Tuesday, July 22, 2008

I thought this was one of the clearest, most evenly written pieces on the home birth date that I've seen in a while.

Laboring to save home births
Amish groups rallied politically against state closure of midwife Diane Goslin's practice.

By Mary Beth McCauley / July 22, 2008 edition
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Correspondent Mary Beth McCauley explains the Amish preference for home birth.

Mary Beth McCauley


Bradley Bower/AP

Time of need: Pennsylvania Amish groups rallied last year to save Goslin’s practice. Susan Rocca, with her son, Nicea, supported Goslin at the state capitol.

Midwife Diane Goslin’s farmhouse office bustles with activity this summer morning. Horse drawn buggies line the driveway, while pregnant women line the waiting room inside – their hair tucked into bonnets, their dark dresses covered by black aprons.

A mother expecting her 11th child arrives with her daughter, who is expecting her first. Women do mending as toddlers scoot around their ankles. Childhood friends reunite, chattering in Pennsylvania Dutch. Sisters shriek with laughter at the unexpected sight of their expectant aunt.

Outside, on the porch – in a waiting room of his own – a lone, straw-hatted man rocks, amused, pretending not to overhear the women.

The Amish here in Lancaster County may go to the hospital if they break an arm or need surgery, but when it’s time to give birth they stay home. Usually, they deliver their babies with the aid of a midwife, and the women in this waiting room half-joke that if Ms. Goslin goes out of business, they are through with childbearing.

It appeared to be coming to just that last fall when the Pennsylvania Board of Medicine ordered Goslin to cease and desist assisting her mothers, deeming it “practicing medicine and nurse midwifery without the appropriate licensure.”

Though the case arose because an infant delivered by Goslin died a day after birth, it was never considered her fault, nor has there ever been any suggestion that her rates of death or complication are unusual. If she were practicing in any of the 24 states that recognize her status as Certified Professional Midwife (CPM) by the North American Registry of Midwives, she’d have proceeded with her usual 200 to 300 deliveries a year.

But Goslin’s case illustrates the debate about whether childbirth is a natural bodily function or a medical event necessitating hospitalization. As in all ethics-meet-medicine turf battles, one party’s science is often another’s smokescreen.

Indeed, this isn’t new for the Pennsylvania midwife. Last fall’s case was the third time similar charges were brought against her in 18 years, and the third time they were dropped. In May, a 5 to 2 decision by the Pennsylvania Commonwealth Court overturned an $11,000 fine and lifted the cease-and-desist order. All three cases were brought after the state received complaints that Goslin was violating its licensing regulations. Simply doing what she does is against the law, maintains the state. And her business card, on which Goslin “is advertising her services,” is “clearly evidence of unlicensed practice,” says Leslie Amoros, of the Pennsylvania Department of State, which oversees the board of medicine.

Though cleared, Goslin’s work continues under a legal question mark because Pennsylvania recognizes only nurse midwives. Most of those are hospital affiliated and unavailable for home birth.

• • •

In the Amish farmhouses of this rolling hill country, Goslin is considered family. For some women, she’s delivered a dozen babies. And, in Goslin’s own time of need, this community rallied to help – a departure for the reticent Amish who generally refuse to be photographed or be quoted by name. But on behalf of their midwife, they protested at the state capitol, staged benefits and teas, and filed an amicus brief.

Non-Amish – who make up 35 percent of Goslin‘s practice – also turned out, as did advocates of women’s right to give birth in whatever setting and with the attendant of their choice.

The home birth debate has been joined recently by such participants as talk show host Ricki Lake, with her pro-home-birth documentary film, as well as by traditional players such as the American College of Obstetricians and Gynecologists, which recently reiterated its opposition to home birth.

“The [issue of] the medicalization of childbirth has been around for a long time, now,” says Arthur Caplan director of the Center for Bioethics at the University of Pennsylvania. “There will always be [people like] the Amish, who want no technology” on one end of a continuum, and those who will refuse to have a baby “if they can’t deliver at University of Pennsylvania” on the other. He argues that the home-vs.-hospital argument should be removed from the ideological push and pull, and instead be driven by safety data specific to the woman‘s age and risk factors as well as the availability of emergency backup care.

