Natural childbirth, white privilege and denial

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It’s no surprise that a privileged, white natural childbirth advocate would deny my claim that white privilege plays a large role in natural childbirth advocacy. I am surprised, however, by the weakness of her denial.

As the title of her piece, The Obstetrician Who Cried “White Privilege”, indicates, history Prof. Lara Freidenfelds considers my claim irresponsible.

In December of 2016, I wrote an essay for Nursing Clio called Nurse-Midwives are With Women, Walking a Middle Path to a Safe and Rewarding Birth. In the piece, I advocated that all women be given the option of delivering with hospital-based nurse-midwives … I only recently, quite belatedly, realized that OB-GYN Amy Tuteur had responded on her blog to my essay. She offered a belittling (and inaccurate) representation of my position on hospital-based nurse-midwifery, specifically invoking the specter of “white privilege.” Why? As far as I can see, it was an attempt to shut me down with highly-charged language that was intended to shame me and alienate those likely to be my allies.

Well, yes, natural childbirth advocates ought to be ashamed that in their privilege they imagine that what all women need is what privileged white women want. For better of for worse, Prof. Freidenfelds is a perfect example of white, pregnancy privilege.

Who wants to be accused of being a privileged white person? Certainly not a privileged white person!

As I’ve written before, pregnancy privilege is defined by 25 attributes:

1. My pregnancy is planned and wanted.
2. I am healthy.
3. I have health insurance.
4. I have a choice of healthcare providers and do not have to rely on a clinic.
5. I can access a hospital that has excellent statistics for neonatal and maternal outcomes.
6. I can be sure that the majority of my caregivers belong to my racial and demographic group.
7. I speak English.
8. I am married or have a reliable long term partner who is available to care for me when needed.
9. I have easy access to and can afford healthy food.
10. I can afford books on pregnancy.
11. I can afford to take childbirth classes.
12. I may have to sacrifice, but if I wish I can afford a doula or midwife.
13. I can hire a birth photographer.
14. I can afford weeks or months of maternity leave from my job.
15. I have easy, reliable access to the internet so I can share information with other pregnant women.
16. I can write well enough to create a birth plan.
17. I am not a victim of domestic violence.
18. I am not addicted to alcohol or drugs.
19. If I have older children, I have family or friends to care for them when needed.
20. I can create a baby registry on the assumption that I and my friends can afford to purchase new baby items.
21. I can afford a breast pump.
22. I have a job that offers both privacy and time to pump without loss of income.
23. I have a spouse or partner who is supportive of breastfeeding.
24. I don’t face a dramatically increased risk of premature birth.
25. I don’t face a dramatically increased risk of maternal death

Freidenfelds can correct me if I’m wrong, but suspect she scores close to if not exactly 25 out of 25 on the pregnancy privilege scale. And, like many beneficiaries of privilege, she’s in denial about her own privileged status.

Why? Acknowledging privilege is embarrassing, especially when you view yourself as speaking from a position of moral superiority.

My primary claim is that privileged, white women imagine that the childbirth experience that they want is what less privileged women need. I’ve analogized this in the past to sending sterling silver flatware to people dying of starvation.

To the extent that Prof. Freidenfelds engages with this claim, she deliberately misrepresents it (or, perhaps, misunderstands it).

Tuteur claims that nurse-midwifery could only possibly be appealing to middle-class white women such as myself, who she believes are inordinately attached to the idea that women might value a low-intervention birth experience, and therefore, when I advocate that nurse-midwives be available to all pregnant and birthing women who want them, I am cluelessly advocating from a position of white privilege. (my emphasis)

But that’s not my argument at all. I’m not talking about what is or is not appealing. I claim that nurse-midwifery is only appropriate for low risk women.

To use my sterling silver analogy, I would never say that fine flatware could only possibly be appealing to privileged, white women. Who wouldn’t want sterling silver flatware if they had plenty of everything else in their lives? But it is worse than meaningless for people who don’t have enough food to eat. Recommending midwives (specialists in low risk pregnancy and birth) to women who suffer inordinately from high risk conditions and complications is also worse than meaningless.

Freidenfelds also misrepresents my position on the safety of nurse midwives:

Tuteur will never accept evidence that any form of midwifery is safe. She is completely committed, at least publicly, to advocating for OB-GYNs at every birth, and no evidence of nurse-midwifery’s safety will ever be enough for her. That means that, at least as long as the evidence available to me supports the safety of nurse-midwife care for low-risk women, we will have to agree to disagree about the role of nurse-midwives.

That’s a bald faced lie. I’ve written more times than I can count that I always worked with certified nurse midwives, found them to be excellent practitioners and that the scientific evidence shows that they have a great safety record for low risk women. But by definition they can’t care for the most high risk women who are disproportionately African American, suffering from pre-existing medical problems and severe pregnancy complications. For example, the leading cause of maternal death in this country is cardiac disease. What, exactly, can midwives do to prevent cardiac deaths? Absolutely nothing.

That’s not the only thing that Freidenfelds refused to address.

Specifically:

The racist, sexist origins of natural childbirth advocacy.
The biological essentialism at the heart of natural childbirth advocacy.
The remarkable elitism of the movement that has only token representation of women of color and poor women.

Freidenfelds has nothing to say. She doesn’t deny any of that since it is all true; she simply ignores it.

How about the questions I ask in my piece?

What distinguishes midwifery from obstetrics? Is it truly a difference in outlook or merely midwives clawing for market share?
Should women be reduced to their reproductive organs and does reproduction mean the same thing to every woman?
Are midwives with all women or just privileged white women?

Freidenfelds doesn’t bother to answer these questions. As I noted in my original essay:

Natural childbirth advocates are overwhelmingly Western, white, and well off. Certified nurse midwives are overwhelmingly Western, white and well off. I find it quite shocking that in a country that struggles with high black perinatal mortality and high black maternal mortality, Freidenfelds doesn’t even bother to give lip service to the many women of color, women of other nationalities, and women with pre-existing medical conditions and pregnancy complications whose have no interest in and cannot be helped in any way by the philosophy of natural childbirth.

It’s almost as if these non-privileged women do not exist.

Freidenfelds writes:

As I explained in the essay, nurse-midwifery was originally developed to serve lower-income women who could not afford physicians’ fees. Midwives continue to disproportionately serve low-income rural and inner-city women, many of whom have difficulty accessing care otherwise.

And as I explained, that’s not true. While some nurse midwives prior to 1970 cared for poor women, they represented only a few hundred providers. Since then the number of nurse midwives has grown exponentially (now approximately 12,000) and there is no evidence they disproportionately serve poor women.

According to CDC Wonder, in 2016 African American women represented 16% of births attended by doctors and 13.5% of midwife attended births. CDC Wonder does not collect income statistics but it does collected statistics on maternal education. Women with a high school degree or less represent 40% of births attended by doctors and 37% of midwife attended births. In other words, midwives are LESS likely than doctors to attend births of African American women or poor rural/inner city women.

