Midwifery without Fear

I have had some particularly challenging times in my life. I've come to appreciate faith as a spiritual gift that each believer is not equally gifted. I have witnessed sisters in Christ, great beacons of light, crumble in fear of man. As a homebirth midwife, one must get their eyes off their own weaknesses and inabilities and focus on God's provisions. The world will hate you.

 II Timothy 1:7
For God hath not given us the spirit of fear; but of power, and of love, and of a sound mind.

Proverbs 29:25
The fear of man bringeth a snare: but whoso putteth his trust in the Lord shall be safe.

A snare is a trap. It's something that holds you and stops you in your tracks. It prevents you from moving freely and being able to make forward progress. It's not God that brings a snare; it's the fear of man that brings the snare.

Homebirth midwives often feel like the men of Israel facing Goliath. They focus on Goliath and his imposing stature. They can't see past the obstacle in front of them, albeit a formidable obstacle. The successful midwife faces him like David. They don't flee in fear. They rely on God's strength and ability.

God's message throughout the Word is, "Fear not." When Mary was presented by the angel, she had questions. Her questions were answered because she wasn't afraid to ask. Her focus was fixed on God and His Word. Rather than allowing fear and her own concerns to dictate the situation, Mary sought answers and trusted God.

The Lord can deliver us out of the paw of the lion, and out of the paw of the bear... II Timothy states he has saved us from fear through power, love and a sound mind. The Holy Spirit gives us power. With His power we can expect His super abundant blessings. Love is the antidote for fear. Love is the light in darkness.

In addition to His love and power, God has given us a sound mind. We gain victory in believing God's Word and then disciplining our minds to carry it out. God gave us the ability to choose the thoughts we think. We can choose to think and believe God's Word in each challenging situation. As we do, we eliminate fear.

A sound mind means to be sober-minded, controlling negative thoughts with self-restraint. A sound mind demonstrates good judgment and wisdom. Disciplined thinking. Our lives are determined by what we think. Our lives are determined by what we believe. Since all believing starts with thinking, we want to discipline our sound minds to think of ourselves as God sees us.

We must not float along in our mind, day-dreaming or fantasizing freely. There is a duty to be a disciplined thinker. The power to determine what you will not think about is a valuable aid in resisting temptation. Do not allow mental, moral, or spiritual deterioration. Have knowledge of yourself. Know where you are and redirect yourself. I have often asked God, "remove these thoughts from my head." He has done so immediately, every single time.

The key is to run from these thoughts. Don't dwell. Keeping our minds on God allows us to enjoy His perfect peace. What we think on we will manifest. We cannot rise above what we think.

Romans 12:2
And be not conformed to this world: but be ye transformed by the renewing of your mind, that ye may prove what is that good, and acceptable, and perfect, will of God.

Homebirth after THREE cesareans - a beautiful story.

Who was the first US president to be born in a hospital?
a. Harry Truman
b. Jimmy Carter
c. Bill Clinton
d. William Harding







Jimmy Carter..all previous presidents were born at home.

Interesting Week

Nurse Midwives build relationships with their clients. Many of us that return to graduate school to fulfill the role of a primary practitioner are eager to finally give women a voice, to empower them, and too often we forget to create our own boundaries. I have learned with absolute certainty that in utter desire to be an advocate, I have neglected my own needs, which unfortunately has had a negative impact on my practice.

I have learned this last year however that sticking to my guidelines, primarily with respect to business matters, almost unanimously improves care and eliminates a great deal of inevitable heartache later. One particular client this week seemed to misunderstand midwifery to mean she was completely in control, rather than our having a relationship. I attempted to make clear what my expectations were (an appropriate risk assessment for homebirth candidacy) and she disagreed. She had complete confidence in herself and felt I needed only to respond to her labor call, no need to know her medical history or participate in care management. When I pointed out that clearly our relationship had come to an end she was absolutely beside herself. I was grateful the Lord revealed her heart to me before being presented a scenario that potentially would have impacted her or her child's safety.

This wasn't the only spring cleaning I did this week and I'll admit that during my first year of practice, I wanted to give the benefit of the doubt without regard to the whispers of my gut. I am learning quickly that the Lord helped me established clinical practice guidelines and administrative policies so that He can protect me. If this means confronting a situation that would otherwise be easier to ignore, or hope that it dissolves on its own, then it is my responsibility to gown the robe no one likes to wear. I am learning self-discipline. I just wish I could learn to get to bed at a reasonable time!

Today I had the opportunity to speak at the Indiana Perinatal Network Forum: Controversies & Innovations in Perinatal Health. My presentation was about the Use of Sterile Water Papules and TENS machines in labor. It was great fun. Immediately after walking into the room, two ladies at the back had mentioned seeing me at the Salute to Nurses banquet and I immediately responded that I did have the ability to speak to an audience, not to worry. That day, shamefully, just completely over whelmed me. They mentioned that they were thrilled to meet the original doula, Penny Simpkin and then realized that wasn't me. Ha! I shared that I was more than happy to be mistaken for Penny Simpkin. Numerous times though prior to my presentation someone would mention, "Penny Lane! I know you!" I would say, "No, you are probably thinking of the Beetles." Then the time arrived and I was told a very nice lady from IPN would introduce me. "I am pleased to announce Penny Lane, which as most of you know has become quite famous within the field of maternity care...." Oh no! I am sure she too thought I was Penny Simpkin. Funny.

It was a nice presentation though. I think those that attended were intrigued by my teaching. I am going to tell myself that either way. Several stayed after class to ask specific questions. A Nurse Manager from a large hospital corporation asked if she could have my presentation so she could present it at her own hospital. (I was sort of surprised by this. Isn't this, uh, poor form? Maybe I can talk her into letting me present the material to her staff.)

I also met with two Nursing Directors for a local hospital who had concerns that their nursing staff had no awareness of how to support women that didn't have epidurals. She wanted to know if she could send her nursing staff to our birth assistant course, so I recommended Paula for the DONA doula course instead. I was surprised to discover that not only were they unfamiliar with DONA, but also the concept of a doula. Interesting. I also had a lady, director of a particular center with which I had a very disrespectful encounter last year, share an apology and desire to get together to network. She also shared that she hadn't heard the term, Leopold's, for nearly twenty years until I spoke it today. Interesting...with a fancy little roll of my tongue.

