Midwife: Sage Femme, Hebamme, Comadrona, Partera

Tina Cassidy, brilliant author of Birth: The Surprising Way We are Born added this to my last post:

I will just add that obesity goes hand in hand with race and class. The poorer, the heavier, statistics have shown. One of the worst-kept secrets in modern maternity is that African-American women have the highest c-section rates of any race or class in the country. Perhaps size bias is, unfortunately, another factor they must face.

Perhaps this is really where the ambivalence to making changes to help lower the rising maternal mortality rate comes from. If more white, upper class women were dying in birth….well, you get what I’m saying.

This is a huge crisis. I imagine that we’ll definitely see the cesarean rate hit a near 80% rate before things get any better…and by better I mean women rising up and asking for something different. Of course, my pessimist side says that this is unlikely to happen - it appears that most people I know are not only ok with the way the technocratic model of birth is but feel that it saves their lives or their babies lives. (It’s the whole “thank goodness we were in the hospital or me/my baby would have died”…never mind the induction, the continuous monitoring on your back, the epidural, the hyperstimulation of the uterus…..)

These two excerpts from the article also point out how grossly overstated prenatal care as we know it is:

-Race: Studies have found that the maternal death rate in black women is at least three times greater than is it is for whites. Black women are more susceptible to complications like high blood pressure and are more likely to get inadequate prenatal care.

-Quality of care: Three different studies indicate at least 40 percent of maternal deaths could have been prevented.

I suppose if we’re talking about women walking around with undiagnosed TRUE pre-eclampsia (not just a normal rise in blood pressure at the end of pregnancy, which seems to get called pre-e all the time) or HELLP syndrome because they never go to a care provider, that’s one thing. Blood pressure issues are typically rooted, from a holistic standpoint, in stress and anxiety issues that have no outlet.

But really, it is women of a lower socioeconomic status, black, white, latina, asian, that are at risk because the quality of prenatal care they receive sucks. Let’s talk about “quality of care”.

What sort of “quality of care” are they referring to? What is “poor quality of care”?

Sitting in an office, one of 30 to 40 women that will be seen that day by two providers. The wait is upwards of 30 minutes to an hour.

A nurse or medical assistant calls you in, weighs you, has you pee in a cup (both of which could bring up questionable results that cause some anxiety…or they could be checking you for drugs along with the ritual of protein and glucose). Your blood pressure is taken.

You get undressed in the cold office, sit in a paper gown with no clothes on. The provider comes in, and for the first time of you meeting him/her, a pelvic exam is done. Sometimes there is a bit of pelvimetry done (an antiquated measurement of the pelvis to see if it’s “adequate” for childbirth), but more likely a Pap Smear is also done (even though the cells of your cervix are undergoing rapid change and this smear in pregnancy is more likely to bring up an inconclusive result, so it has to be repeated postpartum).

It is often this time, too, that OBs are known to make small comments to prepare a woman to eventually agree to an elective cesarean rather than go through a “trial of labor only to end in cesarean”: your pelvis seems a bit small; your baby is growing pretty fast, which puts you at risk for a big baby; women at your age/weight often have problems birthing babies vaginally.

Blood is drawn that most women have no idea what is being checked for (did you know that many states require a mandatory HIV test? Don’t forget that pregnancy is one of hundreds of things that can cause a false positive on the ELISA test!), the discussion around the Triple or Quad Screen is small - and the huge rate of false positives never really mentioned. Nor is it a choice. You just DO these things…like swallowing 50 grams of glucose syrup to inaccurately diagnose blood sugar issues in pregnancy…even though the evidence shows that this sort of testing is not beneficial to women and outcomes.

The provider may ask you about some things in your medical history, palpate the measurement of your uterus (sometimes bimanually - vaginally), use a doppler or one of their handy ultrasound machines in their office (are they trained as ultrasound technicians?).

Often, a hand is put on the doorknob as the provider begins to leave, while asking, “Do you have any questions?” Chances are, he / she is on a harsh schedule, perhaps there is a woman in labor across at the hospital that they need to rush out to or just see four more patients quickly before she does deliver. You can bet that you won’t be talking about your ideas for your birth right now.

Women usually receive three ultrasounds in their pregnancy - the first for dating (because even if you think you know your conception date, the technocratic model trusts nobody but their technology), the second for gross abnormalities that can be seen (and some issues that will never be a problem, but hey, better be safe with that anxiety than sorry!), and the third for size/dating (both off by so much that it would be comical if it didn’t set women up for unnecessary inductions and cesareans).

On average, an OB visit lasts 4 to 6 minutes. CNMs sometimes can stretch it further - usually 15 to 20 minutes.

The book “Expecting Trouble: The Myth of Prenatal Care in America” by Thomas Strong, MD (a third generation MD, second generation OB/Gyn) is an insightful look at just how much our idea of prenatal care is lacking. The focus becomes testing, fancy technology and looking at the fetus as an antagonist to the mother’s health - or vice versa. He criticizes all the testing done - and says that it still is NOT improving outcomes.

His idea that CNMs deal with all low-risk, normal healthy women and leave the high-risk surgical cases to Obstetricians (who are, after all, surgeons) is not something new. However, it is new to the United States. Many countries, like Holland and New Zealand have adopted the idea that OBs are only for high risk or surgical birth - with tremendous outcomes. And you can bet their prenatal care is far superior than ours.

What we don’t need: more technology, more tests, more anxiety. But would American women stand for less of the technology and testing? Are they wanting more assurance from these tests? Do they get it? Chances are, it only creates more of an ambiguous stance on their current pregnancy and baby’s health.

What we do need: time to address socioeconomic concerns of women (is the father with you? does he support you? are you getting the food you need? do you smoke cigarettes? do you worry about someone in your home hurting you or your baby?, etc). time to really hear women - and see beyond their words to find the truth of their life. Without judgment, but a real willingness to want to help them. No shame. No guilt. Maybe some women don’t get prenatal care because their home life/health/socioeconomic issues are ones that typically bring shame to them by the people that are supposed to be helping them. After they’re drug tested, scolded or talked to like children, they won’t come back.

What’s even more interesting is that some people would assume that because poor, black women are on state aid that less cesareans would be done (because of cost). Doctors that have patients on medicaid receive the same amount for a cesarean or a vaginal birth. However, if you have a Medicaid recipient laboring in a bed that could be used by a private insurance patient, it’s likely that poor woman will “need” a cesarean right away. I’m sure the “failure to progress” rates are higher in these situations.

So, somehow this idea of a lack of “quality prenatal care” causing poor outcomes…is well, odd to me. Since it’s the common acceptance of what is currently disguised as prenatal care that is adding to the problem. Maybe if we discussed the problem of NO care at all for women who are at risk of falling through the cracks….that I could get behind.

I feel like the current ritual of what most American women know to be “prenatal care” is so grossly inept at addressing anything but a linear, technocratic-focused, fear-based model. We continually accept a model that removes power from the birthing woman and places it in the hands of the surgeon. It’s really no wonder why women are angry and surprised when, after all that testing that they’ve been through, something is wrong with their baby. Wasn’t that the point? To make sure the baby is healthy? Perhaps the point is to have it look like the surgeon did everything possible using his blood tests, machines and skills in a malpractice suit.

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