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Freidenfelds concludes:

I do not accept Tuteur’s mis-use of the critical terminology of “white privilege.” Specious arguments based on claims about white privilege are pernicious because they weaken and discredit the concept.

I understand; who wants to be accused of being a privileged white person? Certainly not a privileged white person like Freidenfelds. She ought to present actual arguments debunking my claims instead of misrepresenting them or ignoring them. The fact that Freidenfelds cannot suggests she ought to check her privilege.

  • Mishimoo

    In related news, has anyone else seen this: http://www.globalfistulamap.org
    I ran across it while on uni placement and thought I should share.

  • guest

    When I had my first baby, there was a program for student midwives and doulas to attend women at the local hospital, which serves mostly very poor women of color (mostly Southeast Asian, East African, and Central American immigrants). It was supposed to help them branch out and work with more diverse populations

    I had a student midwife and a doula, and two instructors nearby the whole time I was in labor (3 days)

    This is what they provided for me – they helped me get to the bathroom, and brought me water. I appreciate that, but really, they couldn’t do much else.

    In our community, we have to wait 4-6 hours in a packed waiting room, with our babies in arms, every time we want see a nurse at the public clinic.

    When I was in labor and the baby was in distress and transverse, we had to wait twelve hours before they could find an available surgeon to perform the C-section. That was on my second day of labor.

    While I waited, there was a midwife sitting with me, wearing a rebozo she had gotten while backpacking in Belize. She did not know how to use it. She offered to hold my hand instead.

    We don’t need well-off white women to hold our hands. We need doctors.

    Barring that, we need helpers who are not afraid to get their fancy shawls dirty with pregnant lady sweat.

    • guest

      Sorry, meant to say after my second day of labor. The third morning we waited for a surgeon.

      • guest

        No doctors were available, for over two days, and the midwives could do nothing. They did not even believe anything was wrong, because I did not cry or carry on, but spoke calmly. With contractions 2 minutes apart, they did not believe I was in active labor because all of us brown women are supposed to emote loudly when we are in pain.

        Aren’t midwives supposed to be able to recognize labor signs? Or to know how the baby was positioned? Why did it take someone with a medical doctorate?

        • Mishimoo

          I’m so sorry. You deserved better care, it’s ridiculous that you had to go through this.

          • guest

            Thank you, but all is well. In the end, my baby was born healthy, and I am healthy.

            The care I did receive from the nurses and the surgeon was very good, very compassionate. But they were too overbooked. I cannot hold that against them.

            I am mostly concerned that midwives and doulas are being brought into hospitals to cut costs. They are not doctors, nurses or aides, and are not empowered to do what doctors, nurses and aides do. It does not seem fair to anyone involved.

            Many hospitals serving poor areas are dealing with severe budget cuts, and I do not know how to solve that problem. Bringing in midwives doesn’t seem like a solution, though. It is like slapping a bandaid on something that requires a tourniquet.

    • The Bofa on the Sofa

      We don’t need well-off white women to hold our hands. We need doctors.

      Quoted for the fact that it needs to be repeated. Again and again.

    • SOB

      Haha. Trust me the nurse midwives and doulas don’t WANT to work with a whiney middle aged woman dead set on a c-section. Go get your repeat c section and quit whining about “how this will affect YOUR care.” No one gives a rats arse about your CSMR…No one is going to force you into a VBAC; only 10% of women attempt a VBAC after a primary CS. Explaining that a VBAC is recommended by research (ACOG) and that it is a safer option than RCS (if criteria are met) is NOT guilting you… it’s informing you of your options but some people don’t want to be informed but rather blissfully ignorant because they might feel guilty if they know they are choosing an option that is not in line with current best evidence…only you can allow something or someone to make you feel guilty. Put on your big girl panties and move on.

      • guest

        You make an awful lot of incorrect assumptions – about my age, my number of children, my medical history, my attitude towards c-sections and VBACs, and my conduct in general.

        I hope you found arguing with the strawman you created satisfying. You obviously had a lot of frustration to get out towards middle-aged multiparous women who want elective c-sections.

        Good luck working through those issues, SOB.

      • guest

        Are you replying to the wrong thread?

        • Madtowngirl

          I’m relatively sure SOB was trying to reply to me. Which is pretty ironic, given that the medical professionals I saw were very much in agreement that best practices were for me to NOT attempt a VBAC. But whatever, I’m “middle aged” apparently and that somehow means my concern is invalid. Lol.

          • MaineJen

            Whoa, that makes her comment even *more* rude (if that’s possible). She and her fellow “professionals” would turn their noses up at you for being 35 and having a previous c section. For those sins, you are considered “whiny” and not in possession of “big girl panties.”

            Sounds like they prefer their clients 22, healthy and passive. How dare we be anything but that??

          • Madtowngirl

            Right? Lol! It’s a shining example of *why* I’m skeptical of the hospital’s motives.

        • Amazed

          Hardly. She might have gotten the poster wrong but there is no thread that can be wrong for such a shining, concerned individual to make us aware of her values.

          Of course, there’s no thread that can be right for such garbage either, so…

        • Who?

          The reply would be the same regardless of the thread, so even if she is, it hardly matters.

      • Who?

        Well that’s a lot of anger in a paragraph. Is guest making you angry, or are you allowing yourself to be made angry? Perhaps reflect on that before jumping to conclusions about guest’s feelings on the topic.

        If nurses and midwives only want to work with a sub-class of pregant women they should not be in a public hospital wasting everyone’s time.

        It’s not whiny to say what you want. It’s not whiny to note that it is apparent that your primary carers are good for nothing but forehead wiping and handholding, and that these may be inadequate skills in certain situations.

        Wanting a CS is a good enough reason to have one. End of discussion.

        BTW, the state of anyone else’s panties is none of your business.

      • Amazed

        Your tone totally convinced me, dear little young midwife. I’ll totally take my medical advice from someone feeding their inferiority complex towards white coats, instead of white coats themselves.

        It’s a sad state of affairs that people who don’t feel up to the task of becoming a doctor demean their own profession like this.

      • Charybdis

        So if a woman decided that she was going to have an elective CS and was going to exclusively formula feed the baby, would you take her on as a client, if she had decided that she wanted to have a doula or student midwife as a support person? Would you take her on as a client anyway and try your damnedest to “change her mind” about her CS and EFF choices?

        Being a professional entails doing things that *you* personally would not choose to do. There is nothing wrong with having an elective CS, it is a perfectly valid choice for a woman to make. There is nothing wrong with exclusively formula feeding a newborn; it is also a perfectly valid choice for a woman to make. Same with epidurals, other pharmeceutical pain relief, constant fetal monitoring, IV’s, etc.

