Doctor's Birth Plans and Doula Bans: Think it's not happening in your area?

This is a bit of a "round-up", but I couldn't let the hot (read: infuriating) items that have been circulating in our circles the last few days go without mention - especially since this very issue was brought home to me yesterday in a client meeting, live and local and in-our-faces.

Before I get to yesterday's incident, here's a little background from a while back.

Once upon a time (last November), this sign prohibiting Bradley Method and/or "doulah"-assisted births from a practice in Utah was shared on The Unnecesarean, and everyone had a semi-good time roasting it in appalled mockery:

This came on the heels of one OB's disclosure to his patient, who fortunately took it for what it was and RAN FOR THE HILLS, as of October. Excerpts:

* Home delivery, underwater delivery, and delivery in a dark room is not allowed.

* I do not accept birth plans. Many birth plans conflict with approved modern obstetrical techniques and guidelines. I follow the guidelines of the American College of Obstetrics and Gynecology which is the organization responsible for setting the standard of care in the United States. Certain organizations, under the guise of “Natural Birth” promote practices that are outdated and unsafe. You should notify me immediately, if you are enrolled in courses that encourage a specific birth plan. Conflicts should be resolved long before we approach your due date. Please note that I do not accept the Bradley Birth Plan. You may ask my office staff for our list of recommended childbirth classes.

* Doulas and labor coaches are allowed and will be treated like other visitors. However, like other visitors, they may be asked to leave if their presence or recommendations hinder my ability to monitor your labor or your baby’s well-being.

* IV access during labor is mandatory. Even though labor usually progresses well, not too infrequently, emergencies arise suddenly, necessitating an emergency c-section. The precious few minutes wasted trying to start an IV in an emergency may be crucial to your and your baby’s well being.

* Continuous monitoring of your baby’s heart rate during the active phase (usually when your cervix is dilated 4cm) is mandatory. This may be done using external belts or if not adequate, by using internal monitors at my discretion. This is the only way I can be sure that your baby is tolerating every contraction. Labor positions that hinder my ability to continuously monitor your baby’s heart rate are not allowed.

* Rupture of membranes may become helpful or necessary during your labor. The decision as whether and when to perform this procedure is made at my discretion.

* Epidural anesthesia is optional and available at all times. The most recent scientific data suggest that epidurals are safe and do not interfere with labor in anyway even if administered very early in labor.

* I perform all vaginal deliveries on a standard labor and delivery bed. Your legs will be positioned in the standard delivery stirrups. This is the most comfortable position for you. It also provides maximum space in your pelvis, minimizing the risk of trauma to you and your baby during delivery.

Amazing. Trust me, it goes on and on, I just had to crop it for length.

So just the other day, this letter from an Ohio practice came to light, courtesy of Birthing Beautiful Ideas. Same crap, different zip code:

The team at Kingsdale Gynecologic Associates is so pleased that you are expecting. We look forward to helping you enjoy your pregnancy and hope to provide a meaningful and safe birthing experience.

Because of concerns for increased risk to you or your baby, the doctors at KGA have made a thoughtful, unanimous decision not to allow doulas to participate in the birthing process. It has been our experience that they may serve to create a state of confusion and tension in the delivery room, which may compromise our ability to provide the safest delivery situation possible for you and your baby.

Again, with safety in mind, we have created a Kingsdale Birth Plan (which can be viewed in the obstetric packet provided at your initial visit), outlining the philosophy of our doctors with regard to labor and delivery. It is our opinion that other birth plans are unnecessary. We feel that our many years of obstetric experience in a setting of modern day challenges (larger babies, more difficult deliveries) enable us to provide sound judgment with regard to each woman’s particular needs during her course of labor.

Thank you for your understanding in our hopes of facilitating a safe pregnancy and birth process.

Patient’s signature

________________________

She goes on to post a revised version of this letter (make sure to check it out, it says everything I would have said and more), and then, the next day, shared a copy of the actual "Kingsdale birth plan" this practice offers. Click over to read it itself in all its chocolately paternalistic glory.

