A flawed study published in “a second-tier journal”

That was the conclusion of Dr. Nicholas Fogelson about the much-publicized recent meta-analysis on home-birth, in a comment on Science & Sensibility’s post about it. [Honestly, I didn’t know that the AJOG was so poorly respected. Makes me rethink what studies I’d look at, if it was published there.] In the S&S post, Amy Romano questions whether the meta-analysis was even appropriate, in light of the huge de Jonge study of over 300,000 planned home births in the Netherlands. She writes,

Lack of statistical power could not possibly be the rationale for conducting a meta-analysis on the safety of home birth. [The de Jonge study] contributed 94% of the data on planned home birth in the meta-analysis (321,307 of 342,056 planned home births). That study found virtually identical rates of neonatal death in both the planned home and planned hospital births, with relatively narrow confidence intervals.

The blog “Birth Sense” has two posts on this study: a prologue of sorts and then a discussion of the 12 studies included in the meta-analysis. And despite Dr. Fogelson’s comment that AJOG is a “low-impact” journal, many news sources apparently didn’t get that memo, and had no problem trying to make a huge impact with the sensational headlines that “home birth is three times as deadly as hospital birth.”

I have read numerous blog posts and news articles about this study and will include links to them below, but I want to comment on some things. First, since the study isn’t going to be released for a few more months, I haven’t read it (I know it’s available by request, and I presume for a price or if you have a subscription), so I’m not sure what I can add to what those who have read it have said. In some ways, what I’ve read has raised more questions than answers. The main question is, what were the inclusion criteria? From some sources, I’ve discovered that the original study had to have been published in English (a common enough restriction — gotta make sure the doctors don’t get bogged down in any bad translations from reading foreign language studies!), and also to studies that reported outcomes of mothers and babies in both home and hospital births (apparently the reason why the Johnson & Daviss 2005 article on CPM births, published in the BMJ was not included — they didn’t have a hospital “control group”).  But I wonder, did they not have any exclusion criteria for the size? They included one study that had 5 women in each group — a total of 10 women studied! If I may say so, “Good grief, Charlie Brown!”

Additionally, they included the Pang study, which itself was flawed, in that it reported not only planned home-births (with or without a qualified attendant), but it also included unplanned home-births — this despite a title that declares that it looked at planned home births. Nor was the study limited to the “term” period, but included births as premature as 34 weeks. Since I don’t have the meta-analysis in front of me, I can’t say how heavily it influenced the conclusion, but “garbage in, garbage out” — if the data going into the study is wrong, you can’t reach the right conclusion.

In all meta-analyses I’ve read, there has always been a discussion of inclusion and exclusion factors; if there are others besides the ones I’ve mentioned above, I’d like to know — out of curiosity, if nothing else.

Some of the articles I’ve read have touched on problems researchers may have in reconciling different studies, which may all have different designs, or look at different populations, etc. Again, I don’t have the study, so I don’t know if Wax and associates looked at all the different factors and did an appropriate exclusion or analysis of differing studies. Some differences among studies that I can think of that might need some statistical calculation or exclusion of some births (which may or may not have been included in any of the cited studies), include prospective vs. retrospective study design; inclusion of term, preterm or post-term births; cross-over (women planning a home birth who transferred to the hospital, or women planning a home birth who gave birth precipitously outside of the hospital); whether babies with congenital anomalies were excluded; whether the mothers were properly matched in the groups — same general age, income, health, parity, etc.; whether twins or breech or post-term babies were included or excluded (many studies are limited by design to “singleton vertex babies from 37-42 weeks gestation”); cause of death (for example, excluding accidental deaths by smothering or car wreck would be a good idea, I’d think, if possible); whether there was a trained birth attendant; quality of the original study, and undoubtedly many other things I can’t think of.

One of the confounding factors that some of the articles I’ve read, is that some of the studies examined only the early neonatal period (up to 7 days), while others examined the full neonatal period (up to 28 days). Which reminds me of another factor I should have included in the paragraph above — perinatal deaths including stillbirths, and also possibly intrapartum deaths. Several of the writers have noted that the largest study, the Dutch study, was not included in the actual analysis of the most loudly trumpeted conclusion, namely, that home birth carries a 3x death risk for babies when compared to hospital birth. The largest study which had almost 95% of all of the births in all of the studies, and showed no difference for neonatal death, was excluded for the purposes of  neonatal death. It seems that it is because that study only went up to 7 days. Was there not some sort of statistical analysis that could be done to extrapolate deaths that may have occurred from days 8-28, so that this study could have been included? Or, an analysis that could have excluded deaths from 8-28 days in the other studies? As I said, I have more questions than answers. I’d love to read the study for myself (and the Birth Sense link has links to all 12 of the included studies — some of them are abstracts but some of them are the full studies, so I may start by reading those), but I wonder if any of the questions I have would be answered if I did read it.

