Tuesday, June 13, 2006

Control

What I find fascinating about the various RCM proposals, and the reason why I have devoted so much space to them, is that they show how organized midwifery has veered off from "empowering" women to CONTROLLING birth. What makes the epidural proposal especially remarkable is that it represents a further shift from controlling birth to controlling WOMEN. That's why it is inexcusable.

It's one thing to have a campaign for "normal" birth with cartoon characters and childish fonts, with all that that implies about what the RCM thinks of themselves (a lot) and what they think of women (very little). However, the epidural campaign is a tacit acknowledgement that the RCM has failed to control birth by "educating" women. Now they are trying to convince the government to FORCE women to comply with the RCM definition of what labor should be.

This has very important implications for midwifery. If women believe that midwives feel themselves to be inherently superior and look down on anyone who disagrees, they are not going to think very kindly of midwives. If women believe that midwives have no interest in respecting patient choices and are willing to do whatever it takes to impose THEIR choices, they are not going to think very kindly of midwives. I suspect that this has a lot to do with why most American women would never even consider a DEM. They feel that DEMs do not listen to or respect the average woman.

It is certainly true that doctors can be equally arrogant. However, women need doctors, since there are always complications that can and do occur. That has allowed doctors to get away with arrogant behavior that should have stopped long ago. However, no one needs a DEM.

See original comments here.

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44 Old Comments:

What the heck are you talking about? The RCM didn't officially endorse that. It was a matter brought up by a committee at their annual conference. As far as I can tell, it was voted down IF IT WAS EVEN SERIOUSLY CONSIDERED. Then you found two or three articles displeased with an idea that wasn't even endorsed by the group as a whole.

a) This has little to do with home birth because most midwives in the UK attend hospital births,

b) you have completely mischaracterized how much the idea was, and

c) you have completely mischaracterized the reaction (2 or 3 opinion pieces is hardly a strong reaction in a country as large as the UK)

This is no surprise since you insist on continuing to mischaracterize the stats in the home birth studies that do, indeed, show planned home birth for healthy women is as safe at home as in hospital. It seems that mischaracterization is a favorite of yours. Or is it that you are seriously overreaching for something to gripe about?

You cannot ethically transmit your anger of what you mispercieve at the whole profession, worldwide. Your logic is beyond sanity.

I believe epidurals without clear medical indication are an extra. Does the UK pay for women to have nose jobs (not reconstructive but just for the helluvit)? Does the UK pay for balding men to have hair replacement surgery?

And spare me the if I'm having surgery or dental work I need pain relief. This is childbirth. There are hormonal cycles at work that are altered for the worse, so any decision for pain relief should be only as a last resort. Of course, there's nothing done to help women not need it in our country (U.S.).

Is the epdural medically necessary? I'm not saying it shouldn't be available, but in a system of socialized medicine does it make sense to make it readily available?

Or, here in the U.S. with private payer system ala "insurance" should my insurance rates go up because some women want an elective procedure that is technically not medically necessary?

The sad thing is that the epdirual "seems" necessary to most women because there isn't proper support for labor. Even in the UK, where midwives are the most common provider, generally you're dealing with shift work instead of one-on-one care throughout the entire labor. That lack of continuous support can (and does) increase the mom's perception of pain.

The fact of the matter is that the RCM has done nothing wrong to suggest that an elective procedure might be considered as such.

Oh, and they are right about the increased risks associated with epidurals. Imagine that.

By Anonymous Anonymous, at 5:59 PM  

Dr. Amy: how many of your patients deliver without any pitocin, without having amniotomy and without pain relief? How much time do you spend with your patients during labor? What is your episiotomy rate? What is your c-section rate?

Inquiring minds wanna know!

By Anonymous Anonymous, at 6:04 PM  

You're making sweeping accusations toward American DEMS based on the British version of CNMs. It just doesn't "fit". The more analogous british midwife group for American DEMs is here
http://www.radmid.demon.co.uk/

Why don't you take the time to learn about a situation before you go prematurely spouting off about it?

By Anonymous Anonymous, at 6:12 PM  

Anonymous 5:59,

I'd say you proved my point for me.

"This is childbirth. There are hormonal cycles at work that are altered for the worse, so any decision for pain relief should be only as a last resort."

According to whom? You? The majority of doctors, scientists, and most especially WOMEN don't agree with you.

Women are entitled to make their OWN decisions. They don't exist to confirm your personal biases about birth or anything else.

This is what is so offensive to so many women about homebirth advocates. They make up scientific data to support their own biases. Then they shove it in your face and you are supposed to feel inferior because you don't care about what they think and you aren't swayed by their made up science.