I returned home to an e-mail from the director of a very large Emergency Service who would like for me to come share my thoughts regarding our working together in the event of an emergency transfer, unplanned homebirth scenarios and the like. Fantabulous!

Next on my plate, preparing for a fairly large NRP course in Chicago in May and then a really large NRP course at MANA this October. Oh, did I mention I riped my nose ring out again and did you know Toys-R-Us is now selling food?

My Journey to a VBAC from Lindsey Meehleis on Vimeo.


I had the pleasure of having a week, even a little bit more, of vacation from my practice. The Lord did not send us any moms for the month of January and I took it as a clear indication that He felt it time that I rest. I knew I was exhausted. I just didn't know how much. I knew I was growing bitter. I hadn't realized how much.

I don't know that I could have done it any other way, but the sacrifice that was required the first two years in practice to get to where we are today is accomplished and from here forward I vow to better care for myself and my family and my staff, so that I may be a better midwife.

Never did I grow weary in attending births. They continued to fascinate me and demonstrate how great our Lord is, but anything beyond birth seemed a bit daunting each morning. By Wednesday of this week however, especially by Thursday, I was missing my clients. I longed to feel another pregnant belly and sit and talk with another mommy. Being back in the clinic today was fabulous, in spite of my starting the day with my pants unzipped.

I hope you enjoy the above birth video. It made me cry. Her face speaks to why I do what it is I do, and why I thank the Lord that I was called to be His midwife.

Terminology

I do feel the particular words people choose to use does impact the mindset of others and can alter perspective. In court, attorneys will prep clients regarding whether the offending car "slammed" in their own or, instead "tapped" them for example. The connotation of each term is vital for clearly communicating our point.

For years I have used the term "artificial breastmilk" instead of "formula" when discussing breastfeeding matters. I have also used "government school" verses "public school" for quite some time. Both terms have caused others to question my meaning, offering an opportunity to teach that choosing between breastmilk and formula is not as simple as choosing between coke and pepsi, but instead the choice is whether baby will receive human milk at mom's breast or not. The standard is breastmilk. Home education can be discussed in the same manner. I choose not to send my children to a government school. Their education is directed by our family.

I have decided today that I will no longer refer to homebirth as out-of-hospital birth, but instead use homebirth as the standard and institutional birth as the alternative. Let's see how many minds I can enlighten with that one!

Funny...I was searching google this evening and found this.

http://www.blessed-babies-and-families.com/BlessedBabiesandFamilies/My_Blog/Entries/2009/1/26_Should_Georgia_Legalize_Homebirth_Midwifery_Again.html

A Voice

A friend of mine shared with me a link to Ian's Voice. She hesitated in doing so because she knew she risked causing tears and heartbreak. Her e-mail came many months ago and today I took a deep breath and followed the link, reading the blog and empathizing with Ian's parents.

Ian passed away after receiving the Hepatitis B vaccine. Devastating. His parents have given Ian a voice through educating parents on the risk of this vaccine, particularly when given to a newborn with a compromised immune system. Their testimony is reminder of how often we, as medical providers provide family informed consents that list the plethora of risks associated with various procedures, yet this is solely to avoid liability because "we" really don't allow them to decline our recommended therapy and if a reaction were to occur it would not be from the therapy or treatment itself but from some undiagnosed phenomenon. Worst case scenario, a reason to blame Mom or Dad would be crafted. Genuine truth. Not because medical providers are hateful and cruel, but because they have more faith in their interventions, than in the people they serve.

My son, Lyric, was stolen every opportunity to bring justice to his death. The coroner in Tippecanoe County was/is hostile to homebirth families and in spite of the organ procurement team having tested and prepared to harvest organs from my son upon his death, he prohibited their use. He had no other reason than to punish me and when I asked IOPA if that was even legal, she said, "Unfortunately, yes, Indiana legislature does allow coroners to be assholes." This is a legislative argument that I had no idea how to pursue at the time.

It seems each time I visioned a glimmer of light that might reflect on the purpose of our loss, it was extinguished before it came to fruition. I did pump my breasts for ten months, donating gallons of milk per day to various donors, but that alone simply didn't provide peace I knew the Lord had in store for us.

While the truth will not be revealed to us until we gain revelation in heaven, we do know that our care providers were incompetent both in assessing fetal heart tones and in newborn resuscitation. Had they been sufficient, they might simply have rescued a little one from death yet not prevented life-long suffering from previous brain trauma he endured much earlier in my pregnancy. However, their incompetence, particularly following my diligence to provide a safe birth is hard to accept. My energy was immediately turned towards increasing homebirth standards with regards to intermittent fetal monitoring and neonatal resuscitation. My belief in homebirth has never wavered. Unfortunately, my efforts continued to hit walls and I soon fell into a grief that paralyzed me.

Since establishing my own midwifery practice, I have began to blossom. It seems I am more emotionally healthy now than I have ever been in my entire life, and happiest as well. (I'll save that for another post however.) Immediately upon establishing our practice guidelines, we began providing AAT assessments during labor with the intention of using this data at some point in the future as yet to be determined. My primary concern is that in my experience I have only witnessed midwives validating that fetal heart tones exist and at what rate they were heard, yet viability is only helpful for the next minute or two, but offers no information to the well-being of the fetus. This is a much more thorough process, yet minimally more intrusive.

This past year as well, I have taken the NRP instructor course and co-taught two courses specific to the out-of-hospital provider. It is astonishing to me just how much information needs to be catered to the very unique environment of the home, yet this very simple information is very attainable and at the same time considered "beyond the scope of a homebirth midwife" by most of my profession. I refuse to accept that a midwife can claim competency in providing birth assistance but lack the ability to secure an airway as any other birth attendant would provide in the hospital, including the midwife. If we can't provide the basic ABCs of emergency management, then why exactly do families hire us to attend their homebirths? This is fraudulent midwifery in my opinion.

Today the Lord provided me another gem. He continues to demonstrate to me a path that He has detailed every step of the way. I have no doubt that His path is more than I can vision today. I am eager, yet patient. I am preparing for His will and for Lyric's glory. Come what may.