Now for the links that I read, in addition to those I cited above (some of them include other links to other articles, as well) — obviously, most of them are going to be favorable to the “this meta-analysis is junk” viewpoint, but not all of them are:

Now for some links to other home-birth related stuff that is not about this flawed study:

  • The Unnecesarean’s blog post on a new study in this month’s issue of Obstetrics & Gynecology that says it’s important to distinguish between planned and unplanned home births [and I’m just in the mood right now, due to lack of sleep, to say cheekily, “and next, they’ll tell us that water is wet, and the sun is hot!” :-)]; but seriously, it’s because many times “unplanned” home births are to women with known risk factors that may cause problems with either themselves or their babies
  • the NHS write-up of the de Jonge (Dutch) home-birth study
  • High Tech vs. Nature’s Way,” an article from Minneapolis-St. Paul
  • The College of Physicians and Surgeons of British Columbia “Resource Manual” on planned home births

Ahhh, now I can close out some tabs on my browser.

Oh, and Dr. Amy, I’m pretty sure you’ve been waiting for me to write this up since I know you read me (not to mention you probably have “home birth” on your Google Alerts, and probably regularly add other keywords to make sure you don’t miss any internet discussions), so if/when you comment, just remember that you have to stay on topic. No cut-and-paste jobs like you usually do, m’kay? Oh, and before you bluster that the studies which showed that home birth is safe only in the countries of the study (like the Netherlands and Canada), because of how their midwives are integrated into the health system, I want you to answer a question: if that is true, why don’t you try to integrate midwives into the health system in America, rather than trying to elbow them out? That would solve that problem. 🙂

International Day of the Midwife

Celebrate midwives and midwifery! If you like this video, pass it on.

ISO: Home Birth and/or Midwifery pictures and videos

I’m making several promotional/educational videos about midwives, midwifery, and home birth for our Mississippi Friends of Midwives group, and would like to have more pictures and/or videos that I can use. Here are the two that I’ve gotten done so far.

This second video is clips from my younger son’s newborn exam (we had no video nor pictures from my first home-birth). I edited it for length as well as due to background noise (my mother and sisters talking), so this isn’t the entire exam.

I may even be able to make a lengthier DVD production if I can get enough material. If you have any pictures or video that I can use of midwife-attended births (preferably a home-birth, but I wouldn’t exclude a hospital birth), or even pictures/video of an OB-attended hospital birth to use as a contrast to home birth, or you can video yourself talking about why you chose a home birth, if you’re a midwife why you became a midwife, etc. — if you would like to be included, you can email me the pictures and/or links at kathy_petersen_283 at yahoo dot com [note the spelling of my name!], and in the email please write some sort of statement giving me permission to use the pictures/videos for MS Friends of Midwives.

Thanks!

“We’ve never heard such a ruckus”

That was the quote from the Senate Chairman when talking about the recent Mississippi legislation (that died in committee), that would have made all non-nurse midwives illegal in our state. With over 5,000 phone calls, the response was unprecedented. While that may not seem like a lot of phone calls, apparently, it was! Considering that our whole state population is somewhere around 2.5 million, that is 0.2% of the population calling (assuming that each phone call was by a different person, which we know was not the case, since many people called every Senator, or at least, every Senator on the committee).

What started the bill? I’m not sure, but apparently, there was a midwife (perhaps living in Louisiana, perhaps just down in that area of MS) who attended a birth in which the baby died. It’s possible that it was just one of those things, but it’s also possible that she was not as well-trained as she could have and should have been. Since I know no details, and have only a rough idea of what happened, I most certainly cannot pass judgment. Regardless of what happened or “what might have been,” this case led the Board of Nursing to get with a legislator to introduce a bill to make non-nurse midwives illegal. As far as I know, nobody knew about it until it had already passed the House and was in the Senate. Then we spread the word, and “raised a ruckus,” and got it defeated. Yay!