Sorry. More than 99% of American women are not buying what you're selling.

By Blogger Amy Tuteur, MD, at 8:21 PM  

"If women believe that midwives have no interest in respecting patient choices and are willing to do whatever it takes to impose THEIR choices, they are not going to think very kindly of midwives. I suspect that this has a lot to do with why most American women would never even consider a DEM. They feel that DEMs do not listen to or respect the average woman."

I just about spewed my drink out of my nose due to my uncontrollable laughter when I read this. Most American women don't even know DEMs are an option!!! Hopefully that is changing, but at this point in time, the homebirth community is a very minute percentage of the population. My neighbor's L&D nurse daughter said she didn't even know any women still had babies at home.

By Blogger Mama Liberty, at 8:21 PM  

"how many of your patients deliver without any pitocin, without having amniotomy and without pain relief? How much time do you spend with your patients during labor? What is your episiotomy rate? What is your c-section rate?"

Why don't you guess, and then I will tell you if you are right. I've already posted this info in several other places so others already know.

By Blogger Amy Tuteur, MD, at 8:23 PM  

Amy you've now gone from being against homebirth to being against ALL midwives and claiming ALL midwives hate and control women? It's absurd. It's personal opinion and nothing more. The leap of logic from 'promoting normal birth' (which you might need to be told has to do with a lot more than pain relief) to 'controlling women' is senseless. I knew you were opinionated, and biased, but this degree of angry extremism is really startling. Almost funny in it's absurdity.

By Anonymous maribeth, CNM, at 9:08 PM  

Amy, do tell us -- what to you is "normal birth"?

By Anonymous maribeth, CNM, at 9:18 PM  

Maribeth:

"what to you is "normal birth"?"

A birth that gives a healthy baby to a healthy mother.

Obsessing about "normal", or even trying to define it is pointless.

By Blogger Amy Tuteur, MD, at 9:30 PM  

Oh, now that is hysterical. But then, how can you criticize the RCM for a program promoting births which give healthy babies to healthy moms?

Give just a TRY, Amy, at being more specific about normal birth.

By Anonymous maribeth, CNM, at 9:59 PM  

Don't confuse US midwives and UK ones. Most US consumers have no knowledge or concern for UK midwives.

By Anonymous Anonymous, at 10:22 PM  

"This is what is so offensive to so many women about homebirth advocates. They make up scientific data to support their own biases. Then they shove it in your face and you are supposed to feel inferior because you don't care about what they think and you aren't swayed by their made up science."

Is this why you are on such a vendetta Amy? Did someone try to shove something in your face, and you felt inferior?

By Anonymous Anonymous, at 10:27 PM  

Maribeth:

"But then, how can you criticize the RCM for a program promoting births which give healthy babies to healthy moms?"

The difference is that I don't care how we get there.

Trying to define "normal" birth is absurd. Let's face it, Maribeth, the first time you put on the blood pressure cuff at the first prenatal visit, the pregnancy is no longer "natural". Similarly, most things you do during prenatal care and labor and delivery are not "natural" either.

Midwives have expanded the definition of "normal" labor to include frequent blood pressure checks, and frequently monitoring the fetal heart rate. You carry instruments, suture, drugs and oxygen and you use them all the time.

Last time I checked BP cuffs were not growing on trees and neither were sutures, or tanks of oxygen.

The midwife definition of "normal" is arbitrary. It includes the things that midwives want to do or think must be done, and excludes other things for purely arbitrary reasons.

There is no medical reason to exclude pain relief. It is a purely personal philosophical belief, and frankly, it has no place in any definition of "normal".

By Blogger Amy Tuteur, MD, at 10:49 PM  

So you seem to think that midwifery should be an all or nothing thing, right? Either unassisted, without prenatal care, or no midwives whatsoever. That's what your last post says, basically.

Amy, you definitions of normal and natural make sense to only you. It's time to step back and take a break and re-gather your thoughts, because you're getting a little silly now.

No wonder sailorman took off....

By Anonymous maribeth, CNM, at 11:08 PM  

The midwife definition of "normal" is arbitrary. It includes the things that midwives want to do or think must be done, and excludes other things for purely arbitrary reasons.


Which begs the question, where do you get your midwifery definition of "normal" from?

By Anonymous maribeth, CNM, at 11:33 PM  

Maribeth:

"So you seem to think that midwifery should be an all or nothing thing, right?"

No, I didn't say there was anything wrong with checking BP or using suture. What I said was that midwives don't do "normal" birth (as in nature), either. They have just arbitrarily redefined "normal" to suit their own biases.

