Monday, June 12, 2006

Appalling

In an effort to discourage epidurals, The Royal College of Midwives now proposes that women should pay for them out of pocket!

The RCM education and research committee's motion states that epidurals should be "free to women who have a definite need of it" but says a fee should be "levied for all other women who desire an epidural".

In other words, you can have a free epidural if you need a C-section, but if you want it for pain relief, you have to pay for it. The end result of this, of course, is that rich women would get pain relief and poor women would not.

According to RCM Deputy Secretary Louise Silverton:
Women should be experiencing birth, and although birth is a painful experience, administering an epidural is not always the best thing for the mother.
Really? Isn't the mother supposed to make the choice about what is best for her? Are midwives supposed to support the mother's choice, or do they only support choices they agree with? Who, on earth are they to say what another woman should or should not "experience"?

Sue MacDonald, chairwoman of the RCM's education and research committee said:

Epidurals have become a kind of norm for a lot of women. Sometimes women think 'I just want to get rid of the pain, how fantastic'.
Is that supposed to be a bad thing? How, exactly, is that different than religious fundamentalists who claim that epidurals are wrong because the Bible tells us that women are "supposed" to bring forth their children in pain?

Midwives in Great Britain have a lot more power than they have in the US. Instead of using that power to support all women in their choices for birth, whatever those choices might be, they are using their status to pressure women into adopting their choices. How is this different from what they accuse doctors of doing? And making the poor pay for their epidurals, that it nothing short of appalling.

See original comments here.

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31 Old Comments:

This is what comes with socialized medicine.

By Blogger Mama Liberty, at 10:27 AM  

Mama Liberty:

"This is what comes with socialized medicine."

This has nothing to do with socialized medicine. The NHS did not implement this. It was the midwives who requested it, but it has not happened despite their request.

By Blogger Amy Tuteur, MD, at 10:41 AM  

This has EVERYTHING to do with socialized medicine. Choice and individual decision making are the first casualties in a socialized system. In a socialized system, the groups with power are the decision makers and the individuals have to live with it. The NHS may very well implement it because it will save the system money.

By Blogger Mama Liberty, at 11:16 AM  

Ignorant Canadian here.... but don't you have to pay out of pocket for an epidural in the US too? What is the difference? Just that the midwives are advocating it?
Living in a socialized country, thankfully with fully funded, regulated midwifery (for most provinces).... Who despite Dr. Amys assertation are fully capable of resussitation and intubation at a homebirth... required to have your licence!

By Anonymous Anonymous, at 11:27 AM  

I'm not in agreement, however epidurals not associated with surgical birth are elective. The state of California got into trouble a while back for removing epidurals from covered Medicaid services and anesthesiologists were not providing them unless payment was rendered at the time of service.

By Anonymous clever ID, at 12:16 PM  

Amy asked, "Isn't the mother supposed to make the choice about what is best for her?"

Exactly! Is it simply entertainment to bicker that home birth isn't safe enough and accuse DEMs of being undereducated.

Amy asks, "Are midwives [insert OB & ACOG] supposed to support the mother's choice, or do they only support choices they agree with?
Who, on earth are they to say what another woman should or should not "experience?"


These are exactly the questions to ask of those unsupportive of women's choice to give birth with who she chooses, in her own home (or unattended), and without fear of the her own or attendant's criminal prosecution!
That's apalling!

"How is this different from what they accuse doctors of doing?

Amusing question aside from the fact that most doctors seethe at the mere mention of midwives and home birth.

Two key concepts the RCM will unlikely dismiss as too time consuming or trivial to offer:

- solid education rearding epidurals

- spport to accomplish birth without being numb

Seriously,
Supportive of women's choices.
Not supportive of socialized medical system.

By Anonymous seriously, at 12:22 PM  

I'm 100% for maternal choice.


I would like to see a large scale public education campaign about the effects of epidural, including the loss of the beneficial hormonal cascade when the endorphins don't kick in, and how it's more traumatic for both mother and baby if you can't deliver with your weight on your own FEET (some of it is simple anatomy -- just a few quick examples: where does the mom's tailbone move to and how can her pelvis open fully if she's on your butt or back?)

