic—and did we believe even the embryo to be a “person”?  Absolutely.  He had two names for awhile, and then one when we knew he was a boy.

 

Pregnancy turned out to be more difficult than I expected.  Morning sickness?  Sure, if morning starts at 5 am and ends at 5 or 6 pm! That went on for most of the pregnancy instead of the first 3 months. Fortunately, I was not seeing patients yet and was able to arrange my lab schedule to go in at odd hours on really bad days.  I didn’t have to worry about my job the way families in my practice would have.

 

I took the standard advice to have prenatal screening labs done, and when I got the call that my alpha fetoprotein (AFP) was too high, I panicked.  That was a multiple choice test question to me—high AFP = neural tube defect, such as an open spina bifida. I had it in the stack of index cards I used to study.  I had no idea it was a high error test and was still terrified even after learning more.  I did not want the repeat test or the subsequent amniocentesis—I told my ob that it didn’t matter because it was MY baby and there was no way I was going to abort.  He convinced me that we needed to know because it might affect the birth setting—I might not want to have a sick baby in the middle of the night without full staff there.  So I did the amnio, which was normal but quite frightening.  I kept watching the ultrasound screen and saying silently to my baby, “don’t move, don’t move”, fearing he would skewer himself on the needle.

 

Even though the results were normal, we met more problems I now suspect may have been partly stress-related—he quit growing well.  Which made me even more anxious.  Finally at 6 1/2 months I was put on bed rest at home, so I could lie there and worry constantly, while he still didn’t grow. I’m not nearly such a worrywart at age 49—being an advocate has pretty much cured me of that.  These days if I were stuck at home for that long, I’d probably have written a book or two by the end.

 

Because he wasn’t growing, I was transferred to a high risk specialist.  After stress tests and another amnio, I was told he was in danger and I needed an induction.  So at 36 weeks, I went to the hospital.

 

We had been to childbirth classes, and I thought I was going to be able to walk around like the women in the films they showed.  I had practiced my breathing exercises.  As I’m sure you know, I was immediately strapped down with a monitor around me and hooked to an IV.  If I moved much at all, the alarms went off and made the nurses annoyed.  Because it was a public hospital with a high number of deliveries and the walls for labor areas were not walls but curtains, I was surrounded by screams and all sorts of calamitous goings on.   I made it until about 9 pm, 15 hrs, without pain medication and then the ob said I wasn’t progressing enough and was going to need a c-section.  In preparation, I had an epidural, after which labor did progress and I delivered vaginally.  At 11 pm that night, our beautiful 5 lb 4 oz son was born.  He was quite healthy and gained rapid weight with nursing.

 

Without questioning it, I had the idea that without all the high-tech intervention during pregnancy and delivery, he would have died.  And that might have been true.  There was a section of the placenta which had infarcted and probably had resulted in slow weight gain. We don’t know why.  I didn’t have high blood pressure and to my knowledge don’t have a clotting problem.  It never occurred to me back then that the intense fear and worry I had during pregnancy, triggered partly by medical care, might have been an additional factor.  I don’t blame the obstetricians, who were kind and skillful—as I said, I was a worrier back then.  If someone had told me “don’t worry, you might hurt your baby” I bet THAT would have been extremely helpful—or not!  On the other hand, before the abnormal screening lab I was not afraid.

 

I chose the same practice and medical center for our second baby, born 19 months later.  I thought I needed to be with the hospital having the top neonatal ICU, just in case.  This time, they had a nurse midwife and I decided to get my care with her.  I loved my midwife and thought maybe this time it would be different.  The hospital had added a birthing room I wanted to use—I thought maybe I’d get to actually have a labor more like the films I’d seen.

 

This time I went into labor at home at a little over 40 weeks and delivered only about 3.5 hrs later.  I think I was in labor at the hospital maybe 2.5 hours tops.  When I arrived, I was told my midwife was in the ER herself, having a laceration repaired after a car wreck.  I was again strapped to the monitor.  I declined the epidural, and after some nagging was allowed to go to the birthing room, although I was told I’d have to deliver in the regular room because the obs didn’t use the birthing room (unprintable epithet—really?).  After only about a half hour in the birthing room, they moved me to a delivery room.  On my back, the contractions were much more intense and I felt I couldn’t handle them.  My husband was there but I had no midwife or doula to coach me, and I asked for an epidural after all.  I was too far along.  I told the nurse “well, then I’m not going to do it.” Have mercy.  She laughed and said “Honey, you don’t have a choice.  But women have been doing it this way for thousands of years.”

 

Shortly afterwards I felt the urge to push.  It caught the nurses by surprise that I was fully dilated so soon, and they had to run out and grab the only ob around, about to leave by elevator.  It was the chair of the department, whom I knew would soon be grading me in clinical rotations.  He got frustrated with me after about 30 minutes of pushing and said I wasn’t doing it right.  I wanted to tell him where to put his @#$%^  pushing but couldn’t because of the grade I might get!  She was an 8 pound baby, quite a difference from the first time—I remember wishing, right as her head was coming out, that I could please have an out-of-body experience NOW.  And I heard the ob say, “Oh, she’s face up, that’s why it was hard.”  If you know anything about deliveries, you know he should have been able to tell that before criticizing my pushing.

 

I tore, a 3rd degree, but hardly felt it at the time because she was healthy and in my arms, our beautiful daughter.  I bled much more than the first time, afterwards, and I asked the nurses if this seemed like a lot of blood, but no one bothered to give more than a quick glance.  So I quit complaining.  I remember being tired for weeks and added extra iron to my regular prenatal dose on my own at home.   At my 6 week postpartum check, my HCT had dropped from 40 (at admission for labor) to 32.  I’m guessing it was already on the way back up.

 

Somehow my take-home message from this was that I wouldn’t have bled so much or torn if I had done the epidural from the beginning—that what seemed like a violent labor and delivery had to do with my effort to have my baby naturally.  I think now that I could have had a lower chance of tearing with a better birth position and not being anxious at having my professor there.  I bet if my midwife had been with me, she would have realized I was having a postpartum hemorrhage.

 

I had let my own experiences tell me pregnancy is a minefield and birthing is so scary that it can only be done in the safety of a hospital.  I was appalled that anyone would even consider taking such a dreadful risk as to deliver at home.  I believe that helped me to accept badly done research and biased information without giving it my usual skepticism.