They appear to be obsessed with pain and the perineum. Just about anything besides operative delivery falls into the midwives' "normal", EXCEPT pain relief and episiotomy.

The silliest thing of all is waterbirth. Give birth to a baby in a kiddie wading pool (as if that routinely happened in nature) and you've had a "normal" birth, but get pain relief and you have committed an abomination against nature.

Don't get me wrong, you can give birth in a kiddie wading pool if you want. Just don't kid yourself that you had a "normal" birth and then loftily prattle on about vital hormone cascades that are surely interrupted by an epidural.

With the exception of the unassisted homebirth crowd, NO ONE here has had a truly "normal" birth.

By Blogger Amy Tuteur, MD, at 7:00 AM  

The problem, Amy, is that you are using a very, very confused definition of "normal". Who EVER argued that was what normal meant? Thank you AGAIN for proving the point that OBs don't understand normal.

By Anonymous maribeth, CNM, at 9:05 AM  

Article about ecstatic birth

Are you saying you don't care about this, or you don't know?

FWIW -- I agree mother nature isn't always perfect. However, that doesn't change the fact that there are advanatages for mom and babe to having an undisturbed birth (in which the mom doesn't have to engage her neocortex too much).

And my point was, not to judge women who choose differently, but point out that epi's are usually ELECTIVE. Why should I pay for someone else's ELECTIVE procedure via insurance costs?

By Anonymous Anonymous, at 9:20 AM  

>>>The sad thing is that the epdirual "seems" necessary to most women because there isn't proper support for labor. Even in the UK, where midwives are the most common provider, generally you're dealing with shift work instead of one-on-one care throughout the entire labor. That lack of continuous support can (and does) increase the mom's perception of pain.<<<

What do you do to make sure you patients at least have a decent shot at avoiding pharma pain relief if that's their goal? Or do you tell women desiring no drugs that they need to find another provider?

By Anonymous Anonymous, at 9:23 AM  

"Are you saying you don't care about this, or you don't know?"

I am saying that there is NO scientific evidence that pain in labor is beneficial in any way.

This is just another one of those things that natural childbirth advocates tell themselves in order to feel superior to other women.

I have said it before: Natural childbirth is not an achievement. It is the default mode. Anyone can do it and 99% of the women who have ever lived have already done it. Up until the advent of modern obstetrics, natural childbirth was accompanied by appallingly high rates of neonatal and maternal death.

Natural childbirth is NOT beneficial to the baby. It is all about the mother, her needs, desires and philosophy.

By Blogger Amy Tuteur, MD, at 9:36 AM  

"What do you do to make sure you patients at least have a decent shot at avoiding pharma pain relief if that's their goal?"

The first thing I tell them is that they should wait until they feel the pain before they decide what they want to do about it.

I personally never offered anybody pain relief. They have to ask me for it. I also tell them that, except in very unusual circumstances, I will insist that they wait until they are in active labor before they can get an epidural.

By Blogger Amy Tuteur, MD, at 9:40 AM  

wait -- so Amy do you totally disagree with the recent trend to call all vaginal births "natural", in this case "natural" being a euphemism for "vaginal"?

I mean unmedicated is a lot closer to "natural" than pit&2epis. And home is much more likely to be a lot closer to "natural" than hospital.

Do you think if a woman takes herbs she's still natural? Does a little valerian root tea to relax and RRL tonic for the last few months to gradually relax the opposing uterine muscle bands then make her bith unnatural?

Do you think women" in the wild" didn't know of certain plants that helped them? Apes eat certain plants (herbs) more during pregnancy and around birth. Are they no longer having a "natural" experience?

And so what if someone else values living as natural a life as possible? Are different people not entitled to different value systems?

Your arbitrary change of terms without warning is funny.

By Anonymous Anonymous, at 9:55 AM  

>>>I personally never offered anybody pain relief. They have to ask me for it. I also tell them that, except in very unusual circumstances, I will insist that they wait until they are in active labor before they can get an epidural.

9:40 AM<<

You didn't answer the question, which was: What do you do to make sure you patients at least have a decent shot at avoiding pharma pain relief if that's their goal?

Let's ask it more clearly: what actual practical steps do you take to help women cope with pain if they don't want pharmaceutical drugs? What do you do?

By Anonymous Anonymous, at 10:06 AM  

"Do you think if a woman takes herbs she's still natural?"

No, I think she is contributing to the growth of a $50 billion and growing industry of scam artists.

Beyond that, though, is the fundamental point. NO ONE, except the unassisted folks, are having "natural" births. The RCM and other advocates of "natural" birth have just arbitrarily redefined natural to include what they like, and exclude what they don't like. When they say "natural" what they mean is "approved by us".