But it’s not always that simple. Such data are everchanging, and, debatable. Research, reports the Midwives Alliance of North America, suggests that safety rates of home births are equal to or better than those of hospital births for low-risk women (with no other health problems). Even so, that’s a difficult comparison, because the total – 40,000 to 45,000 babies born at home each year, according to alliance statistics – remains only about 1 percent of all US births.

• • •

But demand is still high enough that in her 28 years of midwifery, Goslin has never advertised, nor had to hang a shingle.
The world of medicine, for Goslin, is no enemy. Raised in an extended family of doctors, and the mother of a physician as well, she became interested in home birth, she explains, when a hospital-acquired infection she sustained at the birth of her oldest child left her infertile.

Seven years later and about to begin medical school herself, Goslin learned that – in spite of her diagnosis – she was pregnant and decided against medical school.“I wanted to raise my miracle baby myself,” she says. She delivered with a midwife and, believing that such care shouldn’t be solely a counter cultural option, began to apprentice with a midwife.

With 5,000 babies under her belt, Goslin seems to have encountered every twist and turn that childbirth can take. She points out that CPM certification requires attendance at more than double the number of births required for nurse-midwife licensing. Many of these births are required to take place outside the hospital, thus affording rare experience in successfully delivering breech babies, twins, and handling many other conditions that in a malpractice-minded age often trigger automatic cesarean sections in hospitalized patients. But, she adds, “I never had a baby that I could say ‘if that baby had been born in a hospital it would have been OK.’ ”

Now a mother of five, Goslin has been married 34 years to her junior-high school sweetheart, a teacher who is so familiar with her work that she calls him her “armchair midwife.”

She is a member of a conservative evangelical church. “I’m a Christian. I pray for each of my patients. I ask God for wisdom.”

During labor, Goslin’s mothers find that Scripture reading often calms them, and in the packet of instructions on diet and exercise she gives new patients are suggested Scripture passages. She says she feels called by God to her work, and assisted by God in her work.

• • •

On Wednesdays, once again, the gentle, dark-haired Goslin presides over her office as staff prepare the women – taking belly measurements, recording vital signs, and screening for conditions requiring special instructions or referral to an obstetrician. They lend books on pregnancy, answer questions, and make appointments – “You say you all want to come back in on the same day?” Though she has been paid in quilts or livestock, the customary charge is $1,000 per delivery.
When labor begins, parents will lay out linen, basins and other supplies, and contact Goslin, who, with an assistant, heads out into the hills, her 2003 Subaru already loaded with delivery bag, emergency equipment, and – the mothers’ favorite – Goslin’s personally designed birthing chair.

After checking on the patient, she may tidy up a kitchen, cook for a husband, or read. “Most of the time, if truth be told, we’re not needed,” she says. But at other times she is perhaps actively directing a mother through an arduous delivery, or removing a wrapped umbilical cord, or suctioning a baby that has breathed in meconium.

Annie (who, agrees to be identified by first name) is expecting her seventh child, and she knows the drill. “I pace my kitchen floor, lean over my chair, say my prayers…. When Diane comes, she’s my boss.” Even Annie’s most difficult delivery was met with a sunrise, a moment so tranquil, she recalls, she gave the child the middle name of “Joy.”

An Amish mother expecting her sixth child recalls how Goslin strapped her birthing supplies on a toboggan and walked uphill to her farm when the road was impassible one winter. “I didn’t even think to be worried. I figured she’d get here. She always does.”

( More backstory articles )

Wednesday, July 16, 2008

A star has a natural birth

Stop the presses.

According to OK Magazine, Jessica Alba's birth of daughter Honor Marie Warren on June 7 was anything but chaotic.

"I didn't scream," Jessica tells OK! in an exclusive interview and photo shoot. "It was really Zen." And Cash could only marvel at his wife's quiet strength when she gave birth. "She didn't make a sound," he says. "It was amazing."

Yes, I'm sure it was.

Tuesday, July 08, 2008

72-year-old gives birth in India

She must be exhausted, is all I have to say.

