Born in the USA (42 page)

Not all of the political struggle to humanize birth goes on at the state level. I was part of a group from a nonprofit called the Tatia French Foundation (named after a woman who died—her baby died also—after being given Cytotec for labor induction) that visited a legislator at the House of Representatives in Washington. The purpose of the meeting was to draft legislation to better control off-label drug use and to have more transparency on drug risks, especially risks for pregnant and birthing women. I have attended meetings at the FDA where consumers testified to the need for better transparency and controls over off-label use of drugs.

There are many issues in the effort to humanize birth, and nearly all require political action. The most important overarching issue, though, is to find a way to guarantee free access to maternity care for all pregnant and birthing women in the United States. Other critical issues include legalization for direct-entry midwives; freedom of midwives to practice full midwifery, collaborating with obstetricians but without their supervision; freedom of women and families to have control over what happens at the birth of their children; freedom of women and families to litigate after an adverse obstetric event; better transparency, accountability, and regulation of maternity care; and midwives' right to an even playing field when competing with obstetricians in finding women and families to serve. Only a couple of key issues can be addressed here.

For the most part, the key political struggle to license direct-entry midwives—and thereby provide women who choose planned out-of-hospital birth with a legally sanctioned person to assist at their childbirths—has been fought successfully state by state. Occasionally, a major bill is put to
a vote in a state legislature, but often the key battles for the autonomy for midwives—and women—go on in state midwifery boards, state nursing boards, and state medical boards (often called medical quality assurance boards). These may sound like staid, boring government entities, but they can have far-reaching influence on women's lives—for good or ill—and are also where witch-hunts against midwives usually play out.

I have appeared before such boards or provided written opinions in about half the states, because in a case brought before such a board, the defendant has the right to bring “experts” to testify on her or his behalf. I testified before several nursing boards that were trying to nail nurse-midwives who left hospital positions and began practicing home birth midwifery, and before others that were trying to prevent non-nurse, direct-entry midwives from creeping into their domain, even though in most cases direct-entry midwifery was not illegal in that state.

Not one of these nursing boards included even one midwife of any stripe, and most board members hadn't a clue about midwifery, much less about out-of-hospital birth. They were righteous in their indignation and clung to their dogma and their “protection” by obstetricians.

Most of these board hearings are open to the public, and large groups of women and families served by these midwives came to the hearings to show their support for their midwives and for midwifery in general. The lawyers for the midwives were for the most part serving pro bono. And there were usually journalists present who brought the case to the attention of the public, usually in support of the midwife—another case of midwives, doctors, women and families, lawyers, and journalists all working together.

At these board meetings, I am frequently asked why I strongly support midwives. I reply that I am not an advocate of midwifery; as a scientist, I am an advocate of evidence-based maternity care—or the care that has been proven to reduce adverse outcomes to a true minimum—and since all the scientific evidence proves that midwives are the safest attendants for low-risk birth, of course I advocate midwifery for all low-risk births.

From these experiences and others, it has become clear to me that in most cases, the struggle is fundamentally a turf battle between nurses and midwives or between doctors and midwives, and the bottom line—a woman's right to have a home birth with a trained birth attendant—gets little attention, unless someone makes a point of expressing the woman's perspective.

Another political battle is fought in the land of insurance companies. ABCs need insurance, but some insurance companies decline to do business with them or charge higher premiums to physicians who provide
backup services to ABCs. As a result, ABCs are being squeezed from both directions. It has also been difficult for midwives attending home births to get malpractice insurance. Why does this happen? As we've seen, the scientific evidence refutes any suggestion that births at ABCs or at home attended by midwives are a bad risk. So it is likely that insurance companies are relying on medical consultants who are simply preaching the obstetricians' party line. Some midwives have worked creatively to obtain insurance with some success. And where ABCs and home birth midwives are being denied insurance because their competitors are advisors to the insurance companies, it is an issue that may eventually have to be addressed in civil court as restraint of fair trade.

Obstetricians can be quite creative in finding reasons to maintain the status quo in maternity care or to make only doctor-friendly changes. I've sat in legislative hearings in a number of states, including Virginia and California, and listened to doctors, nurses, and lobbyists for medical and obstetric organizations say some unbelievable nonsense about childbirth—such as that any woman who chooses a home birth is selfish and doesn't care about her baby or she wouldn't make a choice that may kill her baby.

On the other hand, I sat in a legislative hearing in Vermont once and listened as doctors, midwives, and women's groups testified to the value of midwives and the need for direct-entry midwifery legislation in their state. (They got it.) I also attended a rally under the dome in the capitol building in Indianapolis and heard hundreds of women and families demand direct-entry midwifery legislation in their state. (They didn't get it.)

Sometimes one committed individual can make a difference in the struggle up the evolutionary circle. Meet Maddy Oden. Her daughter and the daughter's newborn baby both died during childbirth after her daughter was given Cytotec to induce labor, even though she had repeatedly told her doctor she did not want her labor induced and had been given no information about Cytotec. Maddy channeled her terrible grief into constructive action and started the Tatia French Foundation (named for her daughter) to work for better maternity care. The foundation has sponsored large public conferences on birth issues, has lobbied Congress and the FDA in Washington, D.C., and Sacramento, and has informed a broad range of journalists about birth issues. Political action taken by a broad range of groups and individuals is a necessary component in the struggle to improve maternity care in the United States.