 

I wouldn’t entirely discount the usefulness of life experience, however, despite the risk of being led astray.  My personal experience during pregnancy, as a mother coping with the later disability of one child, and as a pediatrician seeing what other families go through has taught me that pregnancy and parenthood can involve intense commitments, sometimes lifelong.  I regret nothing about my choices to have children and would do it again even knowing there would be suffering later.  I would find it impossible to think I had the right to force another woman to make the same choices, whether that involves continuing a pregnancy or planning a birth setting.

 

Conclusion

 

I don’t want to give anyone the impression I am now advocating any particular birth setting.  I wish I had known more about other options when I was pregnant, but I don’t know if I would have chosen differently in the end. What I want is more transparency and honesty in data, and more options for women in my state.  I have come to see that birth issues are intricately part of women’s rights as a whole, and that we cannot neglect this critical aspect and expect our advocacy efforts to turn out well.  I support the creation of a Board of Midwifery in Alabama and the licensure of Certified Professional Midwives.  There is a petition to sign if you are of the same mind.  I hope, whether you agree with me or not, that you will at least give the decision your most careful thought and do your best to consider your own possible biases.

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A Woman’s Body is Her Own– Including in Pregnancy and Birth, Part 4


Here is part 4 of a series on why I’ve decided to support licensure of certified professional midwives in Alabama.  You might want to read Part 1 for the background, Part 2 for some safety data, and Part 3 about training plus special circumstances of rural/ poor families.

 

Duty of the State

 

After realizing I had used bad data, I still went through a period of not supporting the home birth bills.  I was concerned about midwives accepting high risk clients.  I also worried that without access to the choice of a hospital, poor women in rural counties might be swayed towards home birth disproportionately and that this was not a true “choice” but a default.  I wanted the options for all women in our state to be equally available, and I still do.  I also was concerned at the high degree of animosity I was hearing among the obstetricians.  How would it work to transfer an infant from home to hospital, if the obstetricians could not have civil relationships with the midwives?  I feared this would impair safety for the mothers.

 

I have worked in settings where specialists were rude and verbally abusive to pediatricians—there have been times when I’ve had to take a deep breath before calling for a consult, knowing I was going to receive general nastiness, but doing it anyway for the sake of my patients.  I know of cases where other doctors have let that reluctance delay their call for help.  I’ve had ER doctors call me about patients who clearly needed a specialist level of care and heard them admit they didn’t want to call that doctor because of anticipated rudeness.   I know that bad relationships put patient care at risk.

 

I had a convoluted and admittedly pie in the sky plan worked out in my head.  First we needed to get labor and delivery hospitals in every county and fully license CNMs to work without needing a supervisory physician.  Right now, advanced practice nurses must have what the state calls “collaborative” practice but which is really supervisory practice.  I work in collaboration with other physicians all the time, and most are wonderful, unlike the bad actors I mentioned above. But even if they are higher up the pay scale, they are not my supervisors.  All the CPMs and CNMs I talked to spoke highly of collaborative work and none wanted to practice without those relationships.  What hampers them is this unnecessary supervisory role.  Other states have done away with such.

 

Then I figured the next step would be free standing birthing centers, nearby to hospitals and staffed by CNMs, followed by cautious expansion into home birth.  One CNM faculty member in Georgia set me straight that her trainees were not getting enough training in birthing center or home birth settings to make that workable.  They were going to be mainly comfortable in a hospital environment.  So I switched my mental plan to including CPMs once we got to the birthing center phase. Don’t I sound like Mao, with my five year plan?

 

Anyway, I had what seemed to me a very rational, stepwise progression that would allow physicians to develop good relationships with midwives.  The problem is, as I’m sure you realized—we are just not going to do that in Alabama.  That’s not how we roll.

 

Right now, in our state, we are already having home births.  Many are unattended, and some are attended by “midwives” of uncertain training and credentials.  The CPMs I talked to are horrified.  They are very protective of their certification and license, and they tell me some of the things they hear about would never be permitted by one of their licensees.  They speak of attending our legislative hearings and knowing the stories told about home birth gone wrong are incorrect in critical details—that some of the women involved had been told by multiple CPMs not to deliver at home or vaginally at all, that the wrong practitioner was being slandered, that the mother had refused the advice of the midwife to transfer to the hospital.  They cannot correct these errors because of patient privacy.  They tell me these horror stories are exactly the reason we need to license and regulate CPMs, so women can have access to well-trained and monitored midwives.  Rich women at low risk will find a qualified home birth attendant, out of state.  Those at high risk may make bad decisions at times, just like we all can do.  Poor mothers bear the brunt of inadequate resources.  CPMs would increase their options, not decrease them.  We do not have time to wait until the Shangri-la of hospitals in every county arises.

 

I have an uneasy feeling about licensure in general.  My ideal set-up would be to have almost nothing be illegal in medicine—I would not have a category of crime for practicing medicine without a license.  Instead, I’d rather we just had strong transparency about qualifications.  People should be able to choose if they want a physician, a midwife, or a taxi driver to charge for medical services, but they should know what their chosen provider can do, who has provided the license, and what sort of ongoing monitoring happens.

 

Because we are so license-oriented, however, it seems that the issuing of a license implies that the state has assumed a duty of quality.  I was ok with an adult woman making her own decision about risks and benefits, even if she chose options most of us would consider unsafe.  I was less ok with taking a risk with the baby, especially knowing there were non-low risk home births being done sometimes.  I did not see a right of the state to prevent abortion, but I viewed the status of an infant intended to be born as somewhat different.  It seemed to me we have a collective duty to prevent that infant from being saddled with life-long injury, if being born at home could be riskier in some cases.  So I continued to obsess about the relatively uncommon incidents of high risk home births, instead of focusing on the more common scenario of low risk, good outcome home births.

 

In the end, what nailed it for me and stopped this endless tail-chasing?  Thinking about the women in Alabama who have been imprisoned for being addicted during pregnancy and not aborting, and the women who have been court-ordered to have c-sections against their wishes.  It felt clear to me that the rights of these women were being grossly violated and set aside, not just being put on equal status with the fetus but being utterly overlooked.  We were losing personhood.  We do not stop a person with cancer from refusing treatment, even if that hastens death and even if the cancer is entirely curable.  But we do not allow a pregnant woman to make her own decisions about birth.

