#178 | How Out-of-Hospital Birth Prejudice and Provider Bias Harms Mothers and Babies With Attorney Hermine Hayes-Klein

There are hospitals where their official policy and there are doctors working at the national level in the United States who have told every hospital to file a complaint on every home birth midwife that makes a transfer. And there are hospitals that do that, we know that the healthiest birth for the mother and baby is one that happens on pure physiology, that they get the best benefits both mother and baby short and long term. And so all these women want is a chance for a healthy birth. But they they're the options available to them or not allowing them that and so the only way that they can access that chance is to leave the hospital, and sometimes to give birth alone with nobody, and the system has failed when women are in that position.

I'm Cynthia Overgard, owner of HypnoBirthing of Connecticut, childbirth advocate and postpartum support specialist. And I'm Trisha Ludwig, certified nurse midwife and international board certified lactation consultant. And this is the Down To Birth Podcast. Childbirth is something we're made to do. But how do we have our safest and most satisfying experience in today's medical culture? Let's dispel the myths and get down to birth.

Welcome everyone to another episode with Attorney Herman Hayes Klein. Herman. Thanks so much for coming back on the podcast again. And again, we always get a really big response every time we do an episode with you because you bring into light, so many aspects of maternity care that I just think isn't on the radar of most of us, and you have insight that a lot of us don't have. So thank you so much for always making the time for us.

It's my great pleasure, Cynthia, Trisha, thank you so much for doing this show. And for welcoming me back to it.

I can't tell you how much we learn. Every time we speak with you. We get off the call. And we're like, wow. Yeah, yes. So today, what we decided is, we're due to cover is just starting off a little bit educationally and then getting into some of the legal aspects down the road. But basically, in looking at this global issue of limited access to good quality maternity care, and basically a relationship between that limited access and birth outcomes and how it is a risk to women and their families when they don't have good quality care. But in just starting from a very high level, I would like us, in particular Trisha and you to go through all the different types of midwives. There are many types of midwives, you hear the terms thrown around CNM, CPM, there's are unlicensed midwives. And there's even a free birth movement of people who birth without a birth attendant, some by choice, and others because they don't have access to care. And it is a risk, in their opinion, to go to a hospital and take the chance of having their baby in a hospital. So let's just if you're both okay with it, let's just start off with all the different credentials and the types of midwives that there are in the world. And her main I know you lived in Europe for a while as well. And I don't know if things are different there. So how would you like to begin? What do you think we should start with?

Well, so as you say, Cynthia, it's worth talking today about what are the choices that should be available or that you know, are available for childbirth. And in the United States, the picture is pretty complicated. We have a real patchwork of midwife types. And that's really a result of our unique historical relationship to Midwifery, in that the United States is kind of unique in the western world in the success with which the medical lobby eliminated midwifery and the in the 20th century. So by the 30s 40s 50s, when childbirth was moved into the hospital in the United States, the way that was done was really to propagandize midwives as incompetent and as somebody that you would never want to have your baby with. And midwives were really eliminated by the medical lobby from maternal health care, until really what was left was doctors and nurses for childbirth. And it was only in the 1970s that midwifery started to become sort of substantially reinvented in the United States and brought back into practice. But the way that that was done and this sort of resulted in a bunch of different midwife types in the United States, which Trisha and I can talk about a little bit today the major types are certified