To top it all off, The Feminist Breeder had JUST posted this unknowingly prescient piece the extremely revealing chart found in Marsden Wagner's book "Born in the USA", exposing the downright contempt many (of course not all) OBs have for patients who dare to think for themselves.
It both precipitated and underscored the garbage from the Kingsdale practice that hit the net the following day.

So, with all this buzzing in my head, I went to meet with a really wonderful young mother and prospective practice labor support client. She's very interested in having doula support, as there's not a lot of other support in her life, and has several pressing reasons of her own that she'd like to pursue a natural birth if at all possible. Hasn't read a whole lot yet but is very eager for information (I lent her "Your Best Birth" to start with) and is starting a childbirth ed course next week. All sounds good, right?

Well, she's also slowly figuring out that she may have to change care providers, as they recently informed her that she is allowed to use one of two pre-approved specific doulas - anyone else would be prohibited. I would have been more stunned if I hadn't just read and re-read all of the above, but as it was, I just had to sigh and shake my head.

If I were one of the two approved doulas, I wouldn't know whether to be flattered or appalled. (I'm not at all insulted at not being included, as I literally haven't even gotten started attending births in the area yet.) Frankly, I'm leaning towards appalled. I'd want to know WHY I was kosher and others weren't - was it because I was most likely to go with the hospital ride and not make waves? It's also possible that some other doulas had been too confrontational, perhaps, and gone beyond our scope of practice. Could it be a combination of the two?

Regardless of the reasoning, I'd so frustrated by all of this. It seems like we've been making progress with educating the public about doulas, and improving doula training, and increasing access - but then, what good does it do if more and more OB practices are issuing official kiboshes on us when it comes time to actually go into action? The bottom line probably does fall to the consumer.

Readers who are appalled at the Aspen Women's Health Center, the Kingsdale Gynecologic Associates, the doctor in Texas, and the group practice here in Erie - don't assume it's not also happening in your own backyard. We advocates can blog about this stuff until we're blue in the fingers, and we will and do, but it really comes down to the individual women themselves. Mothers who care about their births (no matter what their own goals are), have to stop patronizing care providers like this, and let them know why.

P.S. This was one of my entries for the Unnecesarean's Photoshop contest:

P.P.S. But wait! There's more! The Feminist Breeder and I basically simulposted today, and in her latest, she shares YET ANOTHER doctor-generated mandatory "birth plan", this time from the Chicago area practice WomanCarePC. I can't even be buggered to quote it here - click on over to read, it's exactly what, by the end of this post, you'd expect. But I will quote TFB herself, echoing my sentiment on using our power as consumers:

We all want to believe that it’s just angry women making hostile accusations toward well-meaning OBs and hospitals. Calm down honey, it’s all in your head. However, it’s pretty hard to ignore when the obstetricians are the ones sending out their patriarchal beliefs in writing, and then asking pregnant women to sign it.

There is a solution. Fire them. Take back your body. Refuse to be treated as a wombpod. Let them know that we ARE consumers in this process, and if they won’t treat us with respect, then by golly we’ll get our birth attendants elsewhere, thankyouverymuch.

*****


In medical billing courses, you’ll learn about the birth process.

Weekend Movie: Taking on nonconsensual exams by med students

After finding out yesterday about the abhorrent practice of medical students performing pelvic exams on patients under general anesthesia without their consent, I MUST feature this documentary, Check out "At Your Cervix" (not to be confused by the fabulous eponymous blog).

"The documentary 'At Your Cervix' explores the connection between the way medical and nursing students are taught pelvic exams and the reality that most women experience them as painful and disempowering.

'At Your Cervix' breaks the silence around the unethical methods used by medical and nursing schools to teach students how to perform pelvic exams; the most egregious being on unconsenting, anaesthetized women."