There is another group of health care providers, who, like midwives, have had to fight for their place in the sun in health care. Chiropractors fought
for decades to be licensed and to be acknowledged by health care organizations and medical professionals as legitimate members of the health care team. Over time, they have won many battles in many states, despite the efforts of many medical organizations and some individuals to keep them out. Midwives could learn a few things from these politically successful chiropractors, such as perseverance (it was a long, difficult struggle for them), how to use support and testimonials from a broad range of satisfied patients, and the value of placing emphasis on open competition on a level playing field without any restraint of trade.

The political process can seem painfully slow at times, but progress is being made. As time passes, more and more states pass legislation to license certified professional (non-nurse, direct-entry) midwives, and thereby guarantee the families in these states free choice of birth options with qualified assistance for all options. These successes have a momentum of their own. When I testify in hearings, I can now point out all the states that have passed this legislation and say that it's reasonable to assume that the legislators in these states are intelligent, have listened carefully to all opinions, and have made their decision to approve the legislation with the safety of the families in their states firmly in mind.

This political progress would not have been possible without the active participation of midwifery organizations and consumer organizations, which can be quite savvy in their approach. It's fun to see the look on the faces of legislators when they come into a hearing room full of breast-feeding women and kids running around. This serves to remind legislators in a visceral way that the issue before them is all about women and babies, not just about doctors getting a bigger piece of the pie. Some legislators clearly love it and others clearly hate it but are smart enough not to object. It's called democracy.

5. STRENGTHEN MONITORING AND REGULATION OF OBSTETRIC PRACTICES

One reason for the vigilante obstetric practices I've discussed in this book is that the monitoring and regulation in our maternity care system are inadequate. Obstetricians are free to behave as if they're in the Wild West and there's no sheriff or judge in town. This creates obstetric lawlessness, and patients who have become victims have figured out that the only way to get the sheriff and judge to come to town is to litigate.

How inadequate are the systems for monitoring and regulating maternity care practices in the United States? Think of a can of soup. In the United States, every ingredient that goes into a can of soup must, by law, be printed on the label—full disclosure required. In most hospitals in the
United States—places where women give birth and life-and-death decisions are made—no disclosure is required. Only two out of fifty states have laws requiring hospitals to disclose information on their maternity services. These laws are the result of a long fight by women's groups against fierce resistance from medical groups, and even in these states, the fight continues because compliance with the law is poor. Many doctors are also strongly opposed to disclosing what they're doing. Could it be that they've got something to hide?

States currently regulate maternity care after the fact in a reactionary manner. When somebody reports that something terrible has happened, they look into the situation. There is almost no effort made to monitor maternity practices in order to prevent harmful practices or to bring harmful practices to light. In Washington State, obstetricians in a private hospital were performing C-sections on 60 percent of their pregnant patients, but neither the hospital nor the state took any action and there have been no consequences for these overzealous surgeons. Consequently, these dangerous levels of mostly unnecessary and always risky major abdominal surgeries—C-sections—continue.

Many people who work in public health believe passionately in the value of prevention, but if that's true, why aren't state health departments monitoring maternity practices and going after “outliers,” the fancy name for people working at the extremes of practice? The answer is simple: public health officials are too often afraid of organized medicine and practicing doctors.
¹⁹
One way to address this dilemma is to get the public health establishment, which is, in general, progressive and courageous, to be more proactive with its members. Every couple of years at the annual meeting of the American Public Health Association (APHA), excellent statements and recommendations are made (for example, the APHA has made strong recommendations for the right to home birth and the need for midwifery), but then everyone goes back home with no follow-up. It is easier to be brave far from home. If the APHA had its own monitoring system to determine whether its members were complying with a key maternity care recommendation, maybe local public health officials would begin to find the courage to do the right thing.

In addition to monitoring hospitals, public health agencies need to monitor individual practitioners. Every state has a process in place to investigate and punish practitioners if a complaint is made and the person is “found guilty,” but, as I discussed in
chapter 2
, tribal loyalties prevent doctors from reporting doctors, except under extreme conditions, so these state medical
quality assurance systems are weak at best. As suggested in
chapter 8
, establishing a national health care system would go a long way to solving this. If monitoring and regulation start at the federal level—far from the scene of the accident—tribal loyalty is less of an issue.

Since it's clear that government agencies are not doing the job, consumer groups have come in and tried to monitor individual practitioners. For example, one situation of concern to consumer groups is the fact that a physician can lose his license because of bad practices and simply move to a new state and open a new office. Naturally, people in the new practice area might like to know this about the new doc in town, but states do not make the names of doctors who have been disciplined by their medical boards available to the public. To correct this situation, the Health Research Group in Washington, D.C., publishes a book that lists the name of any doctor who has been disciplined by a medical board in any state.
²⁰
Anyone can order this book and look up a doctor to see if he or she has been disciplined in the past. This is an important step in the right direction.

Hospitals are required to keep reports of “adverse events,” which usually are reported to the state. That means that state health departments are a mother lode of information on medical practices. A group called the Center for Medical Consumers in New York is one of the first groups I know of to mine this lode.
²¹
They've collected data showing the volume of surgery performed by individual physicians in New York State, listed by the physician's name, as well as the death rate from coronary bypass surgery for each doctor listed by name. This is a good start.