Now, to work.

Last Tuesday, I was part of a group that met in Jackson to begin work on crafting our own legislation to introduce next year that will make CPMs recognized and licensed, and will create a review board to oversee them. I’m not totally sure how that will work, because I’ve just never dealt with that aspect of things before. However, there were some TN CPMs at the meeting that talked about how it worked in their state. You can join the Yahoo group MSFriendsofMidwives to see the latest version of the bill and to stay informed on the process.

Currently in Mississippi, there is only one CPM, although there are several out-of-state CPMs who serve various parts of MS, and many other midwives who could become credentialed and licensed. With licensure and certification not having been required to practice in MS, it could easily be seen by midwives as being an unnecessary use of time and money to get that piece of paper, when there was no risk to not having it and very little if any benefit to getting it. I suppose that saying that you’re a CPM might get you a few extra clients, but it wouldn’t alter your legal status, and you probably couldn’t file for insurance repayment either (I suppose it might be possible, but I highly doubt that without the legal recognition that insurance companies would recognize you either). Under the legislation that will be proposed next year, CPMs would be legally recognized, and current non-certified midwives who can demonstrate that they meet the NARM criteria would be grandmothered in.

So, benefits of the legislation would be that midwives who are currently operating legally and safely in the state will continue to be legal birth attendants, and will also be recognized by the state. I asked about legislation that would make Medicaid be able to pay for such midwives, and was told that the legislation doesn’t specify that, but once CPMs are recognized, that such a step may come in the future — I don’t know if it would need to be a law, passed through the state legislature, or if it’s just one of those things that once they’re legal, they can get set up to file claims, or petition Medicaid to recognize CPMs. Another benefit would be that with credentialing perhaps comes a higher degree of respectability and also recognition. There is a certain something that comes with proof that others recognize the work you’ve done, whether that’s proving you can survive med school and get M.D. after your name, or that you’re a certified piano technician, and become a member of the PTG.

One downside of this particular legislation is that it would make non-certified and non-licensed midwives illegal. Those working on the legislation believe that any measure that allows non-CPMs to practice would be defeated. I can see that, based on the bill that was just defeated, that would have made all midwives (except CNMs) illegal. Yet, midwifery has been unregulated for so long in our state, that I can also see that enough legislators might support the bill, even if it did not criminalize non-licensed midwives. But, it seems prudent to take the safe track. I do wish that legislation such as what is in Oregon could pass, with licensure being optional but having benefits; however, those with much more experience and knowledge about midwifery and legislation are making the suggestions, so I’m going along.

“Why would anyone not want certification??” I can think of a few reasons. Some just don’t like government interfering in your business — it’s simply a libertarian issue. “Government is there to keep the peace, and that’s about it — everything else should be left free and open,” some might say. With certification comes regulation — in some states, non-nurse midwives have become legal, only to be basically legislated out of existence by the laws that made it practically impossible to operate. It’s sort of like the hospitals that have labor tubs, but women can’t use them if their water is broken based on a theoretical but totally unproven risk of infection; and they can’t use them if their water hasn’t broken, lest their water break in the tub, and nobody know it. As long as rules and regulations are sound, then there is minimal problem with them; but when they get to be stupid and over-reaching, they can cause more problems than they solve. In Arizona, the law says that home-birth midwives cannot attend VBACs. If you agree that VBACs should not take place at home, then you’d probably agree that this is good legislation. However, if you think that the risk of adverse events is so small that HBAC is a reasonable choice for women to make, then you’ll probably disagree with the legislation.

John Stossel is in a series of articles discussing the downside of certification (not mentioning midwives at all, and only briefly mentioning doctors). Here are two articles, “The Right to Work,” and “Licensing Madness,” as examples. He makes a pretty good case that certification serves to protect established industries at the expense of those who are equally competent to provide certain services (braiding hair, yoga instructor, writing wills), but don’t have the money (or don’t want to spend thousands of dollars) to certify just for the right to do what they already can do, especially if they’re doing it on the side, or are starting to build up a business. He points out that market forces will serve to weed out incompetent florists at least as well as (if not better than) the lengthy and expensive certification process. When it comes to businesses such as these, I’d have a hard time coming up with a counter argument — the “risk” of a bad florist is that you waste $30 on an ugly flower arrangement, in which case, you’d go tell all your friends and family and neighbors and co-workers to avoid that flower shop, and the florist would soon go out of business. But an incompetent midwife may lead to dead or injured mothers and/or babies, so it’s easier to say that doctors and midwives and such should be regulated and certified.