The original article: Time to end pelvic exams done without consent

Other blog posts on this outrageous practice, besides the one from Unnecesarean at the top of this post:

PhD in Parenting (from whom I got others): Canadian women are livid, and rightfully so
Sassymonkey: Not without my consent
Three Seven: I think I might throw up
Bad Moms Club: Bad Moms don’t Like Non-Consensual Nether-Probing
Living My Social Work: “Implied” Consent
Coffee with Julie: A pelvic exam without my consent?
Chaos Theory: Does the Canadian Medical Association Support the use of Roofies too?

Pissed off? Sign the petition from Her Bad Mother.

Signs, signs, everywhere there's signs

In the last week or so, this has been all over the blogosphere, Facebook, Twitter, and the internet entire:


Just amazing, isn't it? Anyway, it's been so well-distributed I wasn't even going to bother doing my own post, but then Crunchy Domestic Goddess just did a really good round-up on all the other posts about it and I had to share.

In a way, its existence and internet ubiquity is almost a good thing, not just in the "at least they're honest" sense (having known far too many women who have thought that had a supportive OB only to be duped at the last minute, in a sadly common bait & switch) but also because it's really made the internet rounds and is generating a lot of discussion, including some in circles that might normally be much more of the trust-the-doctor mindset.

GAH, though. Really, what's next?

We will not accept clients who have read any of the following: "Pushed" by Jennifer Block, "Your Best Birth" by Ricki Lake and Abby Epstein, or anything by Sheila Kitzinger, Henci Goer, Marsden Wagner or Ina May Gaskin. Writings from the Sears library may be approved on a case by case basis. Viewing of the films "The Business of Being Born" and "Orgasmic Birth" are likewise prohibited. Attending ICAN meetings is strictly forbidden. Please schedule an appointment with our IT assistant to have the following websites blocked from your computer: The Unnecesarean, Science and Sensibility, Mothering.com, Stand and Deliver, Gloria LeMay, My Best Birth, and Navelgazing Midwife. Periodic computer updates will be required. Remember, we care about the welfare of your baby!

The Perils of Lazy, Sensationalistic Journalism

Yup, the Today Show piece. In case you haven't logged into your reader the last two days, the nutshell version is that the Today Show just aired a laughably biased shock piece on "The Perils of Home Birth", linked under Latest Health Features here. Yes, they actually called it that, though only after they changed it online from the original title, "The Perils of Midwifery". Frankly, I think they're both equally bad.

This has been so handily covered by the Birth Blogs already, I hardly know where to start. But here's Stand and Deliver has a great roundup of everything that's been written so far. Check them all out. I wasn't even going to write about it myself, others had done such a righteous job of it. But I decided I at least had to write to the producers of the Today Show, which I did, and once that was done, I figured I might as well share it here. A few bits were lifted from my prior comments on some of the aforementioned fabulous blog posts, so if you feel like you have deja vu in a couple spots, that's probably why. )Mucho props to the other bloggers, especially Your Birth Right, who first pointed out the sneaky semantics they slip in by using the word "allege" selectively.)

I didn't even go into the melodramatic flourishes like showing the mother folding baby clothes in the empty nursery, or the intentionally dead-end questions our intrepid reporter Peter Alexander says doctors recommend parents ask midwives at the end of the piece; I was already running long. Anyway, here's my longwinded letter, for what it's worth.

Dear Today Show Producers,

As soon as Matt Lauer said the words "Extreme Birth" in the intro, I knew what kind of a piece we were in for.

I was astonished to see the one-sided, sensationalist, fear-mongering piece you first called "The Perils of Midwifery" and then changed to "The Perils of Home Birth". It would take pages and pages to point out all the gaping holes that riddle this "report", but I'll limit it to a few main points. Let it be said right off the bat that, of course, I feel terrible for the couple that lost their baby. It is a tragedy no matter where it took place. But I feel strongly that this couple is being completely exploited and manipulated into blaming home birth for their loss - without knowing the details of the case, we don't know if it is one of the situations that could have happened anywhere, sadly.

