Some things are important to me that don't often get talked about here (as you saw a couple posts ago), and sometimes they need to. This is one of those times. This is not a pregnancy blog, nor an infertility blog, nor a mommy blog, and definitely not a debate blog. It isn't going to become one, either. This post is an explanation, and a reference point. You may certainly disagree with me. But I am not planning to put a lot of discussion into this here. There are much better forums, like those listed at the bottom of this post. I'm really not one for debate, and this space has much better uses. I have specifically avoided details and numbers for that reason.
I am part of a movement of women who see problems with the way the medical industry functions. We also see huge problems in the way others have responded to these concerns.
Doctors have become increasingly busy as patient loads swell, and this is no more true than in Obstetric offices. Many people are very rarely ill and an Obstetrician may be the only doctor they see with any regularity and the only time they go to a hospital. So, they are unfamiliar with the complex realities of how our health care industry works. Unfortunately, these and other factors can result in very negative experiences between a woman unfamiliar and uncomfortable in the hospital environment and a doctor feeling rushed and maybe just today a little brusque. We all have different ideas of how to fix these problems, but avoiding the issue isn't a solution, and certainly not safe for the majority of women. (Yes, there are also terrible doctors, but stringent review processes and other doctors interested in protecting the reputation of their field tend to eliminate these when given evidence, as in the case of the negligent Dr. Biter or the abusive Dr. Fischbein.)
Among the women (and fellows!) in our growing movement are many medical professionals, and these people we wish to continue to pursue. It is vital that they be familiar with the misinformation about pregnancy and birth that is seeping through the internet. It is also vital that they take leadership roles in working to continue to respect research and evidence in practice and also respect the rights and needs--and, when safe, wants--of women and their families. Many practices women are seeking to embrace are curious but not harmful. These should not be discouraged (and usually aren't) just because they are strange. But, the most important time that respect matters is in practices that do present a threat of harm. Medical care providers should respect women enough to be truthful with them and be prepared to present solid evidence to support their claims. Women are being lied to, and it is vital to attempt to counteract those lies. Be gentle, but remember that this person before you is a competent adult capable of understanding you. Be respectful by using approachable language. Be informative. Answer questions. Don't ignore a growing problem because it might keep an individual patient in hospital-based care.
It is also worth mentioning that medicine is not a consumer good. It would be highly unethical for a doctor to provide any and all "care" a patient desires and only that "care." You see, it wouldn't be caring for the patient at all. Medicine depends on the mastery of a huge body of knowledge and an expertise that is unmatched without similarly formulated education and training. It is harmful for doctors to practice according only to patient whims or even supposedly educated suggestions. Yes, involved patients who take an active role in their care often have better outcomes. But that does not mean patients who prescribe their own care. It is not respectful for a doctor to abdicate her professional and ethical responsibility in favor of giving a patient temporary satisfaction.
The problems that patients face are more complex than individual interactions, though. Our medical system faces systemic problems in part due to efforts to limit the number of physicians and other staff. As we move forward, this will become increasingly untenable. Medical professionals should work to increase the number of providers by advocating for their patients with professional organizations and governments. (We all know the impact that tuition has on your life.) This will improve another concern of many women--they feel they don't have enough time with their provider. Encourage women to be up front with you and your staff about how much time they feel they need. Do what you can in your practice to meet these needs. Also encourage your patients to understand how their actions (timeliness especially) impact them and others. I personally believe in shifting away from the for-profit model of healthcare. Yes, doctors should make a living sufficient to reward their investment of time and education. But the corporations behind so many hospitals--the ones who cut costs by eliminating medicaid providers and making their ERs inaccessible to indigent patients and encourage doctors not to pursue complex diagnoses of chronic illness in favor of treating immediate symptoms like pain and so forth in order to maximize profits? That is grossly inhuman.
We believe that those trained through years of medical education and practice through thousands of births are best equipped to care for pregnant and birthing women because of their exposure to a wide variety of cases. Those who only see so-called "normal" will not be able to recognize and diagnose the pathological correctly and with sufficient speed. We believe that the evidence demonstrates that while high risk pregnancies individually are more likely to experience complications, most complications occur in low risk pregnancies. We believe that low risk is not no risk and that complications can and do occur insidiously and without warning. We believe that a "normal" birth can only be identified after it has occurred, and that the full consequences and sequelae may not be known until well after birth. We know that hypoxia happens all too easily. We know how varied the injuries from that can be.
We believe that there are four kinds of care providers capable of providing highly effective and safe care for women and their babies: obstetricians, family practice physicians, certified nurse midwives, and certified midwives--only licensed in New York and Rhode Island currently. CNMs are highly skilled and licensed in all states and in many are free to practice both inside and outside the hospital under the oversight of a medical doctor. We feel that, despite the excellent training that CNMs receive, their practice does require a strong relationship with a physician because they must remain involved in the review of pathological birth in order to recognize pathology in those hopeful for "normal" birth.
We have seen that traditional, lay, and DEM/CPM midwives are poorly trained and generally insufficiently experienced to recognize complications that threaten the lives of women and their babies. We have unfortunately watched this demonstrated in case after case of shoddy practice resulting in death and grave mortality, even by those who have been licensed by their states or received comparatively better training (MEAC versus PEP). We believe that states who license these practitioners are allowing their citizens to be victimized by undertrained, unprepared hobbyists who are more committed to their philosophy of birth than the health and safety of their clients. We believe that this is exemplified in the response of the midwifery community to inquiries into possible negligence--that is, the blind support of the midwife at all costs and the maligning of the woman as untrusting of birth and wholly responsible for the provider she selected. We know that sometimes there are providers with these certifications who do practice judiciously, but we question their reasoning behind continuing to practice without better training.