 

Any of us who care about women’s rights cannot allow these injustices to continue without protest.  The bright line of the state’s ability to make decisions for a fetus in loco parentis, against the wishes of the mother if she is acting against the future child’s best interest, must be clearly drawn at one moment—when their bodies become separate.  When there is a baby, out of the mother’s body, and not an instant before.   No matter how we define life or personhood, there is just no other way to do it without removing a woman’s personhood and ordinary civil rights.  A pregnant woman, just like the rest of us, should have the right to choose badly or well.  Yes, I realize that can result in burden to the child, just as being raised by smokers puts a child at risk of asthma or being born to parents with sickle cell trait can results in sickle cell anemia and the attendant suffering.  We don’t get to choose our parents.  Unless we are going to start issuing licenses to conceive, the state must limit its scope of power for pregnant women to the same degree as it does for other adults.

 

That does not mean we citizens (the state) have no duty to provide a good environment and safe options for children intended to be born.  I think we can and should agree to assume that duty.  I just don’t think we have the right to make a woman use those resources.  If it becomes apparent that home birth is indisputably safer under certain circumstances, we should not force those women to leave the hospital and deliver at home.

 

Tomorrow:  Part 5 (the end), with my personal birth stories

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A Woman’s Body is Her Own– Including in Pregnancy and Birth, Part 3


This is the 3rd segment of a series on home birth in Alabama.  Please read the first few paragraphs of part 1 for background.  Part 2 has information on safety data.

 

Training

 

When I first got wind of the CPM bill in 2010, I heard my friends talking about “lay midwives”.  I did not know this label was not only highly inaccurate but highly insulting to the CPMs.  They are most certainly not “lay” midwives, which implies no formal training and sounds sort of like a hobby—“I like to knit and do a little midwifery now and then.”  No matter which side you are on in the debate over licensure, there is no reason to use insulting language.

 

Although the minimal requirements seem just that—minimal—just a number of deliveries does not take into account the reality of the certification.  Seeing those numbers really tripped me up, because I delivered more babies than that in a brief rotation during my 3rd year of medical school, and I know good and well I am not prepared to deliver an infant even in the hospital without backup, certainly not at home.

 

The numbers don’t explain that it would be hard to pass the skills testing without far more experience.  Each CPM must demonstrate specific skills to her preceptor.  (I am going to use the female pronoun in this piece, because around 98% of midwives are female—I mean no disrespect to the male midwives).  She is not even allowed to enter into skills testing until she has been present at enough deliveries to know what she is doing.  I was told by the midwives I spoke to that it took on average 3 to 5 years to acquire enough experience for the certification, usually 100 deliveries at a bare minimum.

 

None of this “see one, do one, teach one” that we have in medical training and which I can personally attest to.  Even though I said above that I am not prepared to deliver an infant in the hospital without backup, I certainly did do it, as a 3rd year student with almost zero weeks of any hands-on patient experience.  I knew the Krebs cycle backwards and forwards, but a live human being in my care was very new.  More than once, it happened that the residents were busy and I was sent in to catch a baby all by myself.  The first time—first time!—I put sutures into a human and not an eggplant, it was an episiotomy repair, after watching the resident do one earlier.  I did not want to do it—I did not feel ready—but no one else was available, and I was instructed that I had to.  Letting the woman lie there with an open wound was not an option.  Thank goodness the nurses were there.

 

Those who compare the CPM training unfavorably to CNM (nurse midwives) should know that the numbers are based on CNM standards at schools around the US, in addition to the job analysis I mentioned earlier.  But the minimum delivery numbers are not reflective of the average actual training.  I wonder if this should be changed to reflect what really happens, mainly for everyone’s peace of mind and for clarity.  However, as it is, without changes, the training is rigorous.

 

CNMs, nurse midwives, receive an RN training plus the advanced practice midwifery. CMs, certified midwives, are the nursing profession’s answer to “direct entry” midwives—it isn’t a commonly used certification.  Interestingly, despite the similarities to a CPM, the CM degree gets touted as an example of a “preferred” qualification by ACOG, the American College of Obstetricians and Gynecologists, with no data to back up their preference.  That tells me they are not just concerned that a midwife should have broad-based RN skills—it is something else, a political problem.  Both CNM’s and CM’s differ from CPMs in that the training must include hospital delivery and does not have to include home delivery.  They read fetal monitor strips, while the CPM’s obtain the same information without the monitor.  They are trained to work with a team, including nurses and physicians, and must know how the hospital environment works.  They provide well-woman care, including contraception, and they can be trained in abortion.  They care for women who have been given induced labor, epidurals and opiate pain medication.  There is no need for a CPM to have these skills to perform home births.

 

Rural Areas and the Poor

 

As I’ve mentioned, we have atrocious infant mortality stats in our rural counties.  Like a third world country.  That’s really what it is, a whole other country, a third world, spread out between and within our cities.

 

Every year, Alabama’s Perinatal Advisory Council publishes a report about the problem.  They lay it out, every sad detail about how we fail our babies.  What gets done?  Nothing much, because they are given no money to do the big jobs.  Read the regional activities for 2012—posters on safe sleep, wellness fairs, and grief support groups for families whose infants have died.  Grief support!  We are doing nothing substantial to increase access to prenatal care or obstetric services in the rural counties—36 of which have NO hospital based labor and delivery units.

 

It might be that if we ever get around to taking the Medicaid Expansion money, some of those funds could go towards building obstetric hospital services.  But a rural doctor doesn’t spring out of the air upon the mention of money.  As I’ve discussed in other posts, a lot more goes into that process, and it won’t happen quickly.

 

We have Mennonites in Cullman County, and they practice home births but cannot legally hire a CPM to assist them.  No matter how nice or fancy a hospital we offered them, they would not likely go deliver a baby there.  We have poor families in the cities and in rural areas who do not trust hospitals and doctors, sometimes because they have been ill-treated and disrespected in those settings.  We have others who are faced with driving hours to a city with a hospital and must consider scheduling a c-section or induction, if they don’t want to risk delivering on the side of the road.