I can't help wishing Cara Mulhahn had been able to say more about the situation, but it's obvious to me that her hands were likely legally tied - which you made seem like an admission of guilt, which is preposterous. But putting that aside - did it ever occur to you to talk to, oh, say, another midwife? Ms. Muhlhahn is actually not the only one in New York City, believe it or not. You could have called MANA, which is the professional organization for certified professional midwives, the ones that most often attend home births, or you could have contacted ACNM, which is the equivalent for nurse-midwives who largely practice in the hospital, but still have an understanding of the goals of home birth and the midwifery model of care.

But you allowed the ACOG to be the mouthpiece for this story. When you mentioned the CDC study that demonstrated home birth outcomes being equal to or better than hospital outcomes, it's just immediately dismissed by the claim that it's because of higher risk women, with no further discussion. End of story. No mention of the recent Canadian study (among others) which specifically compares equivalent risk level! It completely refutes the previous claim about higher risk women, and has, frankly, been widely circulated, so I cannot imagine how a decent reporter could have missed it, so I can only assume it was deliberately left out in order to amp up the scary shock factors.

You also use transparent semantic tactics that insult our intelligence: statements by home birth advocates are "alleged", but anything coming out of a doctor's mouth, or from a doctor's organization, is treated as if it were handed down on a stone tablet, whether the research supports it or not. A few seconds of Marsden Wagner (who is only one among many doctors who also support alternatives to hospital birth) and a clip of one successful home birth do not journalistic balance achieve.

Insinuating that celebrities have anything to do with the rise in home birth is just plain foolish. For every home birthing celebrity, there are celebrities on the opposite end of the spectrum choosing elective, scheduled, non-medically-indicated cesareans. There are plenty of examples on both sides. What is really ridiculous is the ACOG's admonishment that women should not base their birth choices on what is "fashionable and trendy". Do they not realize that birthing in the hospital is the newest "trend" of all, historically speaking? It has been less than a century since this "trend" took hold. So, frankly, if we take their words literally, I actually agree. Women should not birth in hospitals just because everyone else is doing it. They should make that choice based on their risk level, how comfortable they are with their care provider's practices, and most importantly, the real research.

And where do I even begin with the asinine statement about home birth being like a "spa experience"? And "hedonistic"? Yeah, I totally chose a home birth because it would be, like, the ultimate bacchanalian orgy. Who cares if it's supported by research and is the best choice for me and my baby, as a low-risk pregnancy? There was no discussion about the fact that women are really choosing home birth because they want to avoid the cascade of unnecessary interventions that are NOT evidence-based, yet are standard in the vast majority of hospitals, and because of the fact that so many OBs are practicing defensive medicine and thus making choices that hurt their patients, as they themselves admitted just yesterday (what a convenient coincidence). "Cover thy ass" now comes before "First do no harm" for many physicians. Is it all that surprising some families have decided to find another way as a result?

I do not have anything against women choosing to birth in hospitals, as long as it is a truly informed choice. Some women, even low-risk ones, are simply going to feel safer there, and this is fine. The bottom line is that there are risks in both the home AND the hospital (and in birthing centers too, a third option your piece, of course, never even touched). It is up to every family to look at the real evidence, not sensationalism, and weigh those risks for themselves.

Sincerely,

Anne C. Tegtmeier

The First Step

ACOG has taken a commendable first step in releasing the results of their survey this week: the changes OBs have been making to their practices due to fear of litigation are harming their patients.

"By publicizing the widely known fact that defensive medicine is aggressive and harmful to women seeking maternity care, ACOG has taken a profound step in openly admitting and sharing data that women’s options are being severely restricted and iatrogenic injuries are occurring on a large scale due to physician fears."

And you know what? I applaud them, as have some other birthing advocates in their response to the news. A common response is "It's a start," and "At least it's a first step." I agree, and would add that admitting you have a problem is the hardest part.

I look forward to the rest of their recovery, especially the "examining past errors with the help of a sponsor", "making amends for these errors", "learning to live a new life with a new code of behavior" and "helping others that suffer from the same addictions or compulsions". And I definitely know a few OBs who could benefit from the Serenity Prayer now and again.