Still, there are probably some very good healers that could not be certified because they are alternative practitioners. For example, Chris Gardner, who wrote the book The Pursuit of Happyness, which was also a movie by the same name with Will Smith playing him, has an interesting history. If you remember the movie, he became a stockbroker while being homeless much of the time, with his son in tow. That’s only part of the story. When he was in the Navy and for several years afterward, he worked for and with a doctor. While my memory of what all he did is a little fuzzy, he had “great hands,” meaning, he was proficient in the medical work he did. He never went to one class of med school, but he had what it took to do what he did, including operate on people, teach med students how to do the right things — he even had work published in medical journals! But, because he wasn’t a doctor and hadn’t gone to med school, what would have been a promising medical career was necessarily stopped. He didn’t have enough money to become a doctor, and the doctor who employed him couldn’t afford to pay him more. “So, big deal — that’s just what you’ve got to do to become a doctor! We can’t have just anybody calling himself a doctor!” Well, true, but this also kept him from applying his skills and healing a lot of people. Sure, it kept some quacks out of the business of medicine, but it probably keeps some who would be very good doctors from doctoring.

There are definite upsides and downsides to this. Regulation helps to keep bad practitioners from starting a business, although it does not entirely eliminate bad practitioners. However, nothing can. While capitalism is a strong influence in keeping bad practitioners out of business (because people will not willingly spend their money on bad goods or services), they can for a time prosper. And if they’re schmaltzy enough, may be able to keep people blind to their incompetence or poor products or services to stay in business for a while — Bernie Madoff was a master at this (of course, he also blinded them with greed, which is another tangent and topic entirely). We’ve all known people who were certified, licensed, bonded, insured, and/or regulated who were really bad practitioners of their craft or trade. It happens. There are bad apples in every barrel. Regulation can make it so that people don’t have to do their own work to make sure people are really competent, which can be a good thing, or a bad thing if they are lulled to sleep and think that everyone who produces a piece of paper is competent.

As you can see, I’m conflicted about this — mostly because if you’ve got a bad midwife, we’re not talking about losing a little bit of money by not being more conscientious, but perhaps losing your baby’s life. Given enough time, the truly bad will probably be eliminated simply by market forces, but what may happen during that time? How many babies may die? Not something to be talked about lightly. However, we cannot protect people from themselves. Some people are going to choose things that others may think are “woo” (acupuncture, acupressure, magnets, copper, feng shui, craniosacral therapy, chiropractic care, herbs, vitamins, supplements, etc.) — we can’t stop them from doing that. And if a woman thoughtfully considers the matter, and chooses a non-certified midwife, or even just has a few friends over to attend her birth, can we really stop her? Should we? At what point does “society” get to dictate who attends her birth? Recently, there has been a national conference on VBAC (which since you’re birth junkies, you’ve probably heard about, unless you’ve been living under a rock). A similar argument has emerged from the pro-VBAC community, namely, that women have the right to choose how to give birth, and should not be forced into a C-section, even if there is a risk of uterine rupture and perinatal mortality. Does someone else get to choose how women give birth, or is that something that each woman should be able to choose for herself?

I think highly enough of women and our intellect to say that if a woman understands that she is hiring as a midwife someone who has only attended ten births, hasn’t really read too much about birth complications, and has never handled a postpartum hemorrhage or a “slow to start” baby, or any other complication, that she should still be allowed to hire that midwife, knowing the risks. I would want someone more qualified than that, but some women are comfortable with that level of skill and knowledge. Unless the midwife misrepresents herself or her skills, then I just don’t see that “we” should try to save the woman from herself. Others may disagree — it comes down to where on the “libertarian” continuum you find yourself.

Where to draw the line?

I’ll start off by saying, “I don’t know.” There are now and have been in the past different cases which are thorny issues — both related strictly to birth, and those that are not — which have to deal with parents’ rights to choose for their children (or themselves) vs. “the state’s” or “society’s” right to interfere in such matters. There are some clear-cut issues — when a parent is abusing a child… and yet even in that, some people may consider spanking an abuse while others consider it to be merely one form of correction and discipline which parents have a right to use. Some people are trying to get circumcision made to be illegal; and while I think circumcision is unnecessary and ought not be done, I don’t think that I have the right to forbid others to do it, and think it might be trampling on religious rights a bit much (although I think that Christians should not circumcise their children for religious reasons). Yet I don’t think that parents should be allowed to have their females circumcised no matter what their religion. Call me inconsistent.