How about a study from LC's about how differently epidural babies behave when trying to breastfeed and the broader implications? Didn't Brazelton publish something about the behavioral differences of epdirual babies ... measured for a full month?

Has anyone heard about the x-rays done in Europe of women during spontaneous delivery (yes, I know that's totally unethical but they're already produced so let's try to learn something form it). What I've heard through the grapevine is that the standard medical belief of what happens to the woman's anatomy is proved wrong by these x-rays, and midwives are ... ahem ... right. (I'm not a midwife or doctor, so I'm sorry I don't know the technical details.)

Of course, these things are not commonly accepted in the medical community, so not sure if that (public education) will ever happen on a large scale.

Plus -- spontaneous birth produces fewer billable procedures! We all know how much power there is in money. Look at the breastfeeding campaign that has fizzled away to nothing even though there's incontrovertable proof and it's a nobrainer that breastfeeding is vastly superior to formula/bottlefeeding.

By Anonymous Anonymous, at 1:08 PM  

I think it does have to do with socialized medicine- the cost has to come from somewhere-- and they offer another type of pain relief -gas right? it may just very well be that having the extra coverage for anesthesia is putting a pinch on their units.... remember when PEDs went to no free circs?

By Anonymous Anonymous, at 1:21 PM  

No, no, no. You have misunderstood. The National Health Service in Britain has no intention of making people pay for epidurals. The Royal College of Midwives want women to pay for epidurals.

What happens to a woman's choice when it doesn't correspond to a midwife's choice?

By Blogger Amy Tuteur, MD, at 2:45 PM  

Seriously:

"These are exactly the questions to ask of those unsupportive of women's choice to give birth with who she chooses, in her own home (or unattended), and without fear of the her own or attendant's criminal prosecution!"

Then if you believe that, you MUST also believe that midwives in the UK are guilty of the same thing.

It suggests that midwives (at least in the UK) are not respectful of women's choices; they are only respectful of the choices that they agree with. What happened to the much vaunted "taking care of the whole patient"? It sounds to me like the midwives are putting themselves ahead of their own patients.

Don't even bother replying that it's okay for midwives to do it because doctors do it. Homebirth advocates are constantly harping about how midwives are different than doctors. Doesn't sound like it.

By Blogger Amy Tuteur, MD, at 2:50 PM  

"I would like to see a large scale public education campaign about the effects of epidural, including the loss of the beneficial hormonal cascade when the endorphins don't kick in, and how it's more traumatic for both mother and baby if you can't deliver with your weight on your own FEET (some of it is simple anatomy"

I would like to see some SCIENTIFIC EVIDENCE for any of what you just said. I doubt you can find any.

By Blogger Amy Tuteur, MD, at 2:52 PM  

Amy, are you familiar with straw man argumentation?

One way to do it is to describe a bad representative of an issue, one that is easy to argue against (usually an extreme example), pretend that that person/group represents the entire issue, and then, while arguing against the person/group, say that therefore the entire position has been successfully dismantled. It's a logical fallacy.

Now, I'm not saying that what the RCM has proposed is a good idea. I'm not addressing that at all, because I'm more concerned that what you're trying to say is "look what midwives are doing!" as if all midwives are going to rally behind the RCM because of some shared belief about pain medication.

That's a fallacy.

What the RCM is doing is worthy of discussion, but you can't have a real discussion if you're going to put all midwives on trial for this proposal. Drop the straw man and maybe we can talk reasonably.

By Anonymous wasting my breath, at 3:22 PM  

Wasting my breath:

"Amy, are you familiar with straw man argumentation?"

Indeed I am. However, the RCM is hardly a straw man (or woman). The RCM is not just any midwifery organization. It is the trade union for midwives in the 4 countries of the UK. Over 95% of midwives in the UK belong to the RCM, so it represent all of midwifery in a very populous part of the world. They are not extreme; they are the mainstream.