Keep coming back. It works if you work it.

Two births, two mothers, two vicious legal battles.

Two stunning stories revolving around birth and legal rights are currently in the news, each from unique yet equally enraging situations.

First, the somewhat, kinda sorta good news: there's a update to the outrageous case of Catherine Skol, a mother who was mistreated, verbally abused, and I would say physically abused as well, by her obstetrician during her labor last March. She filed a civil suit against Dr. Scott Pierce in December, and while that has yet to transpire, he has been suspended by the medical center, and the the Illinois Department of Financial and Professional Regulation has fined him $500 and put him on one year's probation. He was also required to attend various continuing ed courses, including a class on physician-patient communication - though it's unclear whether he will actually attend these, since he resigned in February this year.

This consequence is pretty petty, if you ask me. As one commenter pointed out, fines for parking tickets can be higher than that! But let's remember that this is not the consequence of the actual lawsuit yet. I can only hope that the upcoming civil suit will serve up some more serious consequences. I'm a little unclear on whether he resigned only from this particular hospital or is giving up medicine permanently. If it's only the former that is true, then I hope the civil suit forces him to lose his license forever. This is not a person who should be practicing medicine. Anyone can have a bad day, but if you read the details in the link to Unnecesarean above, you'll see that this is so over the top that there's no other conclusion to be drawn. Anyone who is capable of treating just ONE person this way should never, ever be allowed to care for another patient. Period. I'll be eagerly awaiting the civil suit.

Now for the indubitably bad news: after three years of struggling with custody issues, a mother who refused to consent to a cesarean in April 2006 ago has now had her parental rights terminated. The details of the case over the course of time are convoluted and full of conflicting opinions and versions of events, but one thing is crystal-clear: the custody challenge began when she refused to sign the consent form for a c-section. It should be noted right here and now that the baby was then born vaginally, without incident.

Read the case for yourself. I find the precedent to be nothing short of terrifying. Mothers beware: if you have ever been on any antidepressant medication, and then have the temerity to stand up for yourself when pressured to submit to an unnecessary c-section, it is now established that you can be declared an unfit parent and your child can be taken away from you. I cannot imagine the nightmare of waging this battle for three full years, even if the ending were a happy one. To lose in the end, too? I don't know how I could go on.

All props to the mighty Unnecesarean for information on both of these stories.

Disclamer. (The first of many, I'm sure.)

I want to add one thing to the previous post. (Promise I won't be too-long-winded about it.)

I just need to say that, when I say "OBs", and when that extends into the universal "They", especially when I'm feeling ranty, I do know that I'm painting with a really broad brush. I definitely recognize that there are INCREDIBLE obstetricians out there, truly wonderful people who care about and believe in women, who regard the wisdom of nature (in most cases) with both faith and humility, and who are as concerned as many of us are about the crisis going on today. Here's part of a great post from Keyboard Revolutionary:

Ya know, sometimes I feel bad for the good physicians out there. I know they exist. We all do. We've all shaken our fists in righteous indignation at the rants of Marsden Wagner. We've listened intently to the poetic, thickly accented declarations of Michel Odent. We've swooned over the tender ministrations of "Dr. Wonderful," a.k.a Dr. Robert M. Biter. God bless those diamonds in the rough, particularly in the obstetrical field. It must be twice as hard to shine when the lumps of coal around you are so horrifically ugly.

I pretty much worship every person she mentions, and would add to that list Christiane Northrup, Sarah Buckley, Jacques Moritz (Abby's doctor in Business of Being Born), and I know there are others. I know it's just a disclaimer, but I feel it's an important one.

In that same post, Keyboard Revolutionary also makes the point of the irony of having to hire a doula at all - how insane has it gotten when we hire someone to, in many ways, protect you from the person who is supposed to be giving you care? Navelgazing Midwife's take on all this was more blunt: "Women don't just need doulas anymore, they need bodyguards."