        And yes, this “vaginal is BETTER! EBF! Skin-to-skin!” nonsense DOES affect the care of those who don’t wish to partake of it. BFHI, closing well baby nurseries, mandatory rooming-in, restriction of formula use, no pacifiers, harassment by LC’s, misinformation about the size of a newborn’s stomach, etc certainly DOES make things harder for those of us who choose other options. And that right there is the rub: OPTIONS. Rather than give the woman proper, factual information regarding her options and letting her choose what she thinks will work best for her, the vaginal/ebf crowd gives biased “information”, all slanted to make the woman choose what *THEY* want, because if the woman had ALL the facts, she might freely choose to have a CS, not opt for a VBAC, exclusively formula feed, use a pacifier, or send her baby to the nursery so she can get some sleep and recover herself. And the natural brigade can’t have that.

      • Sarah

        You do realise that midwives and doulas not wanting to work with an older mother who’d like a section says bad things about them, not the woman, right?

      • Amy Tuteur, MD

        Reall healthcare professionals care for people based on need. It’s hard to imagine anything more privileged than deciding to care for only those who validate your personal beliefs. Thanks for providing my point for me!!

        • The Bofa on the Sofa

          I was thinking the same thing. In fact, I tend to agree with SOB that midwives don’t care about women who want a c-section. But given that, it says an awful lot about those midwives and their motivation, doesn’t it?

          I thought midwives were supposed to be “with women.” No, obviously not. According to SOB, it’s about propping up those who do things the “right way”

      • momofone

        Gee, I can’t understand why anyone wouldn’t buy what you’re selling. Oh wait–maybe it’s lack of qualifications to make recommendations?

      • rosewater1

        Gee, that’s funny. The CNMs I used to work with were all too happy to work with middle aged women who didn’t want to VBAC. And other women who didn’t want to either. They couldn’t deliver them, but they certainly cared for them during their pregnancies.

        If women are informed of their options and choose a c/s…that is their right. It doesn’t mean they aren’t informed. It means they have made a decision that you personally don’t care for.e.

      • Anna

        She seems nice!

        • Who?

          Thankyou for making me smile.

      • MaineJen

        Lovely attitude. Thank you for proving our point! I feel more confident than ever in my decision to avoid midwives and doulas during my pregnancies.

  • Madtowngirl

    Sort of on topic, my local hospital (BFHI) is apparently introducing the option for midwifery (CNM) care. The crooning about how wonderful and “natural” and “feminist” this is is vomit inducing. I just hope it isn’t a sign that I’m going to have another fight with baby #2. Cuz hell will hath no fury like me if someone tries to guilt me into a VBAC.

    • rosewater1

      It infuriates me to hear this. I work at a hospital with a thriving midwifery (CNM) program. But, I can no more picture any of them guilting someone into a VBAC, minimizing the risks of childbirth, etc. then I can picture myself growing wings. They don’t hesitate to risk women out who aren’t safe to be delivered by CNMs. It just makes no sense.

      Madtowngirl, I hope you don’t have to fight for what is yours and yours alone to decide.

      • Madtowngirl

        Thank you. I am trying to be hopeful, because at this hospital the nurses were great, so I am keeping my fingers crossed that the CNMs will also be great. But given my experience there with breastfeeding and discharging my child at a birth weight that I feel was way too low, I’m definitely going to be firm and have my husband know my intentions.

        • rosewater1

          Probably wise, but you shouldn’t have to! Good luck to you and yours, and best wishes for a blissfuly uneventful delivery and hospital stay.

    • EmbraceYourInnerCrone

      Try to get them to put your requirements (like No VBAC) in writing in your records. You may want to type them out as a short list (I know birth plans are mostly not needed but it still might be a good idea).

    • RudyTooty

      Are you working with the CNMs for your care? Or obstetricians? Will they give you a choice? Are you worried about midwives in the hospital influencing the entire unit culture?

      • Madtowngirl

        I’m still in early pregnancy, so I haven’t even had my first appointment yet (that’s tomorrow). This announcement came after I made the appointment, so I’m not sure if they’re going to give me a choice or just go with the OB care as initially planned. So, my answer is that I’m not sure, lol.

        I am 35 with a history of miscarriage, infertility, and a previous C-section, so I would think that I’d be risked out of CNM care, but who knows.

        • RudyTooty

          I don’t know why you would not be able to choose an OB for your care, regardless of your risk-status. I know other countries sometimes initially funnel all patients into midwifery care, and then the decision to be cared for under a physician is based on the risk assessment, but I don’t know that that is true in the US.

          • Madtowngirl

            I hope that is the case. I’m honestly more concerned about what this will mean for the care I get at the hospital. This hospital had no problem compromising my care and my baby’s care for the sake of breastfeeding, so it basically comes down to me being dubious of their intentions. I truly hope I’m wrong, but given the way they promoted a natural birth agenda the first time around, I am skeptical.

            Then again, the nurses were the bright spot in that postpartum care, so maybe….

          • Mimc

            It’s how the clinic I went to worked. They had 5 CNP/NP and 2 OB/GYNs. Though even low risk patients got at least 2 visits with OBs because they wanted every patient to meet every practitioner so that whomever was on duty at the time of birth would be a familiar face.

  • Amy Tuteur, MD

    I’m amazed that Freidenfeld’s response has been so pathetic. I accused her of imagining that what SHE wants is what other women need and she basically confirmed that.

    In a comment on her own blog she wrote: “…[W]omen with medical and personal complications especially need high-touch as part of their care in order to have the best outcomes (physical and emotional),”

    Because SHE wants “high-touch” care she claims that other women who may have different needs and preference will benefit from “high-touch” care. She provides no evidence and seems shocked that anyone would dare ask her for evidence. She presents links to scientific papers that she clearly hasn’t read and tells us to “take Dr. Shah’s arguments to represent my views” as if that were a reasonable response to a request that she defend her claims.

    Mind boggling!

    • demodocus

      High touch? Does she mean she likes lots of literal hand holding and knee and shoulder patting? No thank you! Some of us do not like to be touched.

      • Mishimoo

        Exactly! I didn’t even want my husband touching me, and we’re usually a very high-touch couple*. I didn’t want anyone else touching me at all!

        (*I hate other people touching me, but his touch is comfortable because it’s affection without expectation)

        • crazy mama, PhD

          Same here! I am a giant DON’T TOUCH ME monster when under stress. “High-touch” care would be absolutely awful.

          When I was in labor with my second, hospital staff repeatedly asked me if I wanted the lights dimmed. But it was the middle of the day, I wanted the lights to be bright so it felt like daytime.

          What is comforting and helpful varies dramatically by person.

          • demodocus

            I prefer bright, too. My first was born in a room with windows, which I appreciated. ‘though by the time he was born, it’d gotten dark again.

    • BeatriceC

      She really thinks all women would experience improved outcome in “high touch” situations? That’s absolutely ludicrous. Humans are so varied in needs and desires that you have to get pretty fundamental to make “all people need..” statements. We’re talking statements like “All humans need oxygen to survive”, or “all humans need a source of food”. Beyond that, we’re not a monolithic group at all.