Midwives are a far more important part of healthcare in the UK than in the US and midwives have comensurately more power. I think it is instructive (and appalling) to see what they are doing with it.

By Blogger Amy Tuteur, MD, at 3:37 PM  

Oh yes, here is some proof of the ABSOLUTE SAFETY OF EPIDURALS ...
going to delete this one DR. Amy?

http://www.msnbc.msn.com/id/9818616/

So routine, so simple, so much a womans right.... I agree with one, and that would be the latter.

By Anonymous Anonymous, at 4:21 PM  

>>>>Amy Tuteur, MD (first quoting me) said...
"I would like to see a large scale public education campaign about the effects of epidural, including the loss of the beneficial hormonal cascade when the endorphins don't kick in, and how it's more traumatic for both mother and baby if you can't deliver with your weight on your own FEET (some of it is simple anatomy"

I would like to see some SCIENTIFIC EVIDENCE for any of what you just said. I doubt you can find any.

2:52 PM<<<<

Pithy but tangental. Focusing on a weakness in what I personally desire AS A TANGENT totally ignores the point I made which is: I agree with maternal choice in childbirth options. No, I do not agree with the RCM. I don't know enough about the UK to really comment on them as a group.

Now, to address your statement. There are no double blind studies I know of about position facilitating birth, although there is some evidence in the gaskin maneuver (hands and knees for most shoulder dystocia supposed to be very effective and less traumatic to mother and baby than normal medical management). I wasn't suggesting the public education campaign was feasible (for various reasons). I wasn't even suggesting I had proof of that. And, although this is sheer reversal -- is there proof that being on the butt or back isn't worse?

I submit that basic anatomy and the laws of physics lead us to a very strong and glaringly obvious hypothesis that a woman being on her feet instead of butt will facilitate spontaneous birth better than being perched up on a platform with the weight of her body resting on her pelvis. Who's going to fund that study?

Do you doubt this hypothesis? Can you explain why you would doubt this hypothesis? Do you have a logical reason to doubt it?

Spare me the rhetoric about scientific method. Hypotheses are based on beliefs and assumptions and hunches. Some are more obviously correct from the start than others. I wasn't claiming that was proven. I'd still like to see a public education campaign about it.

You seem to be on a campaign to find fault with home birth supporters to bolster your argument or something.

By Anonymous Anonymous, at 4:24 PM  

None of that is scientific evidence; it is your personal opinion.

By Blogger Amy Tuteur, MD, at 4:27 PM  

I believe midwives's jobs are being cut across Great Britian. Perhaps that has some influence on them trying to lower costs to maintain their jobs.

By Anonymous Anonymous, at 4:28 PM  

>>Amy Tuteur, MD said...

None of that is scientific evidence; it is your personal opinion.

4:27 PM <<

Duh. I did not assert there was scientific evidence. I'd still like to see such a campaign. My saying I have a desire to see it, is not claiming it is feasible. You are mixing eggs with apples. Maybe I was. But thanks for asking for clarification (not).

Care to address anything else in my first post? Or acknowledge that I agree with your point that midwives should not force or deny procedures for women? Or answer my questions about whether or not you believe helping women off their arses (or not forcing them onto their arses) is beneficial and if not, why not?

By Anonymous Anonymous, at 4:34 PM  

Midwives are a far more important part of healthcare in the UK than in the US and midwives have comensurately more power. I think it is instructive (and appalling) to see what they are doing with it.

I daresay you're doing it again.

I don't know what the motives or political ties of the RCM are, but I suspect this isn't just an ordinary group of midwives who unanamously decided to adopt this position.

Whether it's an influential group or not, has no bearing on the weakness of your argument. Your attempt to judge ALL midwives according to what the RCM is doing is as baseless as someone accusing all OBs of being in collusion with ACOG. It can't be done, not reasonably, not without overwhelming bias.

You're trying to say that midwives who get power, make unwise decisions with it, because they don't deserve power, and this RCM proposal is evidence of it. If this is an incorrect interpretation, you really need to change your original post to reflect what you are really trying to say.

