Hypothetically speaking…

I’ve seen a couple of things recently that has turned my mind to this topic, and I’m curious as to what my readers may think.

Let’s say that you’re a midwife who attends home births (for simplicity’s sake, pretend there are no legal or practical obstacles to this), and a woman asks you to attend the birth of her baby at home. No big deal, right? Except at some point you realize that she (or her baby) is high risk and she shouldn’t be giving birth at home — that it really is safest for her to give birth in the hospital. She refuses, and says that if you don’t attend her at home, she will give birth unassisted. What do you do?

If you attend her birth, are you tacitly approving of it, despite verbal protestations?

If you attend her birth, are you enabling her to give birth in a dangerous situation, because she just might change her mind and give birth in the hospital if she really had to “go it alone”?

If you attend her birth, and something happens, will she resist or outright refuse a timely and/or necessary transfer to the hospital?

If she refuses to go to the hospital, what exactly will you be doing as a midwife? — your job description is to keep her and her baby safe, and since she won’t go to the hospital and OB care now when it would be prudent, will she change her mind in labor? or only after her baby dies or is badly injured?

If you refuse to attend her birth and she does go unassisted, and something goes wrong, will you feel guilty that you weren’t there? or glad that you weren’t there, and the responsibility for the negative outcome isn’t on you?

Would you get the authorities involved, or child protective services?

Would you support her right to give birth wherever and however she wanted, even though the baby would possibly be hurt or killed?


5 Responses

  1. I’d like to say in advance that I feel like I’m hogging your blog with all my comments Kathy, and I truly appreciate your allowing people to have their viewpoints posted without the hullabaloo.

    We’re expecting our surprise baby in early August and have hired a private CNM for a planned homebirth. We will utilize a tub for labor pain, and possibly a waterbirth, but who knows what position I’ll finally end up in for the birth.

    As this is a HBAC, I am certainly aware after loads of research that the worst thing that can happen for the family is a true u/r (not dehesience) w/fetal or maternal death, and the worst thing for me personally would be the 1/2500 risk of hemorrage due to placenta accreata/perceta/increta. I’m also aware that hospitals in my area do use prostglandins and syntocinon for induction and augmentation for VBACs. In my mind, HBAC is much safer for my baby as the risk of uterine stimulants being used (in the name of the Friedman Curve, scurrilous post-datism, and speed) is nullified, therefore the overall risk of u/r is reduced. There aren’t enough ethical and qualified practitioners at this time to risk a planned hospital VBAC. I care too much about my family for that.

    But, if a situation arose in which my midwife felt that it would be safer to birth in the hospital, I know she would be there during the L&D or c/s to advocate for and support our family. Having discussed with her what situations would lead to hospitalization, I am confident that this would occur on the off chance and only if necessary.

    I certainly advocate necessary hospitalization and intervention. The problem is that medically necessary procedures mean convenience, preference, training, and defensive medicine to doctors. This attitude leads to many narcotic overdoses (there are even narcotics in epidurals, cocaine and heroin derivatives at that), and uterine stimulant related situations which kill or disable baby and mother.

    To private midwives, necessary procedures are truly medically necessary, and as much as it would suck to hear “In my opinion it would be safer to go to the hospital for this birth”, I would know that it is in our best interests and had better listen.

    For more factual information on current issues surrounding maternity rights and various interventions, drugs, and their impacts, you might want to check out the Alliance for the Improvement of Maternity Services USA at http://www.aimsusa.org. It’s geared toward the US but is globally applicable.

    Thanks again for letting me borrow your soapbox!

    • Evie,

      You’re more than welcome — “hog” away! 🙂

      Thanks for bringing the AIMS USA group to my attention. I’ve seen it before, but had forgotten about it. It is chock-full of useful information!

  2. i’d say the whole situation would be blowing the needed trust factor, going both ways. mom obviously isn’t willing to trust the midwife and her judgement, midwife can’t trust the mom to work with her… i would not see this going well, whether at home or at hospital. i think the midwife fulfills her duties more in standing by her judgement. if mom chooses not to find a new provider, having been cautioned, thats her choice to make… dumb as it may be.

  3. If I were a midwife..
    I would do everything I could to encourage the woman to do the safest thing for her and her baby by having the high risk birth in the hospital. I believe I would refuse to attend it myself. If the woman still wished to birth at home, I would provide her will all of the information I could so that during her labor, if something were to happen, hopefully the best decision would be made.
    Having had my baby with a CNM at a birth center, I would hope that all of my future children will also be born in the same wonderful environment. However, if I was labeled a high-risk pregnancy, I would search till I found a provider that would work with my wishes as much as possible to make the birth safe for my child and myself. A healthy, live child is more important to me and I would be willing to give up SOME of my freedoms to have that.

  4. That’s a really hard question. I’ve thought about it a lot in the past and have not come up with a complete answer. There are good arguments on both sides of the question. On one side, I firmly believe that a woman has the right to birth whenever and however she pleases, regardless of risk factors. On the other hand, adverse outcomes from risky situations that would have probably been better in-hospital demolish the hard work that we’re all doing to legitimize homebirth.

    I personally know two midwives who have the opposite stance on this. One says, “I’ll tell you when i think we should go to the hospital, but if you refuse to go, I won’t abandon you.” The other says, “I’ll tell you when I think we need to go to the hospital, and if you don’t want to go, you’re on your own.” With midwife B, this came up a couple of weeks ago with some friends of ours who were birthing at home but had problems with high maternal blood pressure. At a certain point, the midwife said, “We need to transport. If you want to stay home, then it’s your choice, but I’ll have to leave.” Honestly, I think both midwives have good sense behind their reasoning. One is protecting mothers’ rights; one is protecting herself, her livelihood, and the legality of homebirth midwifery. It’s hard to find the balance between the philosophies.

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