But where will this end? That’s what concerns me. Do parents have the right to choose what is in the best interests of their entire family? Yes — within reason. They cannot decide that because their 13 year-old is “eating them out of house and home” that it is in the best interests of the family as a whole that that child no longer live with them, or that the child stop eating, or that the child should die. But certainly many other things are within the purview of the parents. Most if not all states have laws concerning buckling children into seat belts and approved car seats. A three month-old child cannot buckle himself into a car seat, after all. When I was working at the pharmacy, I’d see all sorts of things, including people driving up to the drive-through window with unbuckled children. The most memorable is a baby in a bouncy seat, in the front passenger’s lap — oh, yeah, that’s protection! If parents don’t buckle their kids, and they have a wreck, the children could be killed, and they were unable to protect themselves. Does the state or local government have a right to step into the family and dictate to the parents how to treat their children? Some might argue “no,” but most would say that most certainly the authorities have a right to protect the innocent child.

What about the right of parents to decline medical treatment for their children? What if the medical treatment is “iffy” — what if there is a strong chance that the treatment will not work, but will only make the child sicker? Some years ago, there was a case in which a woman had two children diagnosed with HIV or AIDS (her other two children were healthy). When the first child was diagnosed, she complied with all of the medication and treatments that the doctors ordered or suggested, and watched her child die a horrible and painful death, sickened and made weak and in pain by the medications which were supposed to be saving his life. When her second child was diagnosed, she refused all the treatments and medications, saying that she’d rather the child quickly die and in less pain than with the “life-saving” (but health-taking) drugs her first child took. The state took her to court, wanting to force her to give the child the medicine, or to terminate her parental rights and turn the child over to foster parents who would medicate the child. The judge ruled in her favor, though, saying that she had every reason to believe that the drugs would not actually help, and she was within her rights to refuse. Despite the dire predictions of the doctors, the second child was still living and seeming to be in perfect health, two years after the diagnosis, without taking any anti-AIDS/HIV medications. But what if the treatment options were more clear — if the child gets the treatment, there’s a 99% chance that he will live and be perfectly healthy; and if he doesn’t get the treatment, there’s a 99% chance that he will get terribly sick and/or die — and the parents still refuse?

What if it’s somewhat murky? Is any increased risk worth terminating parental rights, or overstepping the parental bounds of authority? We’d best be careful. There have been cases in which women have been forced to undergo C-sections for less-than-clear-cut “medical” reasons. It’s possible that these were ultimately overturned… after the woman was cut open — but perhaps some have been upheld. One such case I’ve heard about is a woman who wanted a VBAC. That’s all — no medical problems that I know of other than a previously cut-open-and-sewn-shut uterus. The risk of uterine rupture is about 1/200, with the risk of death or serious injury to the baby a much smaller percentage than that. Yet she was denied a chance of a vaginal birth because the judge found that her baby had sufficient rights of his own to force her to have surgery.

Don’t get me wrong — I’m strongly pro-life… but I’m also strongly pro-family and pro-liberty. I think the baby had the right to be born alive, and should not have been allowed to be killed at that or any other point in his life, before or after birth. But is the slightly increased risk of death from uterine rupture (which is not completely eliminated with a C-section) a strong enough argument to force an otherwise autonomous woman into having surgery? Is it strong enough to override her parental authority to choose what is best for her, her baby, and her family? We’re not talking about killing babies deliberately, here — we’re talking about a slight risk, but in the absence of uterine rupture, the outcomes will be better for both mother and baby with a vaginal birth.

What about drug use during pregnancy? — and “drugs” includes tobacco, alcohol, and illegal or illicit drug use. Smoking cigarettes most definitely increases the risks to the baby — of preterm birth and low birthweight (which by themselves carry with them a whole bunch of risks and longterm consequences) and also of stillbirth and neonatal and infant mortality. Illicit drug use ditto; and alcohol probably the same, but “fetal alcohol syndrome” is more particularly associated with it. As long as women have the right to ingest all of that stuff during pregnancy, exposing their “captive prisoner” (the baby) to the toxic chemicals, then surely loving and thoughtful parents can choose between two medical options that have both risks and benefits, picking the course of action they think is best altogether.

