Thursday, July 29, 2010

Are all cesareans necessary?

In a blog titled "The Myth of The Unnecessary Cesarean" Dr. Nicholoas Fogelson argues that while many cesareans may be preventable, it is impossible to truly call any specific c-section "unnecessary" because we don't know what would have happened had the surgery not been performed. There's some excellent discussion in the comments (and I can't tell you how great it was to see the doctor coming back and responding!), I posted the topic for discussion on BabyCenter's VBAC board, and the discussion has continued on other blogs as well. As you might imagine, many who feel strongly about the cesarean epidemic are taking Dr. Fogelson to task, saying he's missing the point and sometimes suggesting he is no different from any other scalpel-happy OB.

I beg to differ.

Don't get me wrong. I understand the necessity of questioning the reasons behind an unwanted cesarean. I understand needing to look back and find failure in the system that put you in the OR rather than finding failure in your body. I spent literally years trying to pin down how I really felt about my own c-section, and after almost 8 years I still have not been able to finish writing my birth story because by the time I've read what I do have written I'm an emotional wreck and just can't face it. And yet... when I read the responses to Dr. Fogelson's article, what strikes me is the defensiveness, the aggressiveness, the instinct to attack over a single turn of phrase rather than consider that perhaps we are trying to acheive the same goal with different words.

Words are powerful, and the way we talk about birth is important. I've been taken to task for using the word "normal" in my blog title, we talk about how discouraging it can be when we're told we'll be "allowed" to have a "trial" of labor, and I've even seen heated debates about whether or not a cesarean should rightly be called a birth at all. While the perspective offered by this OB may raise our hackles, I think it can be helpful if we sometimes lower our defenses and agree to speak the same language when we're talking about birthing options and outcomes.

Tuesday, July 6, 2010

Mainstreaming Midwifery- are OBs the answer?

I've been reading a little bit lately about the suspension, reinstatement, and subsequent resignation of a popular SoCal OB, Dr. Biter. There's an entire group dedicated to his saga, and I really enjoyed a blog The Navelgazing Midwife wrote about the situation. I don't know enough about the details to address Dr. Biter's situation directly, but it did get me thinking about how we view the hospital experience from a patient perspective vs our expectations of our providers in the same setting. I've seen OBs like Dr. Biter referred to as "a midwife in OB's clothing" and that concept brought me back to something I've been intending to write more about: the mainstreaming of the midwifery model of care.

Here's what I want to know: When women flock to OBs who support birth as a natural physiological process, why are they doing that? I've read that OBs whose practices are similar to the way midwives practice are often incredibly overbooked and women wait hours for their appointments. I've seen and heard members of the birth community rave about Dr. So-and-So who truly supports his patients, has fabulous bedside manner, and should be at the top of everyone's list when they are looking for a provider. I've listened to other moms talk about the kind of care they wish they'd received from their OBs, and even though that care sounds an awful lot like midwifery, most women- even the lowest-risk women- absolutely believe they require an OB's care to have a safe pregnancy.

What would maternity care look like if low-risk women were directed to midwifery care instead of being shoehorned into the only "good" OB practice available? What if those OBs worked with large midwifery groups, where low-risk women received care from midwives, secure in the knowledge that they'd have an incredible OB backing them up if they did become high-risk? What would it take to see true partnership between OBs and midwives in the US- similar to what seems to be the norm in many other countries? I understand that the relationship between obstetrics and midwifery in the US is complex (to say the least), but there clearly are OBs who are willing to buck the system. Could they be the answer to increasing midwifery care for low-risk women? Or is it unrealistic to expect any OB to tell a woman she's low-risk and doesn't need obstetric care for her pregnancy?

I don't have the answers to these questions but they are asked honestly. Women seem to want the kind of care midwives offer, but they want that care from an OB. Up next in my musings: why don't midwives have the kind of instinctive trust and respect we give OBs?