 

Many poor women are uninsured and don’t qualify for Medicaid before becoming pregnant.  They are not used to being part of the healthcare system. Alabama does have a “Plan First” program to provide contraception and tubal ligation, but the program does not include the general medical care needed prior to conception.  It can take awhile to get the paperwork done and get an appointment to start prenatal care, even if there is a doctor available. If women have to travel for those visits, the problem is compounded.

 

When women arrive at some hospitals in labor, if prenatal care is late or they didn’t have it, there is a standing order to obtain a drug test and a social services consult.  Women who have been attending prenatal care put themselves at risk for social services investigation during pregnancy, which can result in DHR records and a plan to either take DHR (Department of Human Resources) custody at birth or require DHR involvement before discharge. Women who are on methadone as treatment for opiate addiction, who should not try to wean methadone during pregnancy if they want a healthy baby, have their babies whisked off to the NICU and are not allowed to breastfeed them at hospitals in my area, despite evidence that this can be done with safety.  On the other hand, if a woman avoids prenatal care and the possible DHR trigger, a social worker consult after delivery may not result in action because she is not already “in the system.”  Whether a woman is using drugs or not, if she knows she will be subjected to special scrutiny for having been poor and pregnant, is it a surprise that she might be reluctant to come for prenatal care?  I have seen DHR investigations triggered solely because the pregnant woman herself had been in the foster care system.

 

Please don’t misunderstand—I am not meaning to badmouth DHR.  They are charged with protecting children in an environment of terribly insufficient personnel and funds.  I am grateful to have a way to help children in my practice who are being actively endangered get to safety.  But there is a bias within the system that results in a higher targeting of poor families and a resulting distrust within those families when they need to interact with medical care.  I do not see any substantial effort being made to change this disconnect.

 

Poor families, rural families with no access to hospitals, and those who have studied the issue and want to deliver at home—these births ARE happening at home, in our state.  Why not make it legal and thus safer, by having a Board of Midwifery to license and provide oversight?

 

That will bring us to tomorrow’s topic:  the duty of the state.

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A Woman’s Body is Her Own– Including in Pregnancy and Birth, Part 2


If you haven’t read Part 1 yet, you might want to at least check out the first few paragraphs for an explanation of this series.

Safety

Sigh.  I’m not going to go into a comprehensive analysis of the data and published literature—others have done it better who have more statistical expertise.  Instead, I’m going to go over how an ordinary pediatrician (me) with my particular biases encountered and interpreted the literature.  It’s going to sound convoluted.  I want you to understand the sort of contortionist thinking that happens, because I’m not the only one doing it.

As a pediatrician, I am trained to regard safety with a devotion nigh unto religion.  My children used to call me “Mrs. Safety”, and I don’t think they meant it as a compliment!  So when I first heard Alabama had home birth legislation proposed in 2010, I went to Medline and pulled up an absolutely terrible meta-analysis, known as the “Wax paper.”  It was supposed to be the definitive analysis of home birth safety, the largest one ever done.  To my present embarrassment, I did not perform what I would consider “due diligence” investigating the credibility of the paper.  I was horrified that the authors found a 3 times higher risk of death in normal low risk infants born at home, in what was supposed to be the largest examination of data to date.  I popped off and wrote a letter to the editor of my local paper basically saying you’d have to be crazy to want a baby born at home and cited the bad paper.  I wish that letter could be removed from the Internet, but I guess it will serve as a reminder that I can be pretty stupid sometimes.  Look at the comments and you’ll see what I mean.

A quick rebuttal to my letter was published, saying the Wax study had been widely discredited.  That surprised me—the study had only just been published, hot off the press.  At the time, I could not locate criticism from a source that seemed likely unbiased.  Some of the criticisms I did find on midwifery sites complained that Wax had included data from studies showing the opposite of his collated results—that made me think the critics didn’t understand meta-analysis, because it makes no sense to only include studies supporting the overall conclusion.  Meta-analysis in general is very difficult and prone to being screwed up, but it is also prone to being attacked by people who just have different opinions on what the outcome should have been.

Turns out the midwife critics were just ahead of me.  It takes awhile to get a letter to medical journals into print, but by 2011 there were plenty.  Wax made so many errors that he had to publish an erratum several months later, but to my knowledge he never did retract the overall conclusions of the “study.”  If I had been careful and not let my preconceived safety notions get the better of me, I would have seen the real conclusion right within the small print of his original paper beneath a table: “[t]he analysis excluding studies that included home births attended by other than certified or certified nurse midwives had findings similar to the original study, except that the ORs for neonatal deaths among all (OR, 1.57; 95% CI, 0.62–3.98) and nonanomalous (OR, 3.00; 95% CI, 0.61–14.88) newborns were not statistically significant.”  That’s right—when he excluded the births where no certified attendant was present, there was no statistical difference in deaths.

I am used to reading papers with a jaundiced eye—we’d love to think that a peer-reviewed journal would do a better job than the National Enquirer at only publishing good work, but that would truly mean a trip to la-la land.  Mostly I am suspicious of studies on brand name drugs, but I have to also remember that even non-drug company work can be rife with bias.  Science is heavily political—what gets published, who knows whom, what gets funded, and it goes well beyond industry manipulation.  I knew that, and I still goofed.  The Wax paper is good for kitchen use wrapping sandwiches, but that’s about all.  If you’d like to suggest a penance for me, I’m open to suggestions.

What else do we need to look at, besides deaths?  Morbidity—non-death resulting conditions—are important as well.  Wax seems to be on a vendetta—he did another paper looking at morbidity, where the results favored home birth tremendously.  In his words “home and birthing center deliveries were associated with less frequent chorioamnionitis, fetal intolerance of labor, meconium staining, assisted ventilation, neonatal intensive care unit admission, and birthweight <2500 g.” Yet he chose to highlight two outcomes of home birth he found worrisome—more labor that was either faster or slower than in the hospital and an Apgar score of less than 7.  Difference in labor duration does not imply that a normal variation is harmful—on the contrary, it tells us the hospital environment is truncating that normal variation.  Apgar scores are most emphatically NOT to be used as a marker for later risk of bad outcome.  Even for scores less than 3, the incidence of later diagnosed cerebral palsy is minimally higher.