Waterbirth is a perfect example. There is nothing "natural" about it unless you are a whale or a dolphin.

By Blogger Amy Tuteur, MD, at 10:08 AM  

"what actual practical steps do you take to help women cope with pain if they don't want pharmaceutical drugs? What do you do?"

Absolutely nothing. I treat them no differently than my other patients who do want pain relief.

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

Actually, water has been used throughout history during labour... It is a natural way to help ease natural labour pains just the same as animals in certain jungles seek out natural mud holes so than can consume a natural product that help prevent poisoning caused by naturally occuring poisonous leaves in their diet.

Just because you don't believe birthing in water is natural doesn't mean it isn't.

I remember reading something that said alot of women in labour feel an urge to get into water.

By Anonymous Anonymous, at 10:48 AM  

"maribeth, CNM said...
So you seem to think that midwifery should be an all or nothing thing, right? Either unassisted, without prenatal care, or no midwives whatsoever. That's what your last post says, basically."


No, you're misreading this again. The point is simple:

Midwives use "natural" childbirth as a synonym for "good" childbirth. This is an improper attempt to coopt the term "natural".

What "natural" MEANS is "occurring in nature". Personally, I do not think that merely because something is natural that it is good. However, it is certainly true that the practice of most midwives is not "natural" as they base their decisions on medicine, and use modern equipment.

So when you say that you promote "natural" childbirth and that Amy does not, it seems as though you are trying to replace the definition of "natural" with "fewer potential interventions than you."

And you know what? If you said THAT, you'd be telling the truth, and nobody would complain about it.\

But as it is, it's ludicrous. If a hospital birth isn't "natural" because they do something not found in nature, a midwife birth sure as hell isn't "natural" if she takes a BP and makes decisions based on that, or if she brings a big tub to the birth (you want to call a New England water birth in January "natural"?) or if she uses pit, or resus, or if she doesn't cut the cord with her teeth.

Amy, your definitions of normal and natural make sense to only you.

Dictionary, grasshopper, use a dictionary. Like this:
http://www.m-w.com/dictionary/natural

See if you can find a definition of "natural" which INCLUDES everything a midwife does, and EXCLUDES everything an OB does. Good luck.

Your sense of the word is wrong. Not "odd" but simply wrong. Words have meanings and you aren't using this word correctly.

No wonder sailorman took off....
I left because my wife had a baby, not because I disagree with Amy. Nice try.

And BTW: If you don't KNOW why I left, it was pretty damn rude of you to give an "explanation" for my absence which is 100% at odds with almost everything I posted. Enough of the misrepresentation already.

By Blogger sailorman, at 11:39 AM  

"Actually, water has been used throughout history during labour... It is a natural way to help ease natural labour pains just the same as animals in certain jungles seek out natural mud holes so than can consume a natural product that help prevent poisoning caused by naturally occuring poisonous leaves in their diet"

That's baloney!

Waterbirth is about as natural as an epidural, maybe less since it puts the baby at risk of aspiration pneumonia and drowning.

By Blogger Amy Tuteur, MD, at 12:22 PM  

"I am saying that there is NO scientific evidence that pain in labor is beneficial in any way."

Amy, there is also NO scientific evidence that labor is always painful. Just because a bunch of people in the hosptial experience pain, doesn't provide scientific evidence that it has to be so.

The point you are missing, is that routine interventions in a hospital create pain through the stimulating of the neo-cortex.

To get scientific proof of this, one would have to do brain scans on women in labor..... and to do that without stimulating the neo-cortex, the scanning device would have to be very small and portable indeed.

Some of these things you can't argue on the basis of scientific evidence. We don't have any studies of 99% of the things that happen during birth. It's not ethical to do many of the studies needed.

Neither side can prove anything conclusively based exclusively on scientific studies.

By Anonymous Anonymous, at 2:00 PM  

"Waterbirth is a perfect example. There is nothing "natural" about it unless you are a whale or a dolphin. "

where is your scientific evidence for this Amy? How do you KNOW that women do not use water for labor 'in the wild'?

By Anonymous Anonymous, at 2:04 PM  

"Waterbirth is about as natural as an epidural, maybe less since it puts the baby at risk of aspiration pneumonia and drowning."

surely SURELY you have some scientific evidence for this statement????

Anon 2:00 & 2:04

By Anonymous Anonymous, at 2:09 PM  

Yes, please hold yourself to the same standards ... please provide SCIENTIFIC EVIDENCE of these assertions, amy.

• "Natural childbirth is NOT beneficial to the baby. It is all about the mother, her needs, desires and philosophy."

• "Waterbirth is about as natural as an epidural, maybe less since it puts the baby at risk of aspiration pneumonia and drowning."