This news from Mumbai, India:

A 72-year-old woman who has two children and five grandchildren has given birth to twins, making her the world's oldest mother.

Omkali Panwar gave birth to twins. Omkari Panwar delivered twins, a boy and a girl, by Caesarean section last week.

"I am very happy," Charam Singh, 75, the father of the twins, told ABC News through an interpreter.

Singh was reluctant to speak because he has received negative publicity for his wife's having children at such an advanced age. Even many people of his village in India's state of Uttar Pradesh haven't supported the decision. Still, he and his wife are happy.

"The desire for a male child has always been there, but God did not bless us with a male child," he said of the son who is a product of in vitro fertilization. "Now, we are very grateful to God, who has answered our prayers."


I have agreed to serve on the advisory board for an amazing organizing called Earth-Birth, a model for a global women's health care collective. The pilot programs are now being set up in Uganda, Sudan and Brazil and sustained by local midwives. The organizers have a vision for holistic women's healthcare that unites women and health care practitioners in a global dialogue. Their birthing centers are not only clinics but community sustained spaces for refuge, learning and the sharing of stories. They are starting in East Africa because of the impact that years of internal genocide has had on women's reproductive and emotional health. They will then model the program in Brazil to begin the global connections in an area where the C-section rate is one of the highest in the world.

The idea is to foster an international women's health movement that encourages and promotes safe and peaceful birth as an act of social justice and community healing. They are offering a holistic approach to women's health care that is both community centered and internationally connected. Their goals include community sustainability, lowered maternal and infant mortality rates, lowered mother to child HIV transmission, access to supplies, access to trauma counseling, the ability to articulate ones story and the facilitation of positive and empowered childbirth experiences.

Check out the website at www.earth-birth.com

And a man gives birth

I have zero interest in the moral debate about Thomas Beatie, the transgendered "pregnant man," who gave birth last Thursday to a healthy baby girl.

What I am fixated on is the idea that he had a "natural" birth. Granted, I know nothing about what it took to reshape Thomas' clitoris to make it more like a penis, but he could still pass a baby through that? Amazing.

What are the odds he had an epidural?

Young women and birth

I received an email from the certified professional midwife in New Hampshire who wants to target young women (college-aged, for starters) about normal birth. She is considering showing the "Business of Being Born." I think it's a great idea to try to shape the way young women think about birth before they are inundated with peer and other cultural experiences...which brings me to the cover of Star magazine. I was in the checkout at CVS printing some pictures of my kids at the beach when I saw the headline "Delivery Room Drama" about the birth of Jamie Lynn Spears' new daughter, Maddie Briann.

"The baby's heart rate dropped every time she tried to push," a family insider told Star. "They did an ultrasound and quickly discovered that the umbilical cord was too short." But despite the doctors' dire warnings, the 17-year-old "was adamant about having a natural delivery." The report goes on to say that "Everyone in the room at Southwest Mississippi Regional Medical Center in McComb, Miss., pleaded with Jamie Lynn to listen to the doctors — including big sister Britney. Brit had already been with Jamie Lynn for hours, massaging her back as she endured painful contractions. 'But she got mad,' says the insider. She told Jamie Lynn to 'just have a damn Caesarian,' as she did. 'Britney then ran out in tears because she couldn't bear to see what was happening.'"

How many 12 year-old fans read this story?

(The next day OK mag was reporting that Spears was induced, but she gave birth " 'naturally' without any complications." Not much natural about a Pit drip.

I fear that by the time girls get to college, it's too late. Any notion of 'normal birth' has been eclipsed by tabloid sensations. Next up: Brangelina's complicated pregancy and expected c-section. Sigh.

Tuesday, July 01, 2008

Making home birth illegal in Massachusetts (part 2)

Although I have already blogged about the American Medical Association's resolution against home birth, I've decided to paste below the full text. The AMA is also now attacking legislation in states where home birth would be sanctioned, including Massachusetts, one of the first states to outlaw midwifery in the early 20th century. It's as if doctors(and there is a great concentration of them in Mass.) and midwives cannot coexist. It's shame, because each bring their own talents to the room.