      Basic logic says that an “all” or “every” statement can be proved false by presenting a single counter example. To that end, I am a woman with extensive medical complications in pregnancy and I would have been extremely upset in a “high touch” situation. I don’t like being touched when I’m healthy. To have tons of people touching me when not absolutely necessary would have driven me over the edge and would have almost certainly caused much worse outcomes that I was already experiencing. Thankfully I had great doctors and was in a great hospital and they actually listened to me and respected my individual needs to the extent possible, as dictated by my medical needs. And when they couldn’t do things in a way I would have preferred, they talked to me like the intelligent adult that I am and explained why their actions were necessary.

      • Amazed

        An ex of mine had the loveliest hands in the world. He gave the best massages ever to relieve a headache. At least that’s what all my friends used to say. Me? I wouldn’t know. When I’m in pain, you stay the fuck well away from me, for your own good, unless it’s absolutely needed. Fortunately, he respected my wishes. We tried a few times, it didn’t work and that was it. I never benefitted from a high-touch care and I see no reason to think I would in labour.

        Shocking, I know.

        • BeatriceC

          There’s a MrC exception to my no touch policy. But even that only goes so far. When I’m really really stick or stressed out, even his touches aren’t welcome.

          • Amazed

            You’re just envious that you dodn’t get to receive high-touch care iin labour. Why won’t you admit this?!

    • Who?

      I am a little scared to ask what exactly ‘high-touch care’ entails. Does it involve button-manipulation per that creepy US midwife, or is that an optional extra?

      And how on earth is it hygenic in a hospital ward?

      Yuck, yuck, yuck.

      • Charybdis

        I’m hoping that she means a lot of “atta girl!’s”, literal and figurative ass-pats, hand-holding, hand-patting, gentle touch, massage, etc that the woo brigade somehow *KNOWS* all women want. Positive affirmations, soft lighting, soft voices, tea-and-honey, space-holding, reminders to breathe, murmurs about being a warrior mama, your body was made for this, trust birth, trust me, trust your body, all that claptrap.

        Personally, I hate having people hover around me, especially when I’m sick or in pain. Bring me some crackers and a beverage, ask if I need anything else and GTFU. “High-touch care” would infuriate me. I certainly don’t expect others to share my “hands-off” attitude, so why would she expect others to want what she wants?

        • Heidi

          Ugh, barf. Yeah, no high touch for me.

        • Madtowngirl

          Nothing says feminism like *KNOWING* what other women want. (sarcasm of course)

          • guest

            Do they not realize that in many cultures, women find being touched by people outside their immediate family offensive?

            If you are not my parent, my sibling, my child, or my husband, you have no right to touch me, no matter how good your intentions.

            Americans treat touch and undress very casually, but for millions of women the world over, it is considered a violation of bodily autonomy.

            If you want women to be relaxed and have an easier labor, you must respect that high touch is distressing to some.

    • Liz Leyden

      From my limited experience working in a “high-touch, low-tech” nursing home, there is no way I would recommend it for maternity care.

    • Russell Jones

      Nice work! Nothing says “Game over” like getting the other side to make help make your case. 🙂

    • EmbraceYourInnerCrone

      High touch would have me contemplating smacking people’s hands…likewise the lovely ” how are we feeling today!” “it’s not really that bad!!”

  • Lara

    A few links that may be helpful to your readers:
    Dr. Neel Shah, a professor of obstetrics at Harvard Medical School, agrees with me about the importance of integrating midwives into the care of African-American and low-income mothers, in order to provide safe, appropriate, and respectful care. Links to his work are here: https://scholar.harvard.edu/shah/home.
    This article shows in detail how an African-American doula provided safe and respectful birth support that allowed her African-American client to have a healthy birth with only necessary interventions:
    https://www.nytimes.com/2018/04/11/magazine/black-mothers-babies-death-maternal-mortality.html
    This African-American maternity care activist is concerned that c-sections rates for African-American women are unnecessarily high (African-American women have more c-sections than any other group):
    http://www.blackwomenbirthingjustice.org/single-post/2015/04/23/Call-to-Action-Reducing-Cesarean-Rates-for-Black-Women-by-Lakeisha-M-Dennis.

    I agree that African-American women urgently need better maternity care. I disagree that the obvious way to provide it is to have more OBs do more procedures during their births.

    • LaMont

      But if women are dying of severe medical conditions, why would the first priority be to lower intervention rates? Isn’t that far down the list? If you’re in a crisis and delivery needs to happen, why is a c-section such a moral menace? If a child is healthy and a low risk for dying of a certain VPD, is that vaccine “unnecessary”? Was my “unnecessary” LASIK procedure, say, “disrespectful” to me in some way? Can you justify your a priori assumptions that c-sections are harmful as opposed to helpful – in fact, SO harmful that limiting them is a higher priority than actually targeting the health issues leading to such dismal mortality rates?

      • Lara

        I have never argued that we should not do c-sections. Necessary c-sections are crucial; in many parts of the world, women die because they don’t have access to surgery. On the other hand, unnecessary c-sections are also harmful. They make it much harder to recover from childbirth, and the burden is much worse on women who have to care for children on their own and have to return to work quickly. The first priority is to deliver targeted, tailored interventions that address exactly what the patient needs, not an automatic c-section just because the woman in question is assumed to need one because she is African-American or low-income. Check out the links I provided, especially the first one. Dr. Neel Shah is doing fantastic work to try to hone hospital and birth attendant practices so that women receive exactly the interventions they need, no more and no less.

        • LaMont

          Who’s arguing for automatic c-sections based on demography? We’re arguing for access to proper medical care that doesn’t take a heavy-handed “natural is always best” hand, that could stall access to potentially necessary care. The fact that c-sections have *risk* is… obvious. But you seem to deny that vaginal birth has any attendant risks at all – if a woman looks at the two options and decides that she’d rather run the c-section risks than the vaginal birth risks, is that automatically invalid? Especially since not all women (particularly the planned-c/s crowd) have the same “c-section recovery was way worse” story, and waiting until there’s an obvious crisis rather than trying to prevent one when early warning signs emerge is literal malpractice.

          • Lara

            Seriously, check out Neel Shah’s work: https://scholar.harvard.edu/shah/home. He’s an OB at Harvard Medical School, and I’m just saying what he’s saying. Or read the American College of Obstetricians and Gynecologists’ statement on the overuse of c-section, and strategies for reducing unnecessary c-sections: https://www.acog.org/Clinical-Guidance-and-Publications/Obstetric-Care-Consensus-Series/Safe-Prevention-of-the-Primary-Cesarean-Delivery. What I’m advocating is not fringe stuff. Obstetrics researchers worry about extraneous c-sections because they are a major cause of maternal morbidity.

          • Amy Tuteur, MD
          • RudyTooty

            Yes.

            Dr Tuteur: “Don’t get me wrong. I’m not arguing that there are no iatrogenic complications to C-sections and I’m not arguing that a 32% C-section rate is necessary. I find such a high rate difficult to understand since I had a C-section rate of 16% when I practiced obstetrics. My point is that high C-section rates and low breastfeeding rates don’t kill very many (if any) mothers and babies while literally hundreds of women and thousands of babies are dying in the US due to lack of high tech care.”

