Nursing, midwifery, and patient/practitioner relations

FemmeRN · Feb 19, 2009

Anthrogirl,

First, congratulations on your pregnancy! Second, I'm so excited that you are interested in this topic, and hope you get some good input from this wonderful community. I'm new to nursing (graduated in May), but was raised by an anthropologist and have a master's in biological anthro myself. I guess anthro is still in my blood, b/c I'm constantly fascinated by both the 'culture of nursing' and in women's choices surrounding pregnancy and birth.

I'm not exactly sure what sort of input you are looking for, but as far as specific questions with policy implications, I think home birth and elective cesarean are probably two of the biggest hot button issues right now.

With homebirth, obviously many women choose it because it feels right to them, it's safe for low risk pregnancies, and clearly it has been done for years and years, and continues to be common around the world. I totally support them. But, on the other side of the coin, it seems like some women choose it not particularly b/c they WANT to be at home, but b/c they specifically DO NOT want what the hospital system has to offer. Not only do they not want the interventions, but they feel like they would be powerless to refuse them. That's sad to me. So, I think from an 'informed consent' perspective, that would be something interesting to look at. As well as what sort of shifts in the 'hospital culture' or whatever, would make a hospital birth as potentially empowering for women as a homebirth is for many. And, how do doctors feel about that.

Regarding elective cesarean, that's a HUGE topic now...here on this board, in mainstream media, and there was a recent article in Nursing for Women's Health about it. Looking at the informed consent for this would be fascinating, imho. Is the rise in c/s rate really b/c women are just asking for it out of the blue? Are doctors suggesting it? How do the two come to a decision together about it? Do women have the proper information about risks/benefits? What information are women receiving from their friends and popular culture about the supposed ease of the procedure?

Anyhow, that's just my 2 cents on what's interesting. Good luck with your research!! Keep us posted on what you end up doing, I'd love to hear about it.

AnthroGirl · Feb 19, 2009

FemmeRN,

Thank you so much for your response! I too, am fascinated by the homebirth movement, for many of the same reasons. I think that it is a little like second-wave feminism, where the (and I hate this line) 'pendulum has swung' to the opposite pole! I think that it does have alot to do with power and knowledge relations. Your comments on elective c/s rates are very interesting. I have followed a lot of threads here on allnurses and I see that this is of major concern, as well as 'social inductions'. Both of which I find fascinating. Perhaps this is an important area for so many reasons: Who are the women that are electing for c/s? Are they really electing for a section? If so, Why? All interesting questions, I will keep wondering and hope for more input.

mamafeliz · Feb 21, 2009

Anthrogirl, Birth culture is a fabulous topic to look at anthropologically. Questions abound and stakeholders include all of us, really. Although I feel fortunate enough to work in a hospital which has a low epidural rate, water birth, VBAC, we still have pockets of providers reflecting the national trend of over-intervention leading to high c/s rate. Hospitals ultimately benefit from high surgical rates (higher reimbursement) despite it being a public health nightmare. Litigation is out of control, mandating unreasonable safeguards and resulting in higher intervention. Many feel that if they don't intervene, they will get sued. Others intervene because much of OB culture is based in fear, and some no longer have the benefit of training which encourages supporting the natural development of labor, which sometimes involves patience, and always deserves 1:1 staffing in active labor (nurse:patient ratio). My institution just went through a painful process of reevaluating nursing staffing--ultimately we won 1:1 in active labor (cost effective for those wanting to avoid intervention) This is a huge victory for nursing satisfaction and the women we care for.

Home birth is especially fascinating in the US, as each state has vastly different lisencing and standards of practice. I am currently looking hard at this question as we have had a series of bad outcomes related to especially lax standards of practice for our LDMs (licensed direct entry midwives) I am a home birth advocate, but feel that to bridge the home/hospital birth cultures, and protect consumers (women and their families) mandatory lisencing is essential, and reasonable standards of practice must be in place. Although I have gotten supportive responses on this site and from local LDMs, I still have not found any research that supports breech, multiples at home. I have found some references I continue to study that hint at VBACS at home might be safe (I still am not totally convinced) given very strict screening. Our larger birth community suffered a loss of a term home birth VBAC attempt recently, so I am hesitant. As I have statted before, some OB risks are real, and if they occur, there is not time for transport to the hospital, and result in death or severe life-long compromise. Why would a home birth provider risk that?