Britain is constantly looking at data for both outcomes and cost for its National Health Service—although this analysis was done primarily for cost, sometimes cost is a proxy for morbidity.  In this case, the risk of infant complications was lowest in home births of non-first time mothers, compared to in-hospital.  Although the risk of newborn complications was still low at home for first time mothers, it was higher than for mothers having given birth before and statistically less likely to result in cost savings.  I wish they had provided more breakdown of actual complications for the first-time delivery infants, because minor issues like a clavicle fracture and potentially serious ones like neonatal encephalopathy got lumped in together.

If we can’t use the big bad meta-analysis, what can we use?  It is hard to say.  Although most of the largest studies do suggest that planned, attended home birth for low risk pregnancies can be safe, there are design questions for each of them.  Cochrane Reviews, which generally appears highly trustworthy in standards for good quality studies, has given a slight nod to increasing quality of data in home birth studies, and the tone of its review seems generally favorable to home birth being relatively safe for low risk cases.  However, ultimately they discarded all but one small study as being flawed in some significant way.  They were unable to draw a conclusion other than that women would like to have more information about safety data for birth settings.

When I mention this to home birth opponents, some of them are aware of the data and counter with “but the midwife training is different in those studies done in European populations.”  Home birth advocates I talk to like to respond with a 2005 study on North American births (98% US, 2% Canada). This study found an overall 1.7 per 1000 neonatal mortality rate in normal infants with low risk, planned, CPM attended deliveries. The authors published additional background on the study as well.   I wasn’t reassured by that number—oddly, it is very close to the properly maligned Wax paper which calculated 1.5 per 1000 neonatal deaths for normal infants born at home.

Although the 2005 study did not select a cohort of hospital births with similar low risk criteria for comparison, the authors did examine several hospital studies.  Knowing the definitions of “low risk” and other selection criteria vary, they correctly pointed out that 1.7 per 1000 deaths was within the general range found for low risk hospital births.  On the other hand, I kept pulling up studies on low risk hospital births with extremely low death rates, around 0.6 per 1000 deaths.  I realized I should not compare those numbers between studies and could not even tell if there was any statistical significance, but I was still worried.  On the other hand, I somehow found it easy to write off papers with a higher hospital death rate—go figure!  It is easy now to see what I was doing.  I just could not believe this idea was safe, so I looked at the numbers in a way I knew was not scientific, a sort of intuitive quasi-meta analysis.

For awhile I decided that maybe Europe had figured it out but the US had not—that maybe we could have safe home birth but we needed to copy their midwife training model.  I also noticed that if breech or twin births were included, the risk increased to 2 per 1000 neonatal deaths.  I was worried that midwives were not restricting their practice to very low risk deliveries.  I was concerned that if we made home birth providers licensed, women who might be safer delivering in hospital would be offered a more risky option and might think it was fine because of that license.  So I was still not in support of Alabama’s home birth legislation.

I’ll get into training later.  First, though, I want to think a little harder about that 1.7 per 1000 deaths.  We cannot say that is 3 times higher than hospital rates, even if we find examples where it appears to be. We don’t know if that is statistically significant.  But because that ratio is getting thrown around a good bit by critics of home birth, let’s just pretend it means something.  Even if we assume the worst case scenario—a statistically significant 3 times higher risk of death—multiples are not always the way to look at risk.  I knew that too, and again forgot it.  We deal with this all the time in medicine—papers talking about very rare conditions being increased 2 or 3 times in frequency by a certain intervention.  If something is rare enough, 3 times rare is still very rare.  Absolute numbers are a better point for discussion.

If I told you that driving down a particular road would make you almost 3 times more likely to die in a crash, I’m guessing you might take a longer, slower route.  But if I said “on the fast route your risk of dying in a crash is 1.7 in 1000 while on the slow route it is 0.6 in 1000,” I’m not so sure.  It would depend on how anxious a person you were and how much you needed to hurry.  You might consider the condition of your tires, the weather, and the time of day.   At any rate, using the 3 times higher approach seems inflammatory and manipulative, versus just using the absolute numbers.

Now compare 1.7 in 1000 neonatal mortality to Alabama’s overall infant mortality rate, constantly staying in the 8 to 9 per 1000 range.  You may protest that this mortality rate is so bad mainly because of prematurity, it includes births that are not low risk, and that infant mortality (up to a year of age) is not the same as perinatal or neonatal mortality.  You’d be right—but guess what can decrease prematurity and some of the other risk conditions?  Prenatal care, which could be provided by CPMs.

If licensing CPM’s would increase our ability to provide prenatal care in the state, especially in those poor, rural counties where infant mortality gets up in the 25 or more per 1000 range, would we see a drop in infant mortality because of a drop in prematurity? I am aware that in counties with fewer births per year, a handful of deaths will give us crazy numbers—but year after year?   I am wondering how we can quibble about 0.6 vs. 1.7 and ignore those counties.  If the argument is that we can’t legally allow babies to be born in an environment that is possibly 1.1 more deaths out of a thousand risky, and we believe it is our job to make that decision, how can we let women in rural counties get pregnant at all, with more than 23 extra deaths out of a thousand risky?

Then let’s get to the business of using statistics to make personal decisions.  I know the risk of relying on personal experience—we tend to remember the dramatic but rare events and count them more heavily.  Statistics help us get the big picture and are very important, but for an individual we must also consider local factors that deviate from the average.  The variables expand dramatically.  How good are the obstetricians and midwives where a woman lives?  Can she afford their fees for prenatal care?  How far is she from the hospital? How clean is her home?  How good are the safety ratings for her particular hospital?  How well does she trust the local obstetricians and hospital or midwives, and to whom will she disclose all the information needed to safely provide care?   Who will best listen to and address her concerns?  Who will she trust to take action in an emergency, so that rapid decisions can be made without losing precious time to persuasion?

The person to ask and answer these questions is one person:  the mother.  Safety information needs to be made known to her in the most transparent manner possible, so she can make her decision.