            This part should be repeated, for the folks in the back:

            “…hundreds of women and thousands of babies are dying in the US due to lack of high tech care.”

            The objective should be ensuring that patients are appropriately referred to the level of care needed, not that all patients are treated like they are low-risk by default.

          • Anj Fabian

            “low risk by default” is sometimes the UK NHS midwifery model of care.

            I wish I knew how often it is the model of care. I remarked to someone that some UK midwives appear to think that events will happen sooner or later, so there’s no reason to do anything extra.

            Eg, If a woman goes far enough postdates, she’ll require an induction. No need to schedule an induction when there’s always a chance she’ll go into labor on her own. This ignore the risks of stillbirth or other complications. Don’t worry, be happy!

          • nata

            In most NHS trusts there would be certain strict policies regarding risks/referrals/complications. The induction is normally booked for around 40+ 12, aiming for delivery before 40+14.

          • Man, the UK lets women go pretty long. The crunchy midwife practice favored by lots of my churchmates won’t let them go longer than 40+11, and my docs don’t like me going more than a week overdue.

          • Sarah

            In some trusts it’s 40+10.

          • Sarah

            Yes, tbf I’m not sure there’s any trust with policy that women just go as far postdates as it takes for them to labour on their own. There’s certainly a discussion to be had about whether 40+12 is too late, but they are pretty hot on inducing at a certain point.

          • Charybdis

            Why in the name of all that is holy do they want to wait so damn long? Going quite a bit over your due date has complications just as much as prematurity does.

          • fiftyfifty1

            “Why in the name of all that is holy do they want to wait so damn long?”

            I can think of 2 main reasons:

            1. Maternity care in the UK is dominated by midwives and they have a Natural is Best bias.
            2. Inductions take a lot of work. You have to schedule them, you have to arrange coverage, you have to answer patient questions. And that’s all before they even happen! Then you have to check the woman in and spend hours monitoring mother and baby waiting for the medicines to work. So much easier and less time consuming to just wait for labor to start naturally.

            But it’s the reason the UK has such a bad term stillbirth rate.

          • mabelcruet

            I’ve never really understood the timing of inductions. At one end of pregnancy, the mums are getting their dating scans and coming out with gestational ages of 5+6, or 8+3. They get their anomaly scan at 20 weeks or thereabouts, and again they are dated to 19+3, or 20+4. And yet, at the other end, its ‘we’ll let you go to T+12 because we can’t be exactly sure on your dates so its safe to go over’. Why be so accurate at one end if you are going to completely disregard it at the other? Maybe there’s an esoteric obstetric/midwifery thing going on, but some of my saddest cases are stillbirths where the clinical history goes ‘term+2, all well-active baby. Term+4, active baby. normal tones. Term+10-no fetal heart heard’. It’s so completely unnecessary.

            And then those poor women whose dates are pushed back and back. Baby measuring small, so obviously the mum’s dates must be wrong, without any consideration of whether its early onset fetal growth restriction. Is it because the midwives are wanting to keep mothers in their low risk group, rather than hand over to an obstetrician? I see this at least a couple times a year. And the fundal height measuring-a huge proportion of third trimester stillbirths aren’t growing properly. I regularly get term stillbirths where the fundal heights are plotting along the 50th centile, or 75th centile, and yet when I get the baby he’s on the 3rd centile. I’m not talking a few grams out from the estimated fetal weight, its a kilogram or more between estimated weight and actual weight. So what happens afterwards? Is there retraining of midwives who failed to assess fundal height correctly? Is anyone looking at this? Maybe I just get the really erroneous ones so I’m seeing a skewed selection, but it worries me, particularly as UK stillbirth rates are so poor and showing little sign of improving.

          • Mel

            My mom pointed out that “we’re not too sure on dates” made a certain amount of sense in the early to mid 1980’s when she had her babies without ultrasound – although she was always pretty sure of at least which menstrual cycle she conceived in.

            Fast forward 30-odd years.

            Thanks to OPKs, I was sure of when I ovulated within 24 hours so that’s a total window of around 48 hours of when my son was conceived. My LMP dates gave me a conception date that was about 10 days early than when I was pretty sure I conceived. At the NT scan at 12(ish) weeks, Spawn measured about 8-10 days younger than my LPM….but right about dead on to when I thought I conceived.

            Didn’t make it to term with him – but I would have fought any attempts to move my due date near term since I had two data points that suggested the same window of time.

          • Empress of the Iguana People

            Thanks to IVF, I know -exactly- how old my babies were. They started splitting on the afternoon of Friday, February 8, 2013. One was implanted and the other frozen 5 days later. Why did they keep messing about with the due date? Especially with kid 2. Made no sense.

          • fiftyfifty1

            The fundal height mis-measurement is willful. We were taught that to measure fundal height you have to do it with the blank side of the tape, and only after you have put your finger on it can you turn over the tape and see what it measures, and that is the number you have to record. If you don’t like that number, you can’t change it. At best you can call a colleague into the room and they can remeasure, once again using the blank side of the tape. Otherwise, we were taught, you are prone to “measuring” what you want to find rather than what’s there. It’s not that it’s hard to measure (this is something that anyone should be able to do without problem after basic training) it’s that it takes integrity.

          • Amy Tuteur, MD

            Thank you for coming over to engage. I’d like to ask you about a couple of comments you made on your piece.

            1.You claimed: “Yes, OBs see a ton of deliveries, but they only see the last few minutes of each one, so it’s not exactly more experience than nurse-midwives, so much as different experience.”

            Really? At this point more than 50% of obstetricians are women and many had children of their own. I can assure you I was there for every minute of my four labors and vaginal births. Do you really mean to suggest that you are qualified to opine as to how the education and experience of a female obstetrician compares to that of a midwife?

            Are you claiming that midwives taking time taking caring for low risk women somehow qualifies them to care for high risk women and those with serious complications of pregnancy? If not, how is it relevant?

            2. You write: “I had my first birth with an Oakland midwife who served an ethnically and socioeconomically diverse population, and she promised to all of us to do her best to get us through the birth safely and without surgery. Her very low c-section rate and excellent safety record showed that she delivered on that promise, to all of us. I’d rather have her practice replicated on a larger scale than automatically send everyone to an OB.”

            I’m struggling to understand why you think your personal experience with one midwife can and should be extrapolated to women who are very different from you, with different needs and desires. Perhaps you can explain.

            Thanks in advance!!

            Moreover, don’t you think it would make more sense to ask women what they want rather than presuming you know what they want?

          • fiftyfifty1

            You don’t seem to get it. We are quite familiar with Dr. Shah’s work. We read his opinion pieces and talk about them in detail on a regular basis here. It’s that we don’t AGREE with him, and we have good reasons why. And it’s not coming out of a place of ignorance either. Many of us here are doctors ourselves, and well positioned to argue the merits, or lack thereof, of Dr. Shah’s opinions. I urge you to read the links Dr. Tuteur has posted.