The biggest challenge now is to bring home birth out into the light so it becomes a more solid option for more families. That is the most sound direction from a public health and fiscal standpoint. But regulations must be in place.

I am off to work--but will be interested in this ongoing discussion.

AnthroGirl · Feb 21, 2009

"Hospitals ultimately benefit from high surgical rates (higher reimbursement) despite it being a public health nightmare. Litigation is out of control, mandating unreasonable safeguards and resulting in higher intervention. Many feel that if they don't intervene, they will get sued. Others intervene because much of OB culture is based in fear, and some no longer have the benefit of training which encourages supporting the natural development of labor, which sometimes involves patience, and always deserves 1:1 staffing in active labor (nurse:patient ratio)."

MamaFeliz, So true! I have heard a lot of these arguments; litigation, the cost/benefit of interventions, the argument that all births are 'potentially pathological', and one of my favorites regarding medicine in general, docs only know what they are taught... They are all so interesting, and I think that they are also inter-related. One argument that seems to pop up in anthropology and sociology a fair bit refers to biomedical culture in general and it has to do with time and standards. That medicine has put life (and life cycles) on a schedule that is relatively narrowly defined. This includes birth, death, aging, illness, and the like. I think the best advice that I have received from my OB and the nurses at L&D is don't rush to the hospital at the start of labor. If you're not here, you can't be timed. But then again, how does that sort of a advice work for a young primip who has little support at home to get her through the early hours of labor?

All very interesting questions. As for the homebirth debate... so heated, so emotional. I think it is hard to be critical and maintain a cool head talking about this because the loss of a mother or baby in birth is devastating for all involved. One thing that I find is really interesting is that the obstetric, nursing, and midwifery literature seems to be coming closer and closer in opinions of normal, low risk birth and the dangers of intervention, but the professional opinions are still divided on whether homebirths are a viable alternative. In a nutshell, it's preferable to birth without intervention, but only at a hospital (according to a lot of docs). To complicate issues, I agree with FemmeRN that often women are planning to homebirth not because it is the ideal option for them, and what they really want, but more so because the hospital is what they don't want. They are afraid of losing control of their body and their experience in the hospital. Also very interesting.

I so appreciate everyone's replies in here, it gives me much food for thought that I can sit down with and chew on for a while. Of course, then my brain begins to hurt...

midwife228 · Feb 21, 2009

This looks like it's shaping up to be a fascinating discussion and I will keep following it and, hopefully, contributing something to it. First of all, congratulations on your pregnancy! May I ask, is your provider a physician or midwife or a group that includes both? I agree totally with the suggestion not to go to the hospital until you feel it is really, really time to go (if a hospital is, in fact, where you choose to give birth and assuming that you are not having a problem like bleeding and that the baby is still moving and active). Have you thought about hiring a doula for labor support, especially in the early hours at home?

AnthroGirl · Feb 22, 2009

Midwife228,

Thanks for responding to the rampling thread. I hope that you will share your thoughts, creating a research project/question has been really hard for me. Because I am so passionate about pregnancy and childbirth, gender equality, and natural childbirth Iam having trouble focussing on one aspect of a very, very complicated issue!Thanks so much for the congrats, we are very excited! There'll be nearly ten years between baby #1 and baby #2, so this has been a whole different experience for me this time. My provider is actually an OB. I would have liked to have gone with a birth centre and a midwife (no homebirth for me, between 200 lbs of dogs at home and a nearly catastrophic PPH with the last one...) but my insurance doesn't cover birth centers and will only cover 80% of a hospital birth with a midwife. So it is sadly, financial. However, I have the utmost respect for my OB, she is young, and very progressive, or rather regressive I guess going the more natural non-interventionist route. The hospital where I will give birth, although a teaching hospital, has revamped and taken a more mother/baby centered approach, so I am pretty happy with them also, and of course the nurses are great;).