By Anonymous Anonymous, at 2:33 PM  

Anonymous said...
"Waterbirth is a perfect example. There is nothing "natural" about it unless you are a whale or a dolphin. "
where is your scientific evidence for this Amy? How do you KNOW that women do not use water for labor 'in the wild'?


Birth. Labor. Two different things. Get it straight.


Anonymous said...
"Waterbirth is about as natural as an epidural, maybe less since it puts the baby at risk of aspiration pneumonia and drowning."
surely SURELY you have some scientific evidence for this statement????


Do you really need to do a study to demonstrate that putting a mammal underwater increases the RISK of inhaling water? I think you're trolling.

In any case, not all water births will go badly, but they obviously have certain risks which are not associated with non-water births.

By Blogger sailorman, at 2:33 PM  

ever heard of the newborn 'dive reflex'?

By Anonymous Anonymous, at 3:06 PM  

"The point you are missing, is that routine interventions in a hospital create pain through the stimulating of the neo-cortex."

There's no scientific evidence for that either, as you acknowledge. It's just another made-up factoid.

Modern obstetrics is barely 100 years old. Human birth has been described as excruciating and agonizing since people learned to write. It's in the Bible, as everyone knows.

The pain of labor is not news nor has it changed with the advent of modern obstetrics.

By Blogger Amy Tuteur, MD, at 3:08 PM  

"Yes, please hold yourself to the same standards ... please provide SCIENTIFIC EVIDENCE of these assertions,"

As Sailorman pointed out a long time ago, you don't have to provide evidence for something that doesn't happen. It's like saying "prove to me that the moon is not made of green cheese". If you think it's made of green cheese, YOU have to prove it.

I'm telling you that waterbirth is not a normal part of human birth. It was made up by women in the 20th century. It is up to YOU to find the extensive anthropological data that would be needed to show that it happened on a regular basis in primitive cultures.

You are not going to be able to provide any proof because there isn't any. Put the words anthropology and waterbirth in Google Scholar and all you get is articles by midwives, none by anthropologists.

By Blogger Amy Tuteur, MD, at 3:20 PM  

NO ONE, except the unassisted folks, are having "natural" births.

I think you're wrong about that. Those women are doing just about everything a midwife will do for them at home from herbs to homeopathy and pharmaceuticals. They might be doing it without an attendant but spend any time on the unassisted birth message boards and you'll find they are not doing "natural" birth as you've defined it.

By Anonymous clever ID, at 8:30 PM  

>>>No wonder sailorman took off....
I left because my wife had a baby, not because I disagree with Amy. Nice try.<<<

Congratulations! 11 lber eh? That's like a one month old! Did you have a home birth? LOL

P.S. Yes, I agree that was stupid to try to connect your disappearance with disagreement with Amy.

By Anonymous Anonymous, at 12:07 AM  

Congratulations! 11 lber eh? That's like a one month old! Did you have a home birth? LOL

Midwife, in a hospital, no epidural...

All is well, baby is great. Good thing. Nobody expected a babe of that size (well off the charts for weight and head size) and to be honest if my wife wasn't in such good shape it'd probably have been a section.

By Blogger sailorman, at 9:52 AM  

Sailorman,

An 11 lb baby, vaginally, in hospital, with no epidural.

Your wife Rocks!

Was THAT an achievement? You bet your sweet arse it was! Right Amy?

By Anonymous Anonymous, at 11:32 AM  

Personally know women who have had 12 lbers at home.... That is an achievement.

By Anonymous Anonymous, at 2:23 PM  

I consider it more of an achievement to accomplish a vaginal birth of a big baby at the hospital than at home. But that's just my opinion.

Anon 11:32

Still waiting to hear if Amy agrees that it was an achievemnt.

By Anonymous Anonymous, at 2:45 PM  

Still waiting to hear if Amy agrees that it was an achievemnt.

Why? She has already declared birth to be no more impressive than her morning crap after coffee. Both are normal body functions. Big whoop.

No offense intended to Mrs. Sailorman of course. I think it's damned impressive, having been there and done that as well ('tho at home).

By Anonymous clever ID, at 4:03 PM  

"Still waiting to hear if Amy agrees that it was an achievement."

Well, I wouldn't want to disappoint you.

Obviously I don't think it is an achievement, I think it is good luck (sorry Mrs. Sailorman).

I have a hunch, and perhaps Sailorman will confirm it or disprove it. My hunch is that it was the midwife who told Mrs. Sailorman that she was able to push out a big baby because she was in such good shape.

By Blogger Amy Tuteur, MD, at 7:14 PM