We think it is not respectful of women and their families to fail to provide them with recourse in the event of an injury. That is, we think all birth care providers (all health care providers) should carry malpractice insurance. Malpractice doesn't mean malicious harm. It means screwing up. Malicious harm is a criminal offense, not a civil one. Everyone makes mistakes, and all providers should be realistic enough to know that they will eventually. Moreover, we believe that continuing education isn't something extra that a really good provider does, but a basic guarantee of continued competence. Being exposed to the changing information and improvement of skills in your selected profession should NEVER be optional.
We also think it is disrespectful that the oversight boards that supervise independent midwifery practices are more interested in preserving the licenses of individual midwives than they are in ensuring that providers who demonstrate incompetence are prevented from practicing. Other professional organizations seek to weed out shoddy providers. This profession coddles them. Social workers who break their professional code of ethics not only lose any license to practice, but can also have their degrees revoked. Attorneys also can have their licenses or degrees revoked depending on the severity of their professional offense. I have already listed medical physicians who have lost their practice privileges. Privileges. That's an important word. It is a privilege to be entrusted with the care of others. It is one that must be earned by demonstration of knowledge, competence, and ethics. We find these lacking in non-nurse midwives. We feel that states that have licensed these persons have permitted a grave injustice based on the idea that women should be given cheaper care and on the misrepresentations of this community that the services they provide are substantially similar in quality to that of better trained professionals.
We believe women should not be afraid to become pregnant or give birth, but we also know that pregnancy and birth are risky processes for both mother and child. They are a delicate balance still being changed through selective pressures... unfortunately those selective pressures don't care about individuals. These risks can sometimes be reduced through behavioral modification (diet, exercise, education, monitoring), but in many cases, the mechanisms are entirely biological and require treatment--which is sometimes immediate delivery. Providers should be up front with patients about the reasons they are concerned about their cases. We know providers already balance the amount of information versus risking scaring patients, but perhaps more information, carefully presented, is the key to respecting patients.
We believe that women should be encouraged to seek comprehensive childbirth education despite their plans for delivery--and that this education should be affordable, not an unattainable privilege. This is especially important in case a pain relief method fails--"natural" or pharmaceutical. We definitely believe women should have unrestricted access to safe pain relief (though we don't think women should be required or pressured to use any particular method). We believe hospitals have, for the most part, made great strides in improving how L&D wards feel. They have increased access to using alternative labor support methods, and we feel these efforts will and should continue. If a provider finds that certain alternative support methods are popular and also finds them to be safe in practice, it might be good to volunteer that information to patients instead of waiting to be asked about them.
We believe that having trained support persons may be very valuable for women in labor, whether these are hired assistants or industrious family or friends. We believe that women should have access to professionals skilled in infant care and feeding, regardless of their philosophical choices. These persons should offer assistance and knowledge, but never judgement. It may be helpful for care providers to develop relationships with support professionals in their areas in order to get a better idea of women's wants and also to have a list of these professionals who provide truthful information along with quality support and who respect women enough to not cross appropriate practice boundaries by giving medical advice.
But, there is another part of respectful health care--a patient that selects her provider based on that provider's expertise and then does not malign the use of that expertise. Sometimes good health care means hearing things that don't make us happy. An oncologist who told patients that their cancer didn't require treatment and would resolve with positive thinking might be very popular, but most of his patients would die. Medicine isn't about feeling sugar-coated. It's about ensuring appropriate preventive and responsive care. Sometimes the things that keep us from dying are really scary and quite traumatic. But being alive--and with the least harm possible--is often worth it. We believe that care that anticipates harm and prevents (whenever possible) it is preferable to care that only responds after an injury has occurred and desperately attempts to minimize harm. We believe this because it has better outcomes, and usually with less care required.
Now, this doesn't mean "lie back and think of England." What it means is pick a qualified and licensed provider whose standard of care is consistent with current research--usually this can be identified through information available from public health bureaus. Choose a provider that you feel respects you and that you feel is willing to listen to your concerns and communicates responses in a way you can understand and with compassion, even if you don't always like the answer. I would also stress that if this provider does not keep a boundary of professional distance that you are comfortable with or tries to be your friend instead of your doctor (even if that kinda feels nice), then you should drop him or her like a bad habit!! Then build a trusting and open rapport with this provider. Share your questions and concerns. Learn everything you can about the care you are receiving. Be open to the fact that life cannot be planned perfectly and neither can birth. Make contingency plans in case things change. Often, physicians are very willing to make accommodations for personalization in even the most sterile conditions.
For other reading on this topic, see the following blogs and communities. Note that these persons may or may not agree with or endorse what I have written. I speak for myself, and have used "we" to describe apparent consensus among those I have spoken with on this topic. That "we" does not necessarily include these persons.
http://www.10centimeters.com/
http://thatsnothowscienceworks.wordpress.com
http://navelgazingmidwife.squarespace.com/
http://oregonmidwifereviews.blogspot.com/
http://mommadata.blogspot.com/
http://momofmanyfeet.blogspot.com/
http://ecmama.blogspot.com/
http://skepticalob.blogspot.com/
http://hospitalbirth.blogspot.com
http://thesensiblemidwife.blogspot.com/
http://midwifeology.blogspot.com/
http://www.facebook.com/groups/199827500028384/ (Fed up with natural childbirth)
http://www.facebook.com/groups/203319963052456/ (Safe and Healthy Mommas, Babies, Families)
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