As for the doula, I think they are fantastic! I haven't decided if I will go with one yet or not. I think I may, as this is my husband's first experience with (human) birth. A doula may take some of the pressure off of him, as well as some of the strain off the nurses in L&D (1:2 ratio at my hospital).

Like I said, any input is wonderful. I am curious to hear what you and other midwives may feel are some of the more pertinant issues surrounding birth (both hospital and other), client practitioner relationships, and processes of prenatal and postpartum care.

romantic, BSN, RN · Feb 22, 2009

Congratulations on your pregnancy!

Talking about "pathological" vs natural childbirth. You might find the following books by Ina May Gaskin to be helpful:

Guide to Childbirth, Spiritual Midwifery.

http://www.inamay.com/archive/books.php

AnthroGirl · Feb 22, 2009

Thanks Romantic! I really do like Ina May Gaskin's work. Another great author is sociologist Barbara Katz Rothman. She has done a lot of work looking at how situations in a L&D setting are negotiated and how there is often a dissonance between medical practitioners and laboring women.

romantic, BSN, RN · Feb 22, 2009

Thank you! I would be glad to read Rothman's work.

SiennaGreen · Feb 26, 2009

While I think this is a HUGE discussion and multi faceted, I believe much of it has to do with our (women, mother's, human) fear. This fear that has been teased out by marketing agencies (buy this, keep yourself protected), gov't agencies (you MUST vaccinate your newborn against Hep B...because if you wait...what happens?) and each other (did you hear about so and so who....).

This fear that is a natural and good instinct, is then manipulated and dramaticized until we feel we can't make a move without an expert somewhere giving us approval or spending a lot of money on some new way to keep ourselves safe which often ends up being ultimately more dangerous than the simple things our Grandmothers did.

I know this is vague, and I apologize. I will try to make it fit somehow. I am a new nursing student, but an older Mom of 3 birth center babies, extended breastfeeder and absolute supporter of women's abilities to mother given the opportunity, a little education, and a supportive environment which encourages them to trust their inner voice. Due to my birth and parenting choices I was belittled, scoffed at, shamed, told I was selfish, and bullied. As a matter of fact, we recently learned about the specific definitions of assault and how assault can be emotionally manipulating someone into complying with what the professional thinks is best by twisting data or the like..well, then I was subjected to assault. It sounds crazy, but it's true.

For example, ultrasounds. Why do we get ultrasounds? Why are US recomended for healthy, low risk pregnancies? Heck, many women are getting a new US to hang on their frig every visit. From the ACOG web site "However, not much is known about the effects of repeated exposure to ultrasound. It seems to be safe, but it is possible that problems could be found in the future." (http://www.acog.org/publications/patient_education/bp025.cfm)

I am beginning this journey into nursing with the desire to pursue a CNM later. I know I am a dreamer but I really want to help women to embrace their bodies, in all it's beauty and amazing ability to grow and nurture life. I hope I can touch even just a few women and as a result they might feel more capable as a mother, more connected to and able to read their babies (without unnecesarily rushing off to a professional with their RX pad), and find some beauty and value in humanity that they may have overlooked before.

yes...i'll let them call me a dreamer and before anyone says it, it's not about the money. really. :bugeyes:

romantic, BSN, RN · Feb 26, 2009

Due to my birth and parenting
choices I was belittled, scoffed at, shamed, told I was selfish, and bullied. As a matter of fact, we recently learned about the specific definitions of assault and how assault can be emotionally manipulating someone into complying with what the professional thinks is best by twisting data or the like..well, then I was subjected to assault. It sounds crazy, but it's true.

Dear SiennaGreen, I read your post with great interest. Would you mind to be more specific and bring at least one example to explain your statement about being shamed and belittled, and told about being selfish?

I would like to explain why I am so interested in your post. As a health care provider, I want my patients to have as safe and enjoyable experience during their hospital stay as possible.