When I first went into practice, I was in rural North Carolina.  I will never forget coming to Labor and Delivery to examine a beautiful, healthy looking newborn with nasty purple bruises on her nipples.  I was utterly perplexed—how on earth would that happen during the process of birth?  Did the baby have low platelets perhaps?  Seeing my puzzled face, the nurse said, “Oh, that’s Dr. X.”  I was still confused, so she went further.  “Dr. X twists their nipples to make them breathe.”  Aghast, I recalled the odd instructions in my neonatal resuscitation course that specifically said “don’t twist the nipples.”  I’d always thought to myself “who on earth would do that?  What a crazy instruction.”  Now I knew why the course designers felt the need to be specific, and also that one of my local obstetricians was obviously not keeping up.  Turns out the bruised nipples were just a marker for even more badness.  I reported him, time and again, and nothing was ever done.  If I were pregnant in a town with a choice between Dr. X and an attended home birth, you can bet I’d have picked home birth.  I am not telling about Dr. X to malign obstetricians.  He was a rare bird—almost all the other obstetricians I’ve known are excellent and skillful.  I just want to say it can happen.

There are many outcomes I don’t see considered often, which may not show up for years.  For example, we are becoming increasingly aware that bowel flora (bacteria and other organisms in the gut) might influence risk for many illnesses, ranging from inflammatory bowel disease to obesity.  We don’t know enough for me to say you should follow one of the popular programs to obtain “good” gut bacteria—we don’t even fully understand what “good” means yet.  But we do know that infants can acquire their initial set of gut flora from the maternal vagina and gut, during the process of vaginal delivery, or through being handled by a variety of other persons, including the mother, after a c-section birth.  Given the high rate of c-section deliveries in the United States, we could say that currently infants are getting their bowel flora in a somewhat novel way compared to the course of human history.  If it is evolutionarily advantageous to infants to have the mother’s vagina right next to her anus, we could be creating problems.  I’m not saying we are—just that the range of factors to consider is very large.

Now what about the mother?  In arguments about home birth, how many times have you heard the mother’s health mentioned?  The lower risk of maternal surgery, vaginal tears and other hospital complications often gets brushed aside as a temporary and maybe trivial inconvenience for the sake of a healthy infant. Because of variability in death certificates between states, there is likely substantial under-reporting of maternal death if it isn’t immediately occurring in the hospital.   Even so, the maternal death rate in our country has risen in recent years.  Without better reporting and careful analysis, we do not definitively know why— it is certainly not because of home births, which are still around only 1% of the population.  We are doing something wrong in the hospital or in prenatal care.  Some obstetricians argue that the higher death rate with c-sections versus vaginal delivery would be even higher without them, because of the circumstances leading to a c-section decision.  It would be impossible to do an ethical randomized prospective trial to find out, but at the least we should be more strenuously comparing our practices to those of developed countries with lower c-section and lower maternal mortality.

In summary, from my perspective, there is evidence at least to say that countries with home birth programs can experience good outcomes.  It may be that there are other factors we need to emulate to achieve optimal results—for instance, universal healthcare throughout the lifespan.  But we have no evidence to say home birth is categorically unsafe.

Whew!  That’s enough numbers.  Tomorrow, I’ll talk about different types of training and special considerations for rural and low income mothers.

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Filed under Alabama Legislative Session 2013, women's healthcare

A Woman’s Body is Her Own—Including in Pregnancy and Birth. Part 1


This blog has been a long time coming.  Kind of like a three year metaphorical pregnancy, during which I have realized my initial stance on home birth was not only wrong but harmful to related women’s advocacy issues.  I imagine I may not get positive reactions from some colleagues, after joining them in opposition to the home birth legislation—they may feel I have betrayed our common cause.   I may also get annoyance from those in favor of the legislation, for having been so slow to come around.  I am sorry.  It is entirely my fault.  I hope you will forgive me.

 

In short, there is no conclusive evidence that favors hospital vs. home birth in cases of low-risk.  The training of certified professional midwives (CPMs) is rigorous.  There is no imminent likelihood of our state doing anything substantial to address perinatal mortality or expand rural hospital/ prenatal care services.  If the perinatal mortality rates in our poorest counties improved even slightly toward the average rates for home birth, because of prenatal care from midwives, we’d have a reason to celebrate.  Most of all, I do not believe the duty of the state to a child can supersede a pregnant woman’s right to make choices about her own care, safe or not.  In the end, it is simply not our decision to make.

 

I am in favor of establishing a Board of Midwifery in Alabama, according to the framework set out in SB 246 and HB 178 without amendment.   I support the right of a woman to make her own decisions about her body.  I apologize for my error in failing to understand the significance of a position on home birth and in failing to do a good job with my prior reading.   That’s the short and sweet version.  Because the underlying issues are complicated, I’m going to discuss them in parts, over several days.  If you decide to argue differently, you might want to wait and read the whole series first, including the links.

 

A Field Trip

 

After hard re-evaluation and thinking, I decided I would speak in favor of these bills.  For the sake of thoroughness, I also wanted to be able to describe for you what would likely take place in our state if we had certified professional midwives—not just the data but something more descriptive.

 

I contacted Hannah Ellis with the Alabama Birth Coalition, an all volunteer, grassroots organization advocating for healthy mothers and babies.  As part of their intention to increase access to evidence-based maternity care in all settings, they support certified professional midwife licensure in Alabama.  If you would like to sign their petition, as I have done, it is here. Similar efforts have been effective in other states, and I am impressed to have an example of citizens serving as advocates for their own needs—really driving the bus—rather than well known persons trying to steer a movement for others who aren’t even participating.  This is what I’d like to see for single payer—the uninsured and underinsured getting seriously active and insisting on change.

 

Hannah kindly agreed to take me on a field trip to meet some midwives in person.  She took a whole day out of her schedule for this, and I can’t thank her enough.

 

The first midwife I met was Tori Dennis.  We didn’t know right up until the last moment if she would be available—one of her clients could have gone into labor.  Unlike most physicians I know, she is on 24-7 call to the mothers in her care.  She led us into the cozy, simply furnished living room, where she had set up some equipment as if it would be done for a home birth.  There was an inflatable tub (with clean, individual liners) for pain relief in warm water during labor, and she had hurricane lamps lit to show me what it might be like in some of the homes without electricity.  She had oxygen and a resuscitation mask/ ambu-bag ready.  There was a portable tray with instruments set up on a sterile drape, ready to be moved quickly from room to room if needed.

