Thursday, September 9, 2010

Midwives and Doulas

My wife has been involved with the midwifery and doulaing community for sometime, and she knows a lot more about it than I do (she's done several doulaing gigs this year, for example).  One of the very first community-involvement things we did when we moved to Terre Haute, was being the host site for a yard sale to raise funds for a midwife's legal defense fund, where we met several other families we are still friends with, including a family with far-right values.  I've always been amazed how some topics like midwives, home schooling, or homebrew manage to draw from the fringes of the far-left and far-right and bring them together.  My wife was instantly skeptical of me doing a post on midwives and doulas, "what's your angle there, Brian, 'cause at the moment I'm not really feeling the love."  As I say, I'm not really an expert, but in the time we've been here in Terre Haute it has felt to me like Terre Haute was a lot better served in the midwife and doula department than the other towns we've lived in - it's just that it seems to be in the process of falling back apart right now.  So my angle is this, I AM proud of how Terre Haute has dealt with its midwives and doulas, at least in the 5 years I've been here, including earlier this year, as well as being worried that it is in the process of changing significantly, but I'm still hopeful too.

Let me back up a step.  Midwifery is a different model for thinking about the birth process than the medical model, the obstetrics model.  It is a different philosophy of birth, and different ideology.  Midwifery typically sees birth as a natural process requiring few medical interventions, and wishes to minimize the technocratic overtones.  It teaches that oh say 90% of births don't really need a doctor present, just someone who can watch and help and send for a doctor if you get warning signs that this might be one of the other 5%-10% of births.  Doctors for their part often think that this is dangerously old-fashioned superstition, that birth is a potentially dangerous medical condition that needs to be closely monitored, that doctors should be present at all births, and that in the memorable comedy of Monty Python's "The Meaning of Life," gosh isn't this expensive machine that goes BING neat!  It doesn't help that the US has an insane high C-section rate (a whopping 32% of all births last year, compared with between 5 and 10% in Western Europe), and that most hospitals get a huge chunk of their funding from births, often over half of the hospital's total income.  So we have a ideological conflict AND a turf fight.  Add to that, that midwives are often less educated (than doctors), and have less clear licensing and legal situations, and lots of state-to-state variations in policy.  Er, ... hmm, well I'm not exactly neutral in these debates, but let's put it this way, doctors and midwifes traditionally get along about as well as punks and preppies, but everyone involved realizes, when they are being good, that they need to be able to cooperate.  There is a lot of historical bad blood, but I think there is a real trend at the moment towards detente.  America's birth mortality rates and other birth statistics are at the bottom of the industrialized world, and the World Health Organization has a lot to say to various countries on how to make their systems safer for childbirth, and in the US they want to see a lot more involvement of midwives.  The whole midwifery model requires being willing to switch over to the medical model if you DO get indications of certain complications (like say, varied decels, or a placental abruption), so midwives need to be willing to work with doctors.  Doctors, for their part, usually discourage midwives, but they need to be able to work with them if the patient is working with a midwife, and even most doctors will admit that the US's C-section rates are out of control.  Doulas are more birth assistants than health care providers.  Their job is just to be there with the laboring woman (doctors typically come and go a lot), making comforting sounds, reassuring them that what's happening is normal, and give non-medical advice and support, etc.  They have training and experience in the birth process, but they spend their time interacting with the laboring woman's face and mind not her nethers.  Doulas tend to work with both doctors and midwives, but they too are often seen as intruders on hospital turf by the medical end of the spectrum, and indeed these roles are often sorta filled by the nurses if there isn't a doula hired.  I'm dealing in exaggerations here, the truth is always more mixed and less clear.  There are MDs where the initials might as well stand for "Midwife in Disguise" and midwives called "medwifes" that might as well have gone to med school, and plenty of health-care providers with ambiguous opinions between the two ends of the spectrum, but there really is a long standing dispute about "the business of birth" and it really does get bitter, ugly, and decidedly unhelpful at times.