However, if the parents (or more particularly, the mother, since she is the one who really calls the shots, since it’s her body carrying the baby) are being grossly negligent, then it’s possible that as the state can step in and remove children who are being subjected to abusive parents, so the state can step in and force a woman to stop prenatally abusing her child. But we must be very, very careful when we do things like this. Horror stories abound in the foster-care system (and all that surrounds it), of children being repeatedly abused but nothing is done about it, while perfectly innocent parents are stringently investigated due to an angry neighbor’s spiteful and false report, and even of children removed from parents (abusive or not) and placed in abusive foster homes. Similar things might exist when tampering with the maternal-fetal relationship. I might liken forcing a woman to undergo a repeat C-section rather than an attempted VBAC as being in the second or third category — the “cure” is worse than the disease; whereas I would have little or no problem with forcing a woman who is pregnant and abusing drugs to enter some sort of treatment, so that her innocent child is not born addicted to crack. But so much of the problem exists not in a particular case, or a case-by-case basis, but rather the precedent that is set when the government starts interfering. What might be perfectly innocent or even laudable interference can become heinous and loathsome, depending on the circumstances. And as this post points out, it is hard to draw the dividing line. When you’re not talking about certainties — such as, “if you do X, then your child WILL die or be harmed,” but just, “if you do X, then your child MIGHT die or be harmed… or might not… and if we do Y instead, your child also might be harmed or killed.” For instance, I think the stillbirth rate is about 1/1000 around 41 weeks and perhaps 2/1000 around 42-43 weeks or above — still pretty darn good odds that any given baby will NOT be born dead if the mother declines an induction or C-section. There is a slightly increased risk of stillbirth, but very, very far from a certainty. And it’s also a possibility that the child will be harmed or killed as a result of an induction or C-section — something like not being able to tolerate an induced labor, or actually being premature so ends up in the NICU for weeks, or with serious asthma or other breathing problems, or something like that.

For me, it seems to come down to the parents’ intentions and desires — if they are good and loving parents, and want what is best for their child, then they have the right to give or withhold treatment as seems best; but if they are selfish or uncaring, then their motives may be suspect. But then the problem becomes, what if the “people in authority” believe that the parents do not have their child’s best interests at heart — such as the woman whose children had AIDS, mentioned above? Whoever took steps and set in motion the process to override her parental decision to withhold the drugs with the horrific side effects was either convinced that the child needed them (and thus that he was acting in the best interests of the child, while the mother was not) or he was some sort of sadist who liked to see children get sick and die horrible and painful deaths. Hindsight proved the mother to be correct; but we don’t always have the luxury of hindsight, nor the luxury of time.

As big as the implications I’ve highlighted are, they are even bigger — this topic is so broad and wide-ranging, covering everything from prenatal care, labor decisions, vaccinations, child care, home school, circumcision, ear-piercing, food choices, etc. If loving and concerned mothers (and fathers) cannot choose what they believe to be in the best interests of their child and/or the whole family, who gets to make that choice? What if society (or science or medicine) decides that eating meat is bad for people, so they take away your child so he can be fed a “proper” vegetarian diet? What if they decide that vegetarianism is bad, so they terminate parental rights so they can feed your child a “proper” omnivorous diet? What if you decide that vaccinations are not in the best interest of your child – that your child’s situation is such that you believe that the risk of vaccinating is higher than the risk of not vaccinating? Should the state overrule you, and decide your child must be vaccinated? What about home birth? or unassisted birth? What if the court system decides that ACOG and the AMA are right and homebirth is unsafe — should they have the right to forbid you to have a home birth, to incarcerate you in a hospital and force you to give birth there?

Does the state have the right to tell you what to do with your child? Why or why not? Tough questions to answer in general, although specific questions may be clearer. I can say, “Absolutely not, because I am a good and loving mother, and I’m doing what I believe to be is best for my child. I am not harming and certainly not killing him, so you have no right nor reason to step into my family and tell me what to do.” And I think that most if not all of you reading this would be able to say the same with a clear conscience. But who decides where the line is drawn between a good parent and a bad one? Ah, now that is a scary thought.

Midwife Kitty Ernst — Neat story!