          • lawyer jane

            Lara, I can believe that more access to CNMs would decrease c-sections.

            But what evidence do you have that decreasing c-sections is going to prevent maternal and infant deaths and injuries?

          • Lara
          • lawyer jane

            Lara – neither of those articles you posted demonstrates that “unnecessary” cesarean sections cause excess maternal and infant mortality in the US, or race-based health care disparities.

            And don’t be mistaken – Dr. Tuteur and the regulars on this blog aren’t against new practices and procedures that reduce c-sections, as long as this is not done at the expense of maternal or infant health, or maternal autonomy. The problem is that the conversation has become very muddled. Rather than focusing on what we actually know reduces maternal and infant mortality (for example, California’s standardization of approaches to hemmorhage), people default to an ideology of “NATURAL IS BETTER! INTERVENTIONS ARE BAD! REDUCE C-SECTIONS.” From that, follows the logical mistake of thinking that more midwives and more doulas are going to reduce maternal mortality, because they will reduce c-sections. But this ignores the fact that maternal mortality is caused by factors other than “unneccesary” c-sections, and will only be resolved with BETTER health care, not LESS healthcare (midwives and a no-intervention mindset.)

            Where privilege comes in is thinking that you can just stick a midwife or doula on top of ALL the disparities in health care, and that that’s somehow going to help poor women and women of color. No. Well-off white women chose midwives ON TOP OF all their health care advantages: good health; planned pregnancies; prenatal care; access to a good hospital with a NICU; and care providers that are not racially prejudiced against them. It is indeed privilege NOT to see that whole substructure underlying the “choice” to opt out of OB care.

            Also on a personal note – some of us are here because we had poor experiences with midwifes, and saw first hand how the ideology of “natural” and avoiding c-sections actually put us and our babies in harms way. My midwife, for example, suggested that she would have ignored a blood pressure spike at 39 weeks 4 days that constituted a hypertensive crisis (160/113), except that it was “already written down” and she knew she couldn’t. Then, she sent me to WALK to the hospital and admit myself … in July, in 100 degree heat! At the time, it was ALREADY well established by research that the proper protocol would have been to induce me at 39 weeks for high BP. But because this midwife had a philosophy of “natural birth FTW!” she took risks with my life and my baby’s life that are hard to think about even now. Everything turned out ok, but it could have been a disaster. It seems like she literally wanted to wait it out until I was pre-eclamptic.

          • demodocus

            I had awesome bp throughout my first pregnancy. 4 hours into labor, before the pitocin was even started, bam. a spike into 200 over something else scary.

          • swbarnes2

            According to your link, these are the 5 most common cause of maternal death

            Complications of preeclampsia 15 16%
            Amniotic fluid embolism 13 14%
            Obstetric hemorrhage 11 12%
            Cardiac disease 10 11%
            Pulmonary thromboembolism 9 9%

            Please explain exactly how fewer C-sections and more CNMs taking over from doctors will make fewer people die of these causes.

          • AnnaPDE

            Thank you, I’ve checked it out often enough. His approach would have led to an emergency CS in my case, with a good chance of pelvic floor damage for me and whatever hours of pushing against bones does to babies for my son.
            No thanks. I’ll take my nice, planned, only in hindsight really necessary CS any day, and Dr Shah can take chances with his own body.

          • PeggySue

            Actually, I don’t think they are. Also, you do know, don’t you, that the WHO some years ago pulled its “ideal” C-section rate out of its collective arse? There is no basis whatsoever for their “ideal” rate, which was 15%.

          • Sarah

            Of course she doesn’t.

    • Amy Tuteur, MD
      • Lara

        Ok, at that point I’m done arguing. Since you know better than the Harvard professor of obstetrics.

        • fiftyfifty1

          You are done arguing? Without even reading what she posted? Read her links and rebut her points (if you can). Think for yourself! I mean you post a bunch of links and expect people to read them, but won’t do the same when others post links!?

          • Lara

            I am posting links to peer-reviewed studies in the obstetrics literature, and an excellent review of the literature by ACOG. I am not going to re-write ACOG’s statement in bits and pieces in response to Dr. Tuteur’s points. I am supplying you with evidence from the peer-reviewed medical literature because when I make my own points, your fellow commenters dismiss me as someone with the wrong kind of degree.

          • Amazed

            What are your qualifications to say which review of the literature by ACOG is excellent and which isn’t? Other than “I found this Harvard professor who supports my already existing notions so he must be the greatest and rightest person in the world and I’ll totally insert his name whenever someone disagrees with said notions?”

            Amos Grunebaum. Feel free to consider him to express MY views. He’s conducted his own studies. And his results are quite meaningful.

            I won’t point at his research. Since you’re so qualified to judge excellent obstetric texts, I’m sure you can find it yourself. When you can spare some time in your very busy schedule, I mean.

        • Amy Tuteur, MD

          Oh, so if a Harvard professor disagrees with your research we should just ignore what you say. How about judging claims on their own merits, not invoking the logical fallacy of arguing from authority?

        • Dr. Tuteur was a Harvard professor, too. Ad verecundiam fail.

          • Lara

            Dr. Tuteur was a clinical instructor at Harvard, not a professor. Please feel free to take Dr. Shah’s arguments to represent my views, and you may argue directly with him at this point. Or yell at him via this blog, if you wish. Arguing directly with Dr. Tuteur is a never-ending rabbit hole, and not the best use of my time.

          • Amy Tuteur, MD
          • Lara

            I’ll be happy to read your future publications in the peer reviewed medical literature.

          • Amy Tuteur, MD

            There’s no reason to dig yourself in even deeper. We get it: you make claims because you like them, won’t read opposing points of view, can’t argue the merits and appeal to authority as if that will excuse your lack of knowledge.

          • The Computer Ate My Nym

            The peer reviewed literature that you largely failed to cite? The NYT is not a peer reviewed publication. Neither is Dr Shah’s home page or even an ACOG position page. The journal article, I will agree, is, but as others have already pointed out, there are problems with it. Why not cite the primary literature to support your position more prominently if that is important to you?

          • momofone

            We see this a lot. People are not bowled over by your argument—have the audacity to challenge it, in fact—so you are suddenly way too busy to engage. I wonder if you’ve actually read what Dr. Tuteur has cited.

          • Lara

            Here’s ACOG saying there’s too many c-sections, i.e., the overly high rate of cesareans causes unnecessary iatrogenic morbidity and mortality:
            https://www.acog.org/Clinical-Guidance-and-Publications/Obstetric-Care-Consensus-Series/Safe-Prevention-of-the-Primary-Cesarean-Delivery
            A research study published in AJOG, the premier obstetrics research journal:
            https://www.sciencedirect.com/science/article/pii/S0002937808002688
            The ACOG statement really is an excellent summary of the evidence. I am not going to re-do their work.

          • momofone

            Amazing-you managed to squeeze one more comment into your very busy schedule!