By Anonymous wasting my breath, at 4:36 PM  

No, I am saying that the RCM, which is the union of UK midwives (unlike ACOG which has voluntary membership), clearly does not support women's choices unless they are midwife approved choices.

I see a real problem with an organization that is actively lobbying its government to deprive women of pain relief in labor. This is entirely about midwives seeking validation for themselves and their choices. It has nothing to do with the interests of the patient.

The RCM represents approximately 25,000 midwives. It is not a fringe group. It is the mainstream group of midwives for 4 entire countries.

I am not sure what point you are trying to make. Are you suggesting that the RCM is not representative of midwifery in the UK?

Why not give up and acknowledge the obvious: the midwives in the UK have committed a reprehensible act and they should be ashamed of themselves.

Hopefully midwives in the US would not do the same if they got a similar opportunity.

By Blogger Amy Tuteur, MD, at 4:51 PM  

Amy said, "Don't even bother replying that it's okay for midwives to do it because doctors do it."

I did not say that.

Just pointing out some of your inflammatory statements, they're so twilight zone.

In fact, I said "I'm supportive of women's choices". Meaning, if women want epidurals they should have them.

Should the government be paying the bills? I recognize the issue is UK's RCM, so it goes hand in hand there.

This is about who's paying the bill, not whether or not women have a 'right' to have an epidural.

That is different debate entirely.

By Anonymous seriously, at 5:45 PM  

we could as easily have the debate on if insurance companies should cover routine circ, or elective Cs.

By Anonymous Anonymous, at 5:59 PM  

"we could as easily have the debate on if insurance companies should cover routine circ, or elective Cs."

No, I would disagree.

First, it already is a covered service. So the RCM is petitioning the government to stop covering it, reasoning that in this way midwives can prevent most women (i.e. poor women) from getting epidurals.

It would be analagous to saying that insurance will pay for your hospital birth, but if you insist on natural childbirth, you will need to pay $1000 out of pocket. Natural childbirth advocates are already angry that hospitals do not support medication free birth, imagine if you had to pay a $1000 premium in addition.

By Blogger Amy Tuteur, MD, at 6:05 PM  

Amy said, "Natural childbirth advocates are already angry that hospitals do not support medication free birth, imagine if you had to pay a $1000 premium in addition."

You may have hit on something here. I imagine that would be considered a good deal by many.

Just please leave me to give birth without the harmful fasting and unnecessary intervention and we'll gladly pay extra. Sort of like going organic. The extra cost of labor is worth the end product.

By Blogger babymidwyfe, at 6:13 PM  

The insurance companies would probably go ahead and pay an extra $1000 since they seem to prefer paying more than they need to pay. Ever try to have them understand a 3-5k reimbursment is a lot less than a 7-12k bill? If it's more, it must be better. LOL.

By Anonymous seriously, at 6:28 PM  

Really busy now so responding briefly. As most of our clients are self-pay, and local hospitals (and prenatal providers) have a self-pay fixed inclusive rate that INCLUDES unnecessary, medical extras that most of our ladies don't use) -- I think the reverse of the 'charge for epidural' thing is happening everyday without any objection whatsoever. Likewise, there are real 'global' savings in decreasing epidurals. Public health, anyone? I don't agree with the RCM on this as it is presented, but I understand the motivations and end goal behind it.

By Anonymous maribeth, CNM, at 12:06 AM  

Amy:
I am not sure what point you are trying to make.

I'm sorry I was unclear. I thought I was fairly frank about my point. I'll make one more attempt:

Obviously not ALL midwives support this. It is WHOLLY incorrect to say that this viewpoint is representative of ALL midwives.

Are you suggesting that the RCM is not representative of midwifery in the UK?

Did I ever say that? I was never talking about what the RCM represents to the UK; I'm addressing what the RCM represents about midwives in general, in the US and worldwide. I don't think they are representatives of midwifery.