I might entitle this “the making of a midwife” — the story of Kitty Ernst who from a young age wanted to be a nurse, and during her obstetrics rotation as a student nurse “vowed never to do obstetrics nursing,” but found out about Mary Breckinridge of Frontier Midwifery Service, and wanted to become a midwife. The remainder of the story is her witnessing her first out-of-hospital birth. Very neat.

h/t Pinky

Permission to Mother

Years ago, I first became acquainted with Dr. Denise Punger by an article that she had written that was posted somewhere on the internet. That she was a pro-natural/home-birth MD was refreshing as well as memorable. I remembered her story about Jayne, who was the first woman she had attended in labor who had a doula, although I didn’t know anything else about Dr. Punger. Fast-forward a few years, and I rediscovered her, along with her blog which was given the same name as her book, Permission to Mother. Now, I have read the book and must say it was thoroughly enjoyable.

It is written from the perspective of a woman and a mother who happens to be a doctor, rather than from the perspective of a doctor who happens to be a woman and a mother. And that makes a big difference. It is her personal story, part autobiography (birth experiences and breastfeeding years up to homeschooling, or unschooling), part “why I chose what I did” (including extended breastfeeding, bringing her child(ren) to work with her, and homeschooling or unschooling), and another part her perspectives on certain medical issues (like the triple screen done during pregnancy, or resolving breastfeeding problems).

The subtitle to the book is “Going Beyond the Standard of Care to Nurture Our Children.” What is the “standard of care”? In a nutshell, “what everybody else is doing.” You remember those times when you were a child or teenager and you did something that was dumb, or you knew you shouldn’t, or you knew your mom wouldn’t approve, and you got caught, and your mom or dad asked you The Dreaded Question — “Why on earth did you do that???” and you shuffled your feet and said defensively, “But everybody else was doing it, too!!” Well, that’s basically the same thing, only nobody’s going to ask the doctor sarcastically, “And if everybody else jumped off a bridge, would you do it too?!?” Instead, it’s a legal safeguard to protect the doctor or hospital — as long as they’re doing what “everybody else” is doing, then they’ve got a defense. And, as long as “everybody else” is doing what is right or best, then we can all be happy. But sometimes that’s not what happens. For example, take my sister who was advised by her doctor to wean her son when she was put on an antibiotic. Sure, that’s what doctors are trained to do (“we don’t know if it’s excreted into breastmilk, so to be on the safe side…”), so that’s what “everybody else” was doing: when in doubt, advise to wean. However, the antibiotic that she was on is also given to infants much younger than her baby was at the time! The amount of drug that might have ended up in her breastmilk was almost certainly less than what the baby would have received had he been prescribed the antibiotic himself. By this example, you can see that “what everybody else is doing” is not always what is right — sometimes, it’s just what is easiest or most defensible.

Starting from her days as a “candy-striper” volunteering at her local hospital, through med school, residency, and beginning her own practice, Denise tells stories of pivotal and memorable experiences that helped to shape her as both a mother and a doctor. From the preface to the book:

People who didn’t know me before I had my three children often assumed that all my births were homebirths, and that it always was easy for me to trust my body to birth and nourish my children the way I do now…

The first birth was not satisfying. It was undermining and left me unfulfilled… I was grateful that my obstetrician had patience with me that night, but for two years afterward I dwelled on what a demoralizing expeirence that birth was.

My second birth, two years later, was also a planned hospital birth. Still, that birth restored to me the trust that my body knows how to labor. It allowed me to regain confidence in myself. It helped that this time I had a doula that had had nine homebirths herself.

Most of my patients find it hard to believe that the field of obstetrics doesn’t teach much about real-life pregnancy and birth, and that pediatrics teaches next to nothing about breastfeeding beyond the first few days of life. Now, I share my own experience.

Some of the chapters and stories in this book were originally written as articles for a doula publication, and are brief (just a page or two), which is very good for the busy mother who wants to squeeze in just a little solo reading while the kids are all happy, or who only has a few minutes to read before falling asleep at night. However, other chapters are lengthier, particularly the stories of her children’s births, or other pivotal stories which need more depth to explore.

Many of the choices that Denise Punger has made are not “the norm” of society — extended breastfeeding, “family bed,” home birth, cloth diapering, baby-wearing, unschooling, etc. Hearing her positive experiences can be helpful to people who are considering these for themselves, moral support for those who are already doing them (and perhaps may be facing family or societal pressure to stop), or a learning experience for those who have never heard of such.

As I said at the beginning of this blog post — thoroughly enjoyable.