Birth Choices

I recently spoke at a local alternative birth choices group and the various birth choices in our area. Clearly I was a biased speaker; however, I gave my best argument for each option. Just prior to my talk I browsed their reading material and found an article on the very topic. It was written by Rosemary Romberg Weiner in 1981.

Advantages for hospital birth was that it is more "socially acceptable." If you plan to delivery at home or in a birth center, you are more likely to encounter criticism or questioning from other people. Twenty years later, this still holds true.

Improvements from twenty years ago are that insurance companies are likely to pay for out-of-hospital births attended by a Certified Nurse Midwife. Either way, hospitals are much more costly than homebirth.

Misconceptions that persist are that emergency services such as surgery, blood transfusions and ultrasounds are immediately available. In most hospitals throughout our country, physicians are not in the hospital and in the event of an emergency are paged and travel in from their homes. This is true for blood bank personnel and ultrasound technicians as well. A homebirth scenario simply means the mother in need of emergency services would travel with her birth team and await the arrival of the medical team. However, the emergency is far less likely to occur in the first place.

The interventions that are more available are inductions, augmentation, epidurals, pitocin drips, continuous fetal monitoring, intrauterine catheters, internal fetal monitors, and non-emergent cesarean deliveries which is why they are so frequently utilized even if a natural birth was planned. Since these interventions are not offered in out-of-hospital birth, birth is more likely to proceed naturally when it does not take place in the hospital.

Families are more capable of supporting the mother in her birth process, including children who might otherwise be limited to the visiting room in a hospital scenario. Some families find the hospital "cold," "clinical" and "impersonal."

Hospitals are managed by healthcare providers, not the clients. They are the territory of physicians and nurses, who are well versed in medical protocol. Many families appreciate this structure. Others feel this is humiliating, intimidating, abusive and unfortunately, too many mothers look back at their birth experience and feel as if they were a victim of a sex crime. Many feel their infants were tortured and they were without any ability to protect their young.
In their own home, families appreciate the peaceful, loving, gentle environment of birth.

It is still true that in the hospital the nurse determines the success of your birth much more so than the obstetrical provider you choose. At home, the midwife chooses with whom she prefers to work with therefore, the birth team are most often of the same philosophy and demeanor.

The hospital if full of a plethora of bacteria and viruses and today, children under the age of thirteen aren't even permitted. Ironically, women are invited to enter and birth their babies who are the most vulnerable when faced with these deadly germs. At home however, there is a natural immunity and baby is colonized with those germs the mother has already developed antibodies in her milk for protecting her newborn.

Praise the Lord hospitals aren't providing pubic shaves or enemas anymore, but many continue the practice of forbidding food and free movement, requiring birth in stirrups, episiotomies, and separation of mom and baby. This of course, is if they escape a surgical birth all together.

I don't entirely understand the concept of birth centers, so I'll skip that discussion all together.

Advantages of homebirth in the early 80's, consisted of not having to travel to give birth in an unfamiliar environment, freedom to choose who will and who will not be present for your birth, freedom to move and drink or behave however their hearts desire. Babies are not separated from moms. In fact, they don't even need identity bands. Families and midwives work together. These still hold true today.

Disadvantages of homebirth as described by the author are criticism that comes with the decision, difficulty in finding an attendant, the legality of lay midwifery varies widely so homebirth attendants might be "hassled", risk the attendant would not arrive in time, lack of insurance coverage and greater time in transporting mom in the event of an emergency.

The first two points, criticism and difficulty in finding an attendant, are still true for the vast majority of families seeking homebirth. At least in central Indiana, I hope I have made a difference. Certified Nurse Midwifery is legal in all fifty states, but many barriers exist to practice, particularly independently and outside of the hospital, which makes very few of us able to work in this role. Direct-entry midwifery is also a tremendous challenge today and in Indiana, midwifery without a license (as a non-nurse) is a felony.

The risk of the birth attendant not making it to the birth simply means baby came quick at home, rather than in the car or worse, midwife is stuck in the snow drift, not laboring mom. The last two points are no longer challenges, in my opinion. The vast majority of insurance companies do pay for homebirth and in each of the births we have transferred thus far, we have arrived at the hospital prior to the physician.

I say lets work hard to create a timeline for the next twenty years that has much more progression in the ways of homebirth.

Biblical Principles and Homebirth

Since becoming a Christian, Mike and I have found ourselves seeking a more Biblical lifestyle and stepping outside of what maybe considered the norm. I don't feel that our lifestyle is any more holy than any other, but rather, the Lord has made us more holy through these lifestyle changes.

I suppose our lifestyle may seem to some, old-fashioned. I feel we are more self-sufficient. Mike and I enjoy pursuing entrepreneurial opportunities. We would prefer this even to corporate careers. We enjoy the security in knowing we can care for ourselves and while doing so, serve others, particularly in this economy. Homeschooling was one of our first steps in this direction and alternative healthcare another. We are currently working on becoming more of a self-sustaining household.

Whole food nutrition is an example of both alternative healthcare and establishing a healthy household. This isn't a popular lifestyle choice, but one that I can't imagine any physician would argue to be harmful. There are Christians who believe it is biblical to use only whole grains. I am not sure I have that conviction, at least not yet. Clearly the health benefits of doing so is indisputable.

Homebirthing is our family's conviction for living biblically, as we feel this optimizes our ability to invite the Lord into our birthing experience. We are leaning on the promises of God and not blindly trusting in man. Don't read too much into what I am saying and assume we don't trust science or don't appreciate medical care. We simply feel it is important to use discernment in this regard.

This issue causes great debate among Christians and it is my belief that those who adamantly oppose homebirth and midwifery, often are arguing from a worldly perspective. Their understanding is clouded and they simply can't apply biblical truths. On the other hand, I am familiar with a good number of Christian midwives who are a bit too enthusiastic and fail to respect birth.

Pregnancy and childbirth are completely natural. It is wholesome and desirable. Not every pregnancy requires an obstetrician and not every birth, a hospital. Midwives are the specialists for pregnancy, birth and mothering. Consider this, "It is not those who are healthy who need a physician, but those who are sick." Matthew 9:12

The hospital, with its germs and tendency toward over-interference, is quite contrary to the wholesome and natural process of childbirth. Aren't we to keep our minds set on what is pure? Aren't we to avoid any unclean thing? Might requesting an epidural without medical need or an induction for convenience considered by our Lord as a glutenous request?