 

In the bedroom, she had more sterile draping, a labor stool, a Swiss ball she said was good for positioning during labor, and 3 bags full of everything you could think of for a home delivery short of a ventilator.  I half expected her to pull one out, by the time she was finished.  Each bag had several plastic sleeves with organized contents—just to pick a few items, she had pitocin in case of hemorrhage, vitamin K shots, antibiotic ointment for the baby’s eyes, cord clamps, suction, a Doppler, and a fetoscope.  The prenatal bag had test kits for group B strep and other infections, blood sugar monitors, everything needed to draw prenatal blood work, vitamins and more.  The post-natal kit had cards for the routine newborn screening state labs, paperwork for registering the home birth and obtaining birth certificates.  That’s just a few of the many supplies—I have not been able to think of anything missing.

 

Tori asked me if the setup was different from what I had expected, and I couldn’t answer—I really did not have any idea at all.  I knew it would be different from Little House on the Prairie, but that’s about as far as I had gotten.  It was very professional and well-thought out, especially the planning for situations both with and without electricity.  She said the midwives had been called on to help in disaster situations, partly because they had experience doing medical work without electric power.

 

We sat down and she told me her story.  She grew up in Pennsylvania, near an Amish community, and came from a background where home birth was normal.  While getting her RN (magna cum laude) from the University of Pennsylvania, she had a “light bulb moment” seeing a 19 year old in the teaching hospital strapped down to the rails in labor and her baby pulled out with forceps by an inexperienced resident.  It seemed barbaric, she said.  The woman didn’t even know she was in a teaching hospital or that there were other ways babies could be born.  This memory stayed with Tori after graduation, when she worked in a neonatal ICU.  At that time, crack cocaine was in its heyday, and pregnancy could be complicated by abruptions of the placenta.  She saw some of the worst things that could happen to disrupt healthy pregnancies and births.

 

Later, as an Army nurse, she assisted with the surgical aspects of women’s reproductive care.  When she finished her military service, she and her husband just wanted some peace and quiet.  They came to Tennessee and bought a farm.  She had no particular plan to become a midwife.  Then she heard about a nearby birthing center.  She initially worked as an RN, with the certified nurse midwife (CNM) there, and then got her certified professional midwife (CPM) training so she could do home births.

 

Tori spoke of mothers with no running water or electricity, with holes in their floor and rats, and people using buckets for toilets.  Mothers who paid her in vegetables and for whom she had to purchase Rho-gam injections out of her own pocket.  She showed me a simple, hand-tied quilt given in payment by an Amish mother—not one of the expensive versions she could have sold.  For these families, she was not just serving as a prenatal care source and a birth attendant but a public health nurse and social worker—she had to teach basic cleanliness practices.  She talked about breastfeeding being even more vital in poor homes, where parents might mix powdered formula from WIC with creek water.

 

She told me about checking on a one month old Amish baby with RSV, who was in distress unrecognized by the family, and convincing them to let her take the baby to the hospital.  She looked frustrated as she talked about the barriers to care in Alabama for families in similar circumstances, such as the Mennonite community.  “We’ve got people going without any care at all,” she said.  “Can we not stop arguing and just get them some help?”

 

She said about half her clients were Amish, poor Amish, not like the ones on television.  Others were middle class or wealthy women, including physicians and lawyers, who had done research and chosen home birth.  Some were past victims of rape or sexual abuse who could not face being examined by male obstetricians or the hospital environment where a male nurse might be on duty.  Many others were just poor and could not get in with an obstetrician.

 

She has a verbal collaborative arrangement with a local obstetrician and she only takes low risk clients.  For her, this means no drugs/ alcohol/ smoking, excellent nutrition (I can’t tell you how many times both CPMs I visited stressed nutrition), no chronic diseases, no first time mothers with breech presentations, no multiples, and VBAC (vaginal birth after c-section) only in very specific cases.  For the higher risk clients, she would not abandon them—instead, she would provide prenatal care in collaboration with the obstetrician and be present as a doula during the birth.  She uses her own car to pick up mothers without transportation for their ob appointments and to the hospital in labor.  She has a low threshold for transfer to the hospital, although her transfer rate is only 2%.  She felt the hospital should be no more than 20 minutes away and would arrange for an alternate home setting for a woman who lived further away.

 

Sadly, the birthing center where she first worked has closed.  CNMs at birthing centers in Tennessee are required to be covered by malpractice insurance, and the rates had become too high.  CPMs are not encumbered so for home births.  Which brings up an important issue.  One of the threatened amendments to Alabama’s legislation would force CPMs to carry malpractice insurance.  This could be similar to the TRAP bills for abortion clinics, something that would prevent CPMs from practicing.  I asked some of my ob friends about it.  They are angry about the perception that a midwife could be involved in a problem delivery, transfer the baby to the hospital, and then walk away without being sued.  They don’t perceive the waiver in the bills to be adequate for their protection, so they want to require midwives to carry insurance also.  I heard some arguments that midwife insurance would protect the families themselves from financial disaster.

 

I disagree.  I would lay part of the blame for our malpractice climate directly on the fact that we are now all heavily insured.  Some patients feel like they are getting insurance money and will sue even if they are not so angry they want to take a doctor’s house or license away.  They believe that money is there to cover their expenses, not necessarily as a punishment.  Civil suits were supposed to replace shooting each other—I’d rather lose my house than get shot, if a patient is that angry.  They weren’t meant to serve as a safety net.  We could do that another way—single payer healthcare would be a start, plus no-fault medical injury compensation funds.  We have messed up in creating this situation.  I see no reason to foist our mistakes on another professional group.

 

I could keep going on about my visit with Tori—I spent a couple of hours talking to her.  Basically it would just come down to her being a saint and wishing we had a whole bunch just like her in Alabama.  I do not know if she is typical of her profession.  I hope she is.

 

The Farm

 

Next we drove to The Farm, an intentional community reminiscent of the 60’s, with a birthing center of international renown.  I met with Carol Nelson, one of the midwives, in their prenatal clinic exam room.  The walls were covered with all sorts of pregnancy and motherhood related art, mixed in with posters about newborn hearing screening and nutrition.

 

Although Carol also had good stories to tell me about home birth, I was most fascinated with her take on the political aspects.  In Tennessee, midwifery was never against the law because it was set apart and not considered medicine.  The midwives and mothers wanted to establish a Board of Midwifery partly to guard against the increasing trend to crack down on midwives in other states and partly to increase the quality of midwifery care from those who were insufficiently trained.  Interestingly, the pediatricians, although they did not actively support the legislation, did not oppose it.  The Tennessee Medical Association did lobby against it hard.  In the end it passed with strong grassroots activism.