          • FormerPhysicist

            The research study is pretty much a fail if it’s going by mode of delivery instead of planned mode of delivery. It says nothing about what would have happened if those c-sections were not performed. I’d be willing to bet a large percentage of the c-sections in that study started out as vaginal births and the c/s was done in response to a medical indication during the birth. Certainly my c/s were done after it became clear each time that I and my baby would die if I attempted to continue with a vaginal delivery.

            I’m not a physician, but I have some small knowledge of statistics.

          • swbarnes2

            We are grown-ups here. We read the papers behind the summaries, not just the summaries.

            For instance, in one of the citations about maternal deaths between vaginal/C-section deliveries, they say they only count 2 deaths as being related to vaginal delivery. But earlier, they claim that 16 deaths happened because a C-section was not done. Those 16 should count in the vaginal death pile, which would make vaginal birth more dangerous than a repeat C-section.

          • RudyTooty

            “Maternal death in the 21st century: causes, prevention, and relationship to cesarean delivery (2008)

            Conclusion

            Most maternal deaths are not preventable. Preventable deaths are equally likely to result from actions by nonmedical persons as from provider error. Given the diversity of causes of maternal death, no systematic reduction in maternal death rate in the United States can be expected unless all women undergoing cesarean delivery receive thromboembolism prophylaxis. Such a policy would be expected to eliminate any statistical difference in death rates caused by cesarean and vaginal delivery.”

            The conclusion of the AJOG article (Science Direct) does not call for a reduction in cesarean sections, but universal thromboembolism prophylaxis for women having surgical births.

            The citations you’ve shared do not entirely support your perspective and opinions.

          • swbarnes2

            Also notice that Lara’s ACOG citation says almost nothing about outcomes for babies.

          • kilda

            “I totally have a good answer for your arguments, but I’m too busy to tell you what it is.” Reminds me of a 10 year old saying “I do so know the answer, but I’m not going to tell you.”

          • Sarah

            Hiding behind Neil Shah isn’t a very good use of your time either, but you appear not to have let that stop you.

          • Anonymous

            I’m sorry what were your qualifications? I don’t see MD in your title.

          • momofone

            Clinical instructor, professor, whatever; she still has education, training, and relevant clinical experience *in the field about which you are pontificating* that your doctorate in history didn’t provide.

        • Russell Jones

          “Ok, at that point I’m done arguing.”

          I kinda doubt that.

        • Sue

          Lara – when you’re not across the obstetrics and childbirth literature and statistics, please don’t insist on arguing with others who are. Just quoting one provider and saying “I believe what he says” doesn’t cut it in a discussion of evidence. If another Harvard OB professor says something different, what is your basis for choosing which Harvard professor to follow?

          In actual medical practice, people follow the evidence and accepted best practice, not individuals.

    • RudyTooty

      The NYTimes article is an interesting one to share – the mother lost a baby due to lack of access to appropriate and timely medical care when she was showing signs of severe pre-eclampsia.

      “A few hours later, a nurse brought Harmony, who had been delivered stillborn via C-section, to her. ”

      ^^^This is the problem that needs to be remedied – lack of access to life-saving care. That baby did not need to die – and she did not need a doula or a midwife – she needed an obstetrician to manage her complications appropriately, and an NICU.

      That she had a nice birth with a doula later on is one hell of a consolation prize. She lost a baby to do lack of appropriate care.

    • I agree with “integrating”, but what is being pushed is “replacing”. I have worked WITH doctors for most of my career, but the parameters are quite clear where my autonomous position changes to a collaborative one. This distinction is lost too much of the time and what should be a collaboration becomes a confrontation.

    • Liz Leyden

      Regarding the NY Times article, a bad outcome happened because the woman *wasn’t offered* necessary interventions. Unless the doula advocated for a C-section, I don’t see how she could have changed that.

  • PeggySue

    It might indeed be helpful if very well-trained CNMs were more available to rural or urban women with low incomes. Access to competent medical care is an issue, and the closing of OB units in rural areas and in low-income urban areas surely won’t be helped by adding CPMs and doulas.

    • RudyTooty

      A CNM *might* be able to provide better access to maternity care in a rural area. And most definitely improved care over a CPM. But it does not negate the requirement for an available surgeon – OBGYN or General Surgeon – who can perform cesarean births.

      There is no safe model of midwifery without surgical services readily available.

      • fiftyfifty1

        “There is no safe model of midwifery without surgical services readily available.”

        This x 1000. The fundamental role of midwife is to watch low risk women like a hawk, and hand off patients who develop complications quickly.

        • RudyTooty

          It’s one reason I go bonkers when anyone suggests that the lack of OB/GYNs in rural areas could be remedied with *more CPMs!!*

          No. That is not a thing. That will not work. A CPM working in an area without hospitals equipped for obstetrics is just a freaking disaster waiting to happen. Maybe many disasters waiting to happen.

          A zero percent cesarean rate is not a good cesarean rate.

      • PeggySue

        Completely agreed. The decreasing access to OBGYN care as hospitals stop offering it is terrifying to me. You could be AT the hospital, but if there’s no OB, no surgeon, no anesthesia, no OR, you might as well be at home.

      • PeggySue

        Doesn’t matter how good a provider is at appropriate referral if there’s no place and no person to refer to.

    • Platos_Redhaired_Stepchild

      Skilled midwife-care didn’t work out so well in the Netherlands.

      http://www.skepticalob.com/2015/03/midwife-led-care-kills-babies-and-mothers.html

      And its not working out too well in UK either.

      http://www.skepticalob.com/2018/02/uk-midwives-deadly-contempt-for-obstetricians.html

      Midwives: We’re Probably Better Than Nothing

      • lawyer jane

        Unfortunately that seems to be where healthcare is going in the US … I mean, how many states are now going to follow Arkansas and say that medical abortions can only be provided by people with hospital privileges? The battle now shifts to getting as many care professionals as possible to have hospital privileges. If that’s gonna be midwives, we’re gonna have to accept it …

      • PeggySue

        Oh, believe me, I agree with you completely. Let me clarify. I was imagining CNMs who worked closely with doctors and could legitimately provide some care AS LONG AS THINGS STAYED SIMPLE. They would of course have to stay out of the woo.

  • lawyer jane

    Off topic: I think some major changes in international “breast feeding promotion” are going to happen in light of the spread of HLTV-1 (cancer-causing virus that transmits through breastfeeding.) It’s hard to tell from this article if the concerns about breastfeeding in Australia are legitimately about families that don’t have access to formula and clean water, or just the same old “breast is best” obsession.

    https://www.sbs.com.au/nitv/nitv-news/article/2018/05/31/we-dont-have-time-breastfeeding-dilemma-delay-on-htlv-1

  • Anonymous

    So….PhD not MD.

    Here’s a hint…if your PhD is in History, you don’t get to argue medical procedure. No more than I get to, and I have a background in statistics. The best I can do is call data in a sample set weak.

    • demodocus

      This is why I ignore my phd psych uncle’s ideas about vaccination. Going with the ped on this one.