Why not give up and acknowledge the obvious: the midwives in the UK have committed a reprehensible act and they should be ashamed of themselves.

Why not acknowledge my point?? Why try to shift the argument? I made a valid point, and you refuse to concede any bit of it. I thought it was a straightforward observation. That you won't admit this, even though it is clear, makes you look foolish.

Hopefully midwives in the US would not do the same if they got a similar opportunity

This is the crux of your argument. While we may agree or disagree on what the RCM has proposed (and whether or not it is an official 'proposal' or just a topic of discussion), your disdain of midwives and your belief that they do not deserve the authority to make medical decisions, is skewing your view.

It appears you tried to find the most extreme example you could, just to vilify midwives. I don't know how this is even related to homebirth.

I'm still not talking about whether this is right or wrong. I have said before that I think that topic is worth discussing. But drop the accusation that all midwives support this.

Midwives don't want to empower women, they want sneer at them, belittle them and hurt them, all to preserve the midwives' idea of an appropriate "birth experience".

This is exactly the kind of dialogue I find highly reprehensible. You're obviously angry at midwives, but anger alone doesn't substantiate an argument. You've set up this blog to refute disinformation, but you are just launching baseless attacks at an entire profession.

By Anonymous wasting my breath, at 10:34 AM  

Amy wrote (exerpted) ...
>>>Midwives don't want to empower women, they want sneer at them, belittle them and hurt them, all to preserve the midwives' idea of an appropriate "birth experience".<<<

wasting my breath responded (also exerpted) ...
>>>This is exactly the kind of dialogue I find highly reprehensible. You're obviously angry at midwives, but anger alone doesn't substantiate an argument. You've set up this blog to refute disinformation, but you are just launching baseless attacks at an entire profession.

10:34 AM<<

I think you have hit the nail on the head. Have you seen Amy's post called My first experience with a lay midwife?

I think this is a peronal vendetta.

Amy -- please seek help!

P.S. People aren't "afraid" to post on your message board, just don't want to. Why would I cast my precious stories before you to try to twist with your personal extreme bias and basic misundestanding of science?

By Anonymous Anonymous, at 12:24 PM  

Wasting my breath;

"Obviously not ALL midwives support this. It is WHOLLY incorrect to say that this viewpoint is representative of ALL midwives."

I didn't say it is representative of all midwives. I did point out, though, that this is the midwife trade union for the entire UK. As far as I can tell, it is the largest group of midwives in the English speaking world.

I find it extremely interesting because the RCM claims to practice by the midwifery model and claims to empower women. At a minimum, the RCM is betraying their own ideals.

I also find it extremely interesting that a large group of midwives seems to have no idea that they are not representing birthing women, they are representing their own interests, primarily validation of their personal actions. There was a tremendous outcry in the UK against the RCM proposal, suggesting that the RCM is out of touch with its own clients.

The irony, to me, is that the RCM has behaved exactly like the arrogant physicians they claim superiority over.

By Blogger Amy Tuteur, MD, at 12:30 PM  

"There was a tremendous outcry in the UK against the RCM proposal, suggesting that the RCM is out of touch with its own clients."

That is an opinion. Do you have proof other than a couple opinion columns? There was not a flood of articles or anything, so where's your PROOF????

By Anonymous Anonymous, at 1:04 PM  

Very hard to say - something like this would not go over well in the US because we have a cultural bias toward this type of birth- they are stating their cultural bias...
it has been done with circumcision in the past

how about insurance companies not paying for birth control in this country? or sterilization?

and I think someone else alluded to the non-insured have to pay an arm and a leg for every procedure

and actually we do have insurance companies saying which meds are covered and which procedures a doctor can perform-- and if you want something other than what they will make the biggest profit from then you will pay out of pocket the highest price there is--- and just look what happened with the medicaid RX/deal..... it isn't that we don't have controversy - or that we don't allow people certain things- like heart meds or how about post transplant meds... HIV meds if there weren't special programs to pay for these things what would these folks do?

By Anonymous Anonymous, at 9:51 PM