 

She told me how the licensure standards for CPMs came about.  It was not a haphazard thing—they had job analysis done, to determine exactly what skills and qualifications were needed.  The National Commission for Certifying Agencies (NCAA), created by the Institute for Credentialing Excellence (ICE) developed the CPM standards.  It is an internationally recognized certificate.  We trust the credentials of a broad range of other health professionals structured by the same agency.  You can read more about the CPM credentials at the North American Registry of Midwives site.  I’m going to talk more about training as well in a later segment of this series.

 

Carol talked about how midwives had helped bring about some of the changes in obstetric care now considered standard, like rooming in with the mother and an increased focus on breastfeeding.  Midwives are participating at the highest levels of policymaking in healthcare, with the World Health Organization, which advocates for increases in the midwife workforce, the Institute of Medicine, and the American Public Health Association (APHA).  APHA is strongly in favor of increased access to good quality out of hospital birth providers, including Certified Professional Midwives.

 

A Tennessee Pediatrician

 

To round things out, I thought I’d better contact a pediatrician in Tennessee who has cared for the infants resulting from home birth.  I called Dr. Rufus Clifford, in Columbia, Tennessee.  Dr. Clifford is on the Board of Midwifery.

 

He had nothing negative to say about the midwives at all and felt they were well accepted in the pediatric community.  He mentioned that they had been quite helpful in providing home visits for newborns for families that couldn’t get to his office soon after a home birth, and that he felt very comfortable with their skills.  When I pressed him to tell me about problems, he paused and said, “Well, they are awfully hard on each other.  When they meet for peer review, they are just awfully hard and don’t cut each other any slack at all.”  I don’t see that as a negative.  Physicians could give each other a little more grief and do better for it.

 

It sounded to me as though the midwives were protective of their credential—they want it to stand for quality care, and they weren’t about to let anyone step out of line and put their profession at risk.

 

That’s it for Part 1, the longest segment of this series.  I hope you will stay tuned tomorrow for Part 2, on safety.

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Filed under Alabama Legislative Session 2013, women's healthcare

Speech at Stop the War on Women Rally II, Huntsville, AL


text of my speech from rally on March 17, 2013, in case you missed us!

It seems like only a few weeks ago we were right here, joining together and ready to fight for a better Alabama.  Same beautiful spring weather.  Last year, we were successful in preventing a great many bad bills from passing—I think we caught Montgomery by surprise.

 

They weren’t expecting us last year.  This year, they were.  Now it seems they believe they can just do whatever they want to do.   They might even think we will give up, when we see how much power they have.  Will we give up?  No!  Because we’ve learned a few things also.  We’ve got power they’ve never even dreamed of.

 

We won’t give up because we know the truth about their agenda.  We won’t give up because we know silence leads to death.  We won’t give up because we know we have a duty to stand together, and that when any one of us is threatened by injustice, all of us are called to speak.

 

Some of our elected leaders say they want to make abortion safer.  The truth is that they want to close down the only remaining women’s health clinics that provide safe and legal abortion.  Because they can’t do that for real safety or legal reasons, they are twisting the law to suit themselves, using whatever arbitrary fire and sedation codes they think will work.  They are lying to the press, implying current clinic physicians are not licensed in our state.  Meanwhile, they are attempting to restrict abortion provider licenses to one community in the state, which has not been done for any other type of medical care.  No other doctors are required to have hospital privileges to practice outpatient medicine.

 

They say they want to protect freedom of religion and conscience, by allowing only one type of religion and conscience to override patient and employee rights.  I hope I don’t shock any of you by saying I’m more concerned with trying to learn how to love my neighbor better in the here and now than I am about the 10 Commandments—but I know the 10 Commandments.  I know them, and not one of them says “Thou shalt force your neighbor to do whatever you want her to do, by lying or intimidating or throwing her in prison.”  There is no 11th Commandment that says to be a bully or to punish or to steal another person’s free will.

 

It’s hard for me to believe they really want to decrease abortion, when at the same time they are throwing women in prison for NOT aborting.  In prison not for possession of drugs, but for the crime of being sick with addiction while pregnant and choosing to give birth to a baby.

 

It’s hard for me to believe they want women to carry a pregnancy to term and at the same time write bills to cut off their food stamps and Medicaid, pregnant or not, if they test positive for drugs.  It’s hard for me to believe they want families to have children at all, when they are steadily dismantling and defunding the services our children need to thrive, like schools and mental healthcare systems.

 

I don’t think any of this is about health, safety, freedom, religion, drugs, life, abortion or even about women.  I say it is all about power.  Women, especially women in poverty, seemed like a convenient target.  There are always people in the world who want to control others, just to show they can.

 

Lots of people are scared.  Scared to lose their jobs if they speak up, and it can happen—some of my friends have lost their jobs.  Scared of death threats.   I’m a pediatrician, and I can tell you some of my doctor friends are frightened.  Some ob-gyn doctors I know fear being killed if they tell the truth about women’s health.  Even some of our leaders are scared, and with good reason.  They’ve seen Alabama take political prisoners.

 

But we who are here today have chosen to be stronger than our fear.

 

I’d be wrong if I told you this next couple of years will be easy.  It won’t.  There are powerful people opposing us.  Things are probably going to get much harder than they are now.  We need to be ready.

 

What I do know is that their kind of power, the kind that depends on lying and twisting the facts and fear and prison is not REAL power—it is false power.  It cannot last.  Never in human history has that sort of power lasted.  It rises, and it falls, always.

 

There’s a different kind of power that DOES last, and we have it right here.  Let’s take just a moment to remember it.  If you have a cold or a health risk and should not hold hands, don’t— you might place your hands over your heart if you like.  You are still connected to the rest of us.  Everyone else, if you want to, reach out and take the hands of your neighbors.  Notice how you are connected to the earth here, connected to our state, connected to each other. You belong here, no matter who you are.  Now lift your hands up high.  Feel how strong we are, together.

 

This is our power, the power that can never be defeated—the power of truth, the power of respect, the power of inclusiveness, the power of connection, the power of community.  When false power has risen and has fallen, we will still be here, standing by each other. We know we are not alone.  The power of our community will prevail.

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Filed under Alabama Legislative Session 2013, women's healthcare