So how does it work here in Terre Haute?  Well, in Indiana it is illegal to attend a homebirth unless you have an Indiana license to practice medicine, and very few, if any folk with the relevant liscences actually will, (in many states someone with a CPM degree (Certified Professional Midwife) are also allowed to attend homebirths and do).  So in Indiana, midwifery either happens illegally under the table, or in hospitals.  So the issue in Indiana, is always to what extent the hospitals are willing to allow midwifery and work with the midwives.  In Alabama, when we had Ian, CPMs attending homebirths were alegal rather than illegal (that is untested legally), but the hospitals were not willing to work with midwives in anyway.  They had no admitting privileges and couldn't even talk to the physician about how the labor had gone so far if they transferred to a hospital.  Likewise, there was no local organization for the doulas, or official recognition of them within the medical community.  You could have a "friend" with you during labor, but no recognition that she might have degrees or certification or training of any sort in assisting laboring women.  Not so here in Terre Haute.  The Maple Center ran a list of local doulas, offered references, recommendations, and matching information and the doctors and hospitals were pretty familiar with them.  There are 2 CNM's (Certified Nurse Midwives, essentially someone with nurse training and midwife training) that had admitting privileges and a contract at Union Hospital.  And, indeed, at the births my wife attended where there were CNMs, the hospitals really did let them practice the midwifery model of care.  They didn't engage in continuous fetal heart monitoring, the laboring women were not fitted with IVs early,  there was work to minimize unnecessary interventions, etc.  That is to say, the hospitals and midwives got along, they were willing to compromise, they worked together.  Other official medical organizations, like the Maple Center and the Maternal Health Clinic, worked to keep doctors, midwives, nurses and doulas all organized, working together, and civil to each other.  And it worked.  The punks and the preppies worked together for the common good.   For a while.  Then this year, I believe, the Maple Center's doula program has an uncertain future (due to funding issues).  There are still doulas around for hire, but there may not be a clearinghouse for them anymore, and no official institution to give them institutional standing at hospitals.  We are going from being above-average in doula care, back to the US norm.  Then, in August, Union Hospital announced that it is ending its Certified Nurse Midwife program, as part of the reorganization and moving of the Maternal Health Clinic, and its folding into the Family Medicine Center, and the services will end Oct 29th.  Union Hospital cites economic concerns, "current economic conditions."  Their spokesperson pointed out that is the Maternal Health Clinic program which focuses on providing health care to low-income women had been funded partly by a federal grant which also was not renewed.  On the other hand, there is a lot of empirical evidence that CNM births are less expensive overall than MD births because of the starkly lower intervention rate.  One respondant to the Tribstar's Aug 14th article on announcement put it this way: "UHHG cut the midwives' positions because they only use intervention when absolutely necessary. Cutting costs? Yeah right. UHHG cut two positions that didn't bring in the 'big bucks' by using needless interventions."

So wait, am I proud of Terre Haute, or complaining?  Well, its more complex than that.  Here is an aspect of the end of Union Hospital's deal with the midwives I hadn't understood before reading the Tribstar's article. Quoting again.

"The nurse midwives at Union Hospital delivered about 10 percent of the hospital’s 1,508 newborn babies in 2009, according to data provided by the hospital.

But that number does not reflect the births attended by midwives in the role of instructors for resident physicians, Mishler said.

“They are essentially faculty,” Dahl agreed. “They are kind of like the people you are apprenticing with.”

Most residents feel the loss of the midwives is equal to the loss of two faculty members from their training, Dahl said. “I think the residents, almost every one of us, think it’s a huge loss.”
That's not just working together for the common good, that is mutual respect.  I've never seen that relationship between doctors and midwives before.  That clearly makes my heart proud of Terre Haute.  And as the hospital spokesperson points out it's not at all clear what will happen next.  Maybe midwife services will disappear completely from the Wabash, and people (who can afford it) will have to drive to Indy for a midwife (or go the illegal, under the table route).  Or maybe "The nurse midwives could form an independent practice or could partner with another physician or health practitioner."  Maybe the hospital will find some other way to let the midwives work within the hospital setting.  Heck, maybe the other hospital will hire the CNMs.  Even if the hospital admins are trying to shut the midwives out, or distance themselves from them, there may be further wrinkles yet to come if the doctors and community get involved.  There is, for example, a petition in favor of the midwives, here.

I'm proud of how well Terre Haute's midwives, doulas, nurses, and doctors have worked together over the past 5 years.  I'm a little worried that this is changing, and taking a step backwards, but even if so we would be going from better than normal, back to the norm.  And I'm not convinced that's what will happen yet.  For the moment, we still have midwives in one of our hospitals, and our community may still find a way to continue to do so.  It may be as simple as a physician stepping forward and opening a joint practice with the midwives.  But for now, our doulas and midwives, and the doctors and nurses that have been willing to work with them are ...

Just one more reason I'm proud of Terre Haute.

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