    • BeatriceC

      MrC has a PhD in biophysics and worked in pharma research and wouldn’t consider himself qualified to argue medical procedure beyond a certain basic level.

    • The Bofa on the Sofa

      I have a PhD in chemistry.

      One of the most important things I know about my PhD is that I am an expert in my field, and I know what it takes to get to be that way.

      This tells me that I am NOT an expert in other fields, and I need to listen to those who are.

      • Merrie

        EXACTLY!

        I have a doctorate in a medical field but I’m not a MD or DO. I have a sense of how much education doctors must have and how much context they have for everything. Someone who took a stats class can pick apart one paper but it doesn’t mean they can hold a candle to the broader knowledge of an expert in the field. (Also, it’s always that one maverick paper that gets trotted out.)

        • BeatriceC

          With stats, I used to tell my students that the whole purpose of taking an introductory level stats class was so they had enough knowledge for their hinky-meters to go off if they read a study that was poorly designed, engaged in poor data analysis techniques, etc. This doesn’t make them experts, but to know enough to know when to go ask an expert.

  • The Kids Aren’t AltRight

    There is also an ugly privileged aspect to natural childbirth, because woman in poorer countries often don’t have a choice but to endure natural birth. Thousands of women and babies globally die (or get injured or disabled) every year for want of medical intervention, and I am sure many of those women would love access to epidurals.

    • RudyTooty

      Yep. It’s only “empowering” to reject an intervention if you have access the the intervention in the first place.

      So. Much. Privilege.

  • lawyer jane

    This is all so frustrating. I would love to see actual research and efforts that do use CNMs (and properly trained doulas) to improve access to health care for poor women and women of color; as well as efforts to get more women of color into these professions. It seems totally plausible to me that they could have a role in improving the outcomes that *matter* (health of mother and baby). But the whole discourse gets so lost in talk about “natural birth” and “unnecessary c-sections”; and misguided emphasis on a narrative about how the ebil OBs stole away maternity care from the wise old midwives.

    • Cartman36

      I agree. This is my third pregnancy and it is the first time that I have seen CNMs regularly because it was so much easier to get an appointment that worked with my schedule and I spent less time waiting to be seen than I did with the OBs. I had a really good experience.

    • LaMont

      With their rhetoric, I’d be legitimately terrified of working with a non-OB if/when I have kids! They themselves describe their job as obstructing access to healthcare – making them worse than a compassionate layperson…

      • lawyer jane

        I wouldn’t be worried about going with a Certified Nurse Midwife (CNM) who is part of a hospital practice, if you are low-risk. I’d just ask a lot of questions about how they refer you to OBs, their position on pain relief in labor, and how they manage complications during labor. As for doulas … much trickier! Some of them are definitely nuts and you’d be better off alone. But others are fine supporting medicated births. The one thing that worries me about doulas the most is that they ALL seem to see as part of their jobs “helping the woman labor as long as possible at home.” I’ve heard too many stories about women delivering at home or getting far too close it it because of this.

    • RudyTooty

      I agree, if the objective became advocating for better access to increased levels of care and necessary medical and obstetrical interventions, midwives (not-so-sure about doulas, but maybe) could actually improve outcomes.

      Waterbirth is not a good outcome.
      No epidural is not a good outcome.
      Hypnobirthing is not a good outcome.
      Beautiful birth photography is not a good outcome.

      It’s just fluff. Puff. It has nothing to do with ensuring the population of patients receives the most appropriate care for their current condition.

      • PeggySue

        CNMs though, not CPMs. And hospital-based. Remember Serena Williams. No CPM or doula could have protected her from almost dying after birth.

    • Anna Lee

      Hi Jane,

      For the record, doulas are not medical professionals of any kind, and do not (and should not) provide medical advice. Even a “properly trained” doula (whatever that means) will not help improve access to good healthcare for women. Doulas are only present to provide support and comfort measures to laboring women.

      I agree wholeheartedly with you that the outcomes that matter and the health of mother & baby!

      • lawyer jane

        Well, there does seem to be support for labor doulas decreasing c-section rates, so that’s solid. I can also understand the argument that well-trained doulas could provide women of color a means to access healthcare and surmount barriers of implicit bias that they wouldn’t get on their own. In the current *imperfect* system, I would think that having a doula on board to advocate for the patient might be a good thing. But that has to be totally severed from the notion of doulas as promoting “natural” birth. Maybe we need a whole new approach of providing Patient Advocates, and just scrap the whole woo-y “doula” terminology?

        • swbarnes2

          Access to a doula =/= health care access. And no one cares about fewer C-sections if the truly bad outcomes increase as a result.

          If you want an example, here’s a doula who pushed the mother to ignore the doc’s recommendations and not get a C-section. So this is a “solid” outcome you are glad of?

          http://www.skepticalob.com/2016/05/gues-post-heres-what-happens-after-the-shoulder-dystocia.html

        • RudyTooty

          I could see doulas acting in a different role than many of them currently acting in. As a patient advocate. As an additional voice in the room, as a person who will speak up when the patient has a concern.

          This is what doulas do for privileged white ladies – speak up for their wants and desires, act as a support and an advocate – but what they want from childbirth is unmedicated and self-centered birth. But I do think a lay person – a doula – could also as as an advocate for many patients in the realm of getting appropriate care, not being discounted, ignored, and advocating for new staff, new providers, when concerns aren’t being heard.

          I see exactly what you’re saying, lawyer jane.

          As a society, we’re biased toward giving white ladies what they want, so doulas and placenta specialists and birth photographers are all welcomed/tolerated. If WOC started coming into hospitals with personal advocates in a quasi-doula role, the hospital might not be as accommodating. All the more reason to have them.

          • Anna

            These people should probably be trained and accountable though if women are relying on them as advocates. Social workers or community workers or indigenous elders who must adhere to a code of ethics and have a spirit of cooperation with allied health professionals? In my mind the term doula is so tarnished. All I can think of is women with barely a high school certificate selling themselves as “experts” and telling women to ignore Drs and hospital policies.

          • Who?

            A bit like patient advocates that are popping up around the place here. They know the system, and know who to talk to and how to talk to them to understand what is on the table and communicate patients’ wishes/concerns etc.

          • RudyTooty

            The word “doula” is tarnished, I agree.

  • Cartman36

    I laughed when I read “As far as I can see, it was an attempt to shut me down with highly-charged language that was intended to shame me and alienate those likely to be my allies.” How old is this woman?

    As a professor she should be able to respond to your claims without resorting to saying you are trying to “shame” her.

    • JDM

      Both in the linked piece and her comments here, Prof. Lara Freidenfelds engaged in an awful lot of logical fallacies, especially considering the ratio of logical fallacies to word count.

      • Cartman36

        I think my favorite is “Seriously, check out Neel Shah’s work: https://scholar.harvard.edu…. He’s an OB at Harvard Medical School, and I’m just saying what he’s saying.”

        I.E. Don’t ask me to justify, clarify, or expand on my claims. I’m just regurgitating what Dr. Shah says.