Whereas, Twenty-one states currently license midwives to attend home births, all using the certified professional midwife (CPM) credential (CPM or "lay” midwives), not the certified midwives (CM) credential which both the American College of Obstetricians and Gynecologists (ACOG) and American College of Nurse Midwives (ACNM) recognize; and

Whereas, There has been much attention in the media by celebrities having home deliveries, with recent Today Show headings such as “Ricki Lake takes on baby birthing industry: Actress and former talk show host shares her at-home delivery in new film” ; and

Whereas, An apparently uncomplicated pregnancy or delivery can quickly become very complicated in the setting of maternal hemorrhage, shoulder dystocia, eclampsia or other obstetric emergencies, necessitating the need for rigorous standards, appropriate oversight of obstetric providers, and the availability of emergency care, for the health of both the mother and the baby during a delivery; therefore be it

RESOLVED, That our American Medical Association support the recent American College of Obstetricians and Gynecologists (ACOG) statement that “the safest setting for labor, delivery, and the immediate post-partum period is in the hospital, or a birthing center within a hospital complex, that meets standards jointly outlined by the American Academy of Pediatrics (AAP) and ACOG, or in a freestanding birthing center that meets the standards of the Accreditation Association for Ambulatory Health Care, The Joint Commission, or the American Association of Birth Centers” (New HOD Policy); and be it further


That our AMA develop model legislation in support of the concept that the safest setting for labor, delivery, and the immediate post-partum period is in the hospital, or a birthing center within a hospital complex, that meets standards jointly outlined by the AAP and ACOG, or in a freestanding birthing center that meets the standards of the Accreditation Association for Ambulatory Health Care, The Joint Commission, or the American Association of Birth Centers.” (Directive to Take Action)

Whereas, A bill has been filed in the Massachusetts (MA) Senate, and passed the first two reads, that would establish a separate “board of registration in midwifery,” with expansion of scopes of practice and with educational requirements for licensure being left to the discretion of membership organizations¹; and

Whereas, This would remove the current oversight exercised by the Massachusetts (MA) Board of Registration in Nursing (involving Certified Nurse Midwives, CNM), and potentially grant MA licenses to certified midwives (CM) and “lay” midwives (or “certified professional midwives, CPM); and

Whereas, As of 1997, CMs were deemed eligible to sit for the national American Midwifery Certification Board, with the requirement being 3 years of university-affiliated training, but no nursing prerequisite²; and

Whereas, CPMs, as defined in the American College of Nurse-Midwives (ACNM) position paper, are “traditional, independent (of the health care system), non-formally trained and community-based provider(s) of care during pregnancy, childbirth and the postnatal period,”often are self taught and in an unregulated apprenticeship-model²; and

Whereas, Twenty-one states currently license midwives to attend home births using the CPM credential, not using the the CM credential which is recognized by both the American College of Obstetricians and Gynecologists (ACOG)³ and ACNM²; and

Whereas, According to the AMA Scope of Practice site, in the 2008 legislative session there are a number of states confronting similar public health issues regarding “lay midwives” of CPMs (certified professional midwives), including Missouri (direct access), Idaho (authority to perform surgery), Massachusetts (separate licensing board), Delaware and Idaho (licensure); and

Whereas, An apparently uncomplicated pregnancy or delivery can quickly become very complicated in the setting of maternal hemorrhage, shoulder dystocia, eclampsia or other obstetric emergencies, necessitating the need for rigorous educational standards and appropriate oversight of obstetric providers to ensure the health of both the mother and the baby during a delivery; therefore be it

RESOLVED, That our American Medical Association develop model legislation regarding appropriate physician and regulatory oversight of midwifery practice, under the jurisdiction of either state nursing or medical boards (Directive to Take Action); and be it further
RESOLVED, That our AMA continue to monitor state legislation activities regarding the licensure and scope of practice of midwives (Directive to Take Action); and be it further

RESOLVED, That our AMA work with state medical societies and interested specialty societies to advocate in the interest of safeguarding maternal and neonatal health regarding the licensure and the scope of practice of midwives. (Directive to Take Action)