Man's science supports homebirth. "Any person who gives it an honest and in-depth look would never choose a hospital," says Stacey Hilbish of Snohomish, Washington. Families who choose to birth at the hospital are uninformed. The modern, techno-savy world we live in today makes staying at home to birth a child seem absurd. The truth is, all the intervention imposed unnecessarily on birth has caused great havoc, which has lead to an over whelming fear of childbirth. Ironically, this has caused society to depend even deeper on technology.

I don't dispute that modern medicine saves lives or even that it has a place in childbirth. We live in a fallen world. I don't simply trust birth; I respect it. I respect that the Lord created the design and His wisdom is far-more reaching than my own. For this reason, often the extent of my control is to simply sit and encourage. I also respect that birth can go awry and as the midwife, I must maintain a keen eye for labor going off course.

Midwifery has a longer history than obstetrics. The timeline for physician attendance at birth is minimal in perspective and while outcomes initially improved (ironically as antibiotics were simultaneously introduced), outcomes have become worse every year. Midwifery wisdom has nearly been washed out. Physicians have lobbied well to monopolize healthcare. Hospital birth became the only option.

What about those that choose hospital birth because it's "better be safe than sorry?" These families are often validated when the hospital or physician saves them from a scary birth scenario. Might they consider that the physician attending them was only trained in the interventions required to manage the very rare medical emergency, and has no real training in maintaining or encouraging the normal process of birth? Unfortunately, those maneuvers for emergency births have seeped into each and every birth -- episiotomies, intraveneous fluids, continuous fetal monitoring and withholding food and fluids. How often does a physician encourage a mother to stand up and push to optimize progression through the birth canal?

I am really discouraged with the continued blind belief that homebirth is reckless and the hospital is necessary for safe birth in spite of the fact that children under thirteen aren't even permitted in the front doors of hospitals today due to all the deadly viruses they may become exposed to, yet this fact is glossed over when women enter in labor.

Women don't choose hospital birth for a safer birth. They are simply choosing the option that brings them less fear. Death is not everyone's worse fear. Pain might be. It might also be stepping outside of the cultural norm. Very little in life is risk-free and childbirth is no exception. For me, it was clear. I don't follow the pack. I have absolutely no hesitation in jumping off the train, even attempting to rally a group with me, when I feel the train is misguided.

My sister informed me when she didn't choose to breastfeed, although knowing full-well it was the best thing for her daughter, "that breastfeeding just isn't what my friends do." I suppose I never thought of her as a follower before. She was always the smarter one.

Who are we to please? If Christians refuse to look at the truth - both biblically and through man's science - are they pleasing God? Man? Themselves? Christians must have the courage to be holy - separated from the world.

ACOG & Homebirth

Response to ACOG Homebirth Survey
Doula Tabaré Depaep, J.D., Esq., CLD (CAPPA), wrote up this response

As most of you already know, ACOG (American College of Obstetricians andGynecologists) is collecting data on elective home deliveries, even if there were no adverse outcomes (see their data collection form at http://www.acog. org/survey/ hdComplications. cfm).

Here is my tongue-in-cheek response (I am a lawyer and a doula):

**Complications Related to Hospital Delivery
*We at Doulable Birth are concerned that high rates of elective hospital delivery have resulted in an increased complication and morbidity rate. Reports from clients indicate that doulas are being called in to try and prevent these emergencies, and in some instances doulas and doula organizations have even suggested legal proceedings against the hospitals and doctors that seem unable or unwilling to learn from and address the deficiencies of their practices. To attempt to determine the extent of the problem, a registry of these cases will be maintained by Doulable Birth on a year-by-year basis.

If you have attended a patient who came to you after an unsuccessful attemptat elective hospital delivery, whether in the emergency room, operating room or labor and delivery suite, please complete the following survey even if there was no adverse outcome. Include only current events after June 15, 2009.

State:

Hospital:

Month/Year of Delivery:

Gravida:1 - 2 - 3 - 4 - More

Para:1 - 2 - 3 - 4 - More

Maternal Age: Less Than 20 - 20-25 - 25-30 - 30-40 - Greater than 40

Gestational Age: Less than 30 weeks - 30-36 - 36-40 - Greater than 40

Problem: (check all that apply)
Convenience Induction
Artificial Rupture of Membranes
Augmented Labor/Pitocin to Distress
Defensive Medicine (e.g., procedures designed merely to prevent lawsuits)
Epidural Induced Fever
Episiotomy
Formula Supplementation
Healthy Baby Removed From Mother
Post-partum Healthy Baby Sent to Nursery
Iatrogenic Infection
Major Abdominal Surgery ("C-section" )
No Continuity of Care
Profit Driven Healthcare (e.g., unnecessary tests/procedures)
Protocol Driven Healthcare (e.g., mandatory IV, monitoring, etc.)
High-tech/low- touch care

Fetal Outcome: (check all that apply)
Fetal Intolerance to Labor
Delayed/Unsuccessful Breastfeeding
Delayed/Unsuccessful Bonding
Routine Deep Suctioning
Sepsis Workup
Unnecessary Bath

Gestational Age at Induction:
2nd trimester - 1 month before due date - 2 weeks before due date -on due date - she's late, she's late for that very important date

Length of Labor Prior to C-Section:
Scheduled prior to labor - less than 30 minutes - less than an hour- Seriously they let it go that long?

Guesstimation of Fetal Weight Prior to Induction:
Off by: less than a pound - 1-2 pounds - Greater than 2 pounds- "Ma'am based on the ultrasound we think you're carrying twins."

Dilation Prior to Epidural:> 8 cm - 6-8 cm - 4-6 cm - 2-4 cm - 1-2 cm - why wait?

Number of Hospital Attendants:
A basketball team (5) - A baseball team (9) - A soccer team (11)- Bring on the marching band

This survey *IS NOT* collecting any identifying information from the respondents. To help detect accidental duplicate submissions, please select the numeric value of your birthday month + day, divide by the square root of your home address, and subtract the absolute value of the ACOG minion that came up with their survey in the first place. For example: ((April (4) + 19) / Ö5922) - ½-25½= -24.07

I hope you enjoyed my survey as much as I enjoyed writing it!

Another Homebirth Article

A client of mine shared with me an obstetrical journal that was shared to her, from her obstetrician friend (who referred her to me). The journal is, OBG Management, August 2009, vol 21, no 8. The article title is: Does home birth empower women, or imperil them and their babies? The author is Erin E. Tracy MD, MPH. She is an attending physician, an OBGYN within the Massachusetts General Hospital.

Agreed, "few issues in obstetrics spark as much controversy as home birth." The author presents the argument however, as safety verses empowerment. Clearly, Dr. Tracy is unaware of the 2009 Boucher article within the Journal of Nurse Midwifery which discovered safety as the number one reason women choose to birth at home. She does recognize that the strong statements from ACOG and AMA opposing homebirth sets up the potential for homebirth criminalization.

Did a rise in hospital births reduce maternal mortality?
As most of my readers are aware, hospital births increased dramatically in the mid-20th century and since that time, maternal death rates have decreased. However, it would be naive to assume the phenomenon of hospital birth is the only variable. Dr. Tracy feels that "others argue" the introduction in aseptic technique contributed more to the decrease in mortality than the place of birth. I can't imagine how she could argue anything differently, as maternal mortality increased the first decade births moved into the hospital, but immediately upon the introduction of antibiotics, death rates dropped.

The author states, "All studies of home birth have serious methodologic flaws." I would disagree (see my website for articles addressing homebirth safety; apologies, I have no source for research demonstrating hospital birth as safe). Oddly enough, today, hospitals are offering a "drive through emergency room," because they fear transmitting the deadly swine virus to any of its healthy patrons; however, pregnant women come forth!

Most data comes from abroad
True. Their maternal and newborn outcomes are better too. Why would we ignore a style of birth that is working and attempt to mimic it? Because Americans didn't think of it first?

The data we do have is difficult to interpret
The author argues that bad outcomes are too few to interpret, yet she uses fancy words to mask her weak argument.

Oft-cited study has weaknesses
She does make a valid point in stating the often cited United States and Canadian study published in 2005, which states authors have no conflict of interest, lacks credibility because it was funded by The Foundation for the Advancement of Midwifery. Not all loss, but recognition of this conflict would have boosted credibility.

A Fast-Track Note:
The author has in bold within the side-line: "The neonatal death rate for unplanned home delivery in North Carolina and Kentucky was 18 to 20 times higher than the rate for planned home birth." I don't know a single person that would advocate for unplanned home birth. Midwives aren't reckless in their advocacy of homebirth. Advocates for unassisted homebirth would likely find unplanned homebirth less than optimal as well. The key to safe birth is preparation. This quote demonstrates the author's desperate attempt to develop an argument with no real evidence in her bag.

Common research flaws regarding homebirth
Birth certificate information is utilized.
Misclassification of planned verses unplanned homebirth.
No identification of the education level of the midwife/attendant.
Inability to provide an RCT trial, the God of medicine.

Risk level can escalate rapidly
True. A woman with little risk antenatally can become a scary obstetrical emergency during the intrapartum period. Dr. Tracy discusses the scenario of a shoulder dystocia and how challenging it is to transfer and/or organize a team of providers in this event. As a homebirth provider who has ten plus years experience working in the hospital, let me attest to the fact that I am not looking forward to a shoulder dystocia in a homebirth scenario. I will also share that a shoulder dystocia in the hospital is also absolutely awful and no matter where this occurs, it sucks. Any baby who-so-ever that has to be cut out of his/her mother's abdomen because of shoulder dystocia, likely will not survive. Having said that, I personally feel that as a homebirth provider, I know a transfer would complicate this scenario and I believe I would institute the Zanvanelli much sooner than other American providers currently. England utilizes this maneuver much more regularly and has far more success than our providers, and I believe that is because in America we wait too long to recognize and act on the situation, then run through the maneuvers that are rarely rehearsed and then call the cesarean, which even in the hospital takes a significant amount of time to orchestrate. The Zanvanelli is rarely, if ever utilized and by the time it is baby is already too compromised to benefit. My last argument regarding this point is that birthing at home decreases the chance shoulder dystocia would occur in the first place and in itself is a valid reason for choosing to birth at home.

Fast Track:
"Certification as a 'lay' or certified professional midwife does not require a high school diploma. Yeah, this concerns me too. I know many very gifted midwives that have mastered the art of what we do, who are non-nurses. However, with research demonstrating safety as the number one reason families choose to birth at home, I believe the nursing factor is paramount. Otherwise the attendant is nothing more than a glorified doula. (Fearing I could be stoned for this one!)

A provider who has only practiced in homebirth has very limited emergency experience. This is credit to the great outcomes experienced within the home, yet if my baby needs resuscitation, I want the attendant that has performed this skill numerous times and can do so without a second thought. I don't want the midwife who has attended hundreds of births that went beautifully and has only picked up the bag and mask a time or two. I don't want to be the mother hemorrhaging and my midwife too sweaty or shaky to start an IV. I hold great value in my hospital-gained skills.

This argument reflects the skill of the provider, not the environment of birth, which leads to the next point.

Skill of the caregiver is important
I was unaware of a study evaluating 4,361 home births attended by "apprentice-trained midwives from 1970 to 1985 and 4,107 home births attended by family physicians from 1969 to 1981." The perineal mortality rate for the midwife-attended births was 14 for every 1,000 births, in contrast to the rate of 5 for every 1,000 physician-attended births. The reference for this article, which I will immediately go on the hunt for is: "Mehl-Madrona L, Mehl-Madrona MM. Physician-and midwife-attended home births. Effects of breech, twin, and post-dates outcome data on mortality rates. J Nurse Midwifery. 1997;42:91-98. Just by the title though, it seems the author may have stretched some statistics to serve her purpose, huh?

I do agree with the author that the CPM credential is what motivated ACOG's decision to issue a statement from its executive board in 2006: "While ACOG supports women having a choice in determining their providers of care, ACOG does not support the provision of care by lay midwives or other midwives who are not certified by the American College of Nurse-Midwives (ACNM) or AMCB." The great tragedy is that very few have read their statement to differentiate between the various types of midwives in homebirth, but instead hospital verses homebirth.

Does the rhetoric surrounding home birth "empower" women?
"I worry that patients may become so caught up in the rhetoric of their own power and choice that, when uncontrollable events occur, the happiness of a healthy delivery is overshadowed by deep disappointment." Well, then lets just remove their choice altogether! If every mother is controlled and manipulated than it will be the norm and that disappointment won't seem so unusual. Sounds like an awfully pessimistic view point. I understand her argument, but don't know that it holds enough weight to even print.

Heated debate isn't helpful
The author does offer great commentary to the unfortunate rift between members of the midwifery community and physicians. She cites the ACOG and ACNM joint position statement regarding practice relations. She further discusses an article describing hostile transfers and their impact on care. Another article I'll be digging for: Davis-Floyd R. Home-birth emergencies in the US and Mexico: the trouble with transport. Soc Sci Med. 2003:56:1911-1931. Are we surprised this is a Davis-Floyd article?

The author does appreciate that both "The American Public Health Association and the American College of Nurse Midwives support home birth.

Conclusion
Dr. Tracy sums up that homebirth isn't going away. Physicians should be supportive and respectful of homebirth providers upon receiving a transport. She even states, "There are certainly data supporting the safety of home birth for the vast majority of women who choose it, but there is also a significant number of women who will experience unpredictable events that could be fatal if blood products or surgery isn't rapidly available. For that reason and in light of the very high stakes involved, I wonder: Why take that chance?"

Such an odd conclusion. Blood products and surgery are only immediately available in a very few hospitals, fewer than ten within Indiana. Should all other facilities close their doors?

What about the fact that simply walking through the door of the hospital increases dramatically the likeliness such an emergency will occur and women seek homebirth to prevent the scenario in the first place!

There is no guarantee of a good outcome once the urine stick shows a positive pregnancy. Most all homebirth families are well aware of their odds, but choose to face a bad outcome as the result of nature, than a bad outcome as the result of medical intervention, all while knowing a bad outcome at all is drastically reduced simply by staying at home.

I would give this article only two stars - not a lot of valuable argument, but not completely bull-headed either. Another bit of irony, the article that follows this one in the journal is medicalVerdicts, a long list of medical mistakes and their law suit outcomes. Here is an example:

"A woman in labor at full term presented at the hospital for delivery. Labor progressed normally, and the physicians performed an amniotomy. Prolapse of the umbilical cord occurred, and a cesarean delivery was performed about an hour later. The child suffered asphyxia, leading to brain damage with cognitive delays and mental retardation.
Patient's Claim: The physicians were negligent for (1) performing the amniotomy before determining that the fetal head was engaged in the bony pelvis; (2) failing to recognize cord prolapse in a timely manner; and (3) failing to perform a timely cesarean delivery.
Physician's defense: The amniotomy was indiated because the fetal heart tones showed unexplained prolonged decelerations [WHAT!?!]. Also the child's condition was unrelated to labor and delivery, because the child had no motor impairments.
Verdict: $500,000 Michigan settlement.

Another case, ironically a mother having planned to birth in the hospital and in fact presented at such facility with an emergent need. Eight months pregnant and taken to the emergency room when experiencing vaginal bleeding. The ER physician evaluted her and judged her condition to be stable. He ordered transfer to another hospital. She continued to bleed during the transfer, and her child was delivered stillborn after arrival at the receiving hospital.
Patient's Claim: The ER physician was negligent for failing to recognize the need for an emergency cesarean delivery. Also, the hospital violated EMTALA because she was not stable.
Physician's Defense: The patient was properly assessed and was stable.
Verdict: $1,674,000 Iowa verdict. Fault was assessed 70% to the hospital and 30% to the physician.

Proving homebirth safe through RCT is like arguing we need research to prove the wheel is round. Redundant and naive.

Offending Someone

I am irritated, frustrated, maybe even quite angry. This post will likely offend. However, I seem unable to stop myself and ultimately, I think the message is important.

I am a midwife. My being a mother is just as important, if not more important, than my being a midwife. I am most importantly, a wife.

I believe when the old testament midwives were blessed by the Lord for their protection of the Israelite boys, they were blessed with fertility. I believe this because I assume the reason they were midwives was because they were either unmarried or infertile. How could a mother blessed with many children attend all the births in the community? Granted, prenatal care wasn't provided in old testament days, or even a few decades ago. There also was no phone or e-mail that allowed pregnant mothers to reach their midwife at all times of the day and night for any reason what-so-ever. This is where I have become frustrated. This expectation that I sit idle, awaiting any need is absurd. However, not nearly is arrogant as the subsequent argument I receive after their bill arrives.

When I first opened my practice, I had little mentorship. I created every network, discovered every resource, wrote every practice guideline, designed my own web site, created my own childbirth education program and each and every one of my chart forms. I researched practice management, hired and trained staff, and organized equipment. All of this, I did almost entirely independently. I then took every phone call, provided each and every interview requested, returned every e-mail, provided each prenatal visit, attended each birth being the first one to arrive and the last one to leave. I've offered each client four times more postpartum visits than any medical provider, and I care for baby as well.

I have missed only four home visits. Two because I was at a birth. One because I was out of the country and the other, because I was simply too exhausted. All but one mother was blatantly upset. These services are just what I provided as a standard, for many mothers I provided much, much more.

During my first year in practice, my daughter was victim to a horrific crime, yet only one of my clients is aware of this. In fact, I attended a blessingway on the evening I was interrogated by the prosecutor and she was brought in for questioning. That mother hadn't a clue. I was her midwife.

During my second year in practice, my husband and I nearly divorced. In fact, papers were filed. My husband was walking out the door the minute I was called to a birth. That mother was completely unaware of my desperately broken heart. I was her midwife.

My clients expect a return phone call in only a few hours. They have no appreciation for piano recitals, birthday parties, days at the pool, or intimacy with my husband. They have no ability to comprehend that they may be the fifth phone call in under an hour and it isn't even 8 am yet! All my clients expect my undivided attention during prenatals, during home visits and of course, during their birth, but then how do they expect me to return each and every one of their phone calls if I am offering the same to another client? What if I have attended three births in five days, plus had a full twelve-hour clinic day? Who cares for my kids during that time, particularly my youngest son who is breastfeeding and needs to see a specialist at Riley hospital in the midst of all these midwifery responsibilities?

I have only missed prenatals twice for births. If I am up late and come home early in the morning, I still attend each prenatal and not one mother is aware of how completely exhausted I am. I missed only a week following my birth and only a handful prior, but clients were irritated by my absence. I attended a birth two weeks after my cesarean section in the middle of the night, two hours north. Then I turned around and did her home visit two days later.

I have more than a handful of clients that call or e-mail almost every single day. I have clients that call when their spouses reject them in bed. I have clients that call to be sure it is safe to eat processed lunch meat. I have women who I have never met call at 1:30 in the morning to share their bad birth experiences, and my request to call during office hours falls on deaf ears. I have women that want me to share my lengthy testimony, as a prerequisite of their choosing me as a provider. I have clients who call late Sunday evening and when I don't immediately answer, they call each of my birth assistants and tattle tell on me. I get at least five e-mails a week from people interested in midwifery and want me to direct them or inspire them.

I've had a client call the office and leave a message. Then call my cell phone and leave a message and because I was in the van with my kids, I missed answering it while it was ringing, but immediately returned the call. However, she was already in the process of calling a birth assistant to discover why she was unable to reach me. She shared with me that she was very concerned, "What if my placenta was coming out of my ear." Then, hunny, you should call 911.

I have ladies that have transferred care because I took three days to attend a conference, the first time I have taken even an hour without call in two years. I had one lady terminate care because it was her understanding that when you hire a midwife, you also gain a best friend.

I have clients that demand appointments on a particular day or particular time of day, or weekends every single time. I have clients that have demanded home visits because they were too tired to drive to the office, less than thirty minutes away. I've had clients demand that I make a home visit on Sunday morning while I was on the way to church, because she was simply too tired of being pregnant and wanted me to strip her membranes. When I declined, yet still offered to meet me back at the office after church, she responded that her and her husband didn't want to drive that far. I've had clients call for an urgent appointment because they felt their breasts were too far apart or just show up to have their cervix checked, assess breastfeeding, weigh baby or have an additional lab checked.

I have clients that stay four and five hours while their children run through the entire house, absolutely destroying my son's room and/or the kid's school room. Clients walk through the house with mud on their shoes or allow their children to urinate on the floor or bathroom wall. Kids climb on my couch with their shoes on, spill food on my furniture and throw toys at the windows. Parents ask for me to provide juice, milk and snacks for their children. Numerous clients ask for tours of my home.

I had a woman demand an interview on a holiday because it was the only day her husband could attend, and then after three hours of interrogation, they asked if their kids could stay for a while and play in our backyard. No, they didn't even choose the practice!

Many of the clients I've mentioned above were offered far more than the standard prenatal package. Each one of them were exceptionally complementary regarding their care. Yet, ironically, each one of them complained about their fee. They didn't realize they had to pay. They didn't receive a bill. They didn't think I really meant it. They knew they were told, but forgot and now haven't a clue how they will pay. They "just wanted to see what a midwife was like" and didn't realize a health history, physical exam, referrals, prescription and/or labs meant they would be charged, even though they signed to that affect including providing their insurance card.

Do I sound bitter? I am. I am offended. I find it grossly disrespectful to ask me to be on-call for you 24/7 for more than nine months, your 24/7 healthcare wicapedia and friend, yet whine that I charged you for one, of the additional five lactation visits I provided. I find it utterly horrendous to call me every day for a week demanding I file a lengthy FMLA or short-term disability, and then make me beg you for payment you have known since the first day we met would be due in full upon your thirty-sixth week of pregnancy. I feel slapped in the face when I give grace for "forgetting the check book" or "having recently changed banks" or whatever other excuse given, prenatal after prenatal, and then ultimately given a check, post-dated, that bounces...all after my services were provided in full.

During our first year in practice we had several clients fail to pay a dime. We had a few clients receive their insurance reimbursement, then decide they were in more need of the cash than their midwife. We had a horrendous midwifery billing company fail to file numerous claims, totalling nearly $100,000.

We filed for a hardship with our mortgage company hoping for a few months grace and because we demonstrated an inability to pay d/t lack of income in my practice, we were immediately placed in foreclosure. That same summer, we had no hot water for several months. Showers are still freezing cold in the middle of summer without any gas to heat your water heater.

My statistics are phenomenal. My experience is exceptional. My birth assistants are top notch. We offer expert lactation services, file insurance claims, high quality tub rentals, TENS machines without additional cost, extra labor support, clean and cook for each family, yahoo groups, a full childbirth education program, supplies at no additional charge, opportunity for families to interrogate on my own time, hours and hours of educating the community and medical providers, and an incredible amount of advocacy work just so families who choose to can have the legal right to birth at home.

Until very recently, I have been the office assistant, the medical assistant, the midwife, the biller, the lab technician, the housekeeper, the answering service, the counselor, the marketer, the advocate, the childbirth educator, the manager, risk management, and every other person that it takes to run any other medical office...and I was expected to perform each task simultaneously.

I had a client call me for a non-urgent concern, months after she had birthed her child and although I referred her to a fabulous specialist for her particular need, offered her extensive on-the-phone counseling, and a plethora of reading material, she quickly became irate when I didn't work within her timeline to call in a prescription. No office visit. No consultation. She wanted an script NOW! She called me repeatedly, hour after hour. Then she called my birth assistant repeatedly and the pharmacy repeatedly. I don't have prescription privileges, so I have to find someone willing to provide a script I recommend and send them a full H&P which can take an hour to dictate in itself. Of course, initially I was at home visits and knowing she wasn't even pregnant, I let the calls go to the answering machine. I was offering the same care to my current client that I provided her. This woman however, became exceptionally angry with me and so when I respond that I am sorry I am unable to meet her needs, and encouraged her to contact a family physician, she responded that she did and he wouldn't talk to her on the phone and couldn't get her in for an appointment for another two weeks! What!?!

Have I mentioned that I owe $90,000 in student loans and don't charge enough money to even cover that expense? Have I mentioned that my birth assistant and I have the same level of education as your expensive attorney, yet we both make less than my twenty-four year old hair stylist?

Am I naive enough to think that if I slacked on the job the way my clients slack in their financial responsibility, that they wouldn't be on the phone immediately connecting with their attorney? Nope.

The sad truth is...all that I have shared isn't really at all the root of the issue for me. The real issue is that I sacrifice time away from my family. I sacrifice friendships. I allow myself to be abused by other medical professionals and mocked at by the community because I have such great empathy for families that genuinely seek homebirth as an option. I do all of this and repeatedly receive over whelming praise for a job well done and gratitude for the ministry I provide, and then in the time it takes to open an envelope and pick up a phone, that gratitude vanishes to nasty messages left on my machine due to money they don't feel they should have to pay when insurance cuts them short. Clients wanting to pay me $20 a month for seven years and irate that I want to include interest. The really sad part is I offer to barter their expenses yet rarely, if ever, are they interested in working off their debt. They never really respected me in the first place.

The beauty in my job is that I have families who genuinely can't afford a gallon of milk, yet call me repeatedly to be sure that I got their check. I have clients who can't pay their own utilities yet find ways to pay their midwife, without a single complaint. I have a few clients who have sold their automobiles to pay their midwife. I have families who bring me corn, applesauce, knit my boys diapers, fix our plumbing, encourage me, send me flowers, take my kids on day trips, invite us to dinner, barter until their arms are numb, and repeatedly thank me for the little things. I have many clients that had I instituted a boundary of "do not call or e-mail unless you meet these certain circumstances" would have respected those boundaries whole heartily and potentially we would never have crossed the boundary into friendship.

I sometimes fear that I am reaping too many earthy rewards because of the work I do, in that I work with women who sacrifice their time, family, and absolutely their pocketbook to assist me in serving the women in our ministry. I have gained friendships with clients that are more valuable than gold. The Lord has provided me more than I ever could have imagined and makes clear daily that this is the work He wants me to do.

However, I can't seem not to be offended by those few that push each and every boundary far beyond what they would ever get away with from any other medical provider, potentially even their own family, and yet, are quick to lash out at me and cry injustice at the first opportunity. I am tired of letting these people run me down. I am tired of being an angry mommy because I was run over by a client. If I've offended you, then maybe you should ask yourself if you would do my job - make the daily sacrifice, assume this level of responsibility, put in the hours it takes to run a midwifery practice, pay each month $700 in student loans, never ever have a moment when you can't be free of the responsibility - so that you can later receive a call from a client arguing a $350 bill or someone wanting an excuse for why you haven't called their ultrasound order in within the last twenty-four hours.

If you've read this far, you are most likely a friend, who maybe use to be a client, who now agrees that I need a margarita. Oops. Another sacrifice. I can't drink alcohol. I might need to give a client my undivided attention. Margarita or not, I must go help finish homework. It is afterall midnight and the last thirty minutes of escape within blog-o-sphere were not in the budget.

Visit to the Capital

Almost two weeks ago, I had a physician call the office and leave a kind message regarding a client of mine who had applied for Medicaid. She was hoping to follow-up on her care. However, upon completion of her message, she failed to hang up appropriately and her continued assault on me and my practice was eloquently recorded on my answering machine.

She shared with her staff that I was working outside my scope with a high risk client. She stated I was unprofessional and she was going to report me and get me into big trouble. She mocked my client for seeking Medicaid coverage and thinking Medicaid would pay for her desire to have an illegal homebirth with an uneducated midwife.

First thing Monday morning, I gave this kind physician a phone call as it was clear that she needed enlightenment. The Lord allowed me an hour-an-a-half on the phone with her to somehow shine a glimmer of light into her very narrow minded vision of homebirth and midwifery. Humility can really open the paths of conversation.

Amazingly, this family physician had absolutely no knowledge of Nurse Midwives (and not a great deal about maternity care either) but was adamantly opposed in every way to the direct entry midwifery. She doesn't attend births as a physician and feels she will raise her kids well enough that they would never choose to birth at home. Therefore, she felt the issue really has no direct affect on her, but as a physician who grew up in a third world country where women and children die daily, she had no ability to understand why women, her own patients, in American, with choice, would choose not to birth in the hospital.

I used this passionate distaste for direct entry midwives to encourage a potential willingness to embrace Nurse Midwives as an alternative, particularly within homebirth scenarios. She agreed with my argument and pointed the finger at me, "Do something about it. Contact your representatives!" I do. I have. I continue to often. She then explained that my efforts have been all wrong. Clearly!

Funny enough, the Lord used this completely humiliating situation for this physician to share her resources with me. Apparently, this physician is exceptionally active within our legislative healthcare committee. It seems she genuinely knows each and every representative and senator, as well as their agendas. I've been waiting for the Lord's tool and praise the Lord I came prepared. Upon my return from Canada, I had a message with an immediate appointment in the capital with a few of our legislative leaders. I gave my all. I was heard. Jaws dropped. My greatest concern is the timing, but the Lord will control that.

Ironically, as I dropped by my local ACNM chapter's web page today, I find... "We will be alert for ways to make home birth better supported for CNMs in the next legislative session." I ask specifically, what is their vision because only one person that I spoke with yesterday had even heard of Nurse Midwives and she was told that they would not work outside of the hospital? They had absolutely no awareness of the barriers we face. I challenge the chapter to step forward and represent its members. Now is the time.

Certified Nurse Midwives providing homebirths in Indiana include:
Our own practice, Believe Midwifery Services, LLC with Penny Lane MSN, CNM
Birthroot Midwifery Services with Lynn McDonald MSN, CNM
Peaceful Beginnings Midwifery with Kate Shantz MSN, CNM
Laura Gilbert CNM (serving North Central Indiana & Southwest Michigan)
Childbirth Choices & Women's Health with Diana Saunders CNM (serving Milford, IN)
Julie Stackhouse CNM (serving Corunna, IN)
Mary Doezema CNM
Moonstone Midwifery with Gretchen Jenkins CNM (serving Ft Wayne, IN)
Central Indiana Nurse Midwives with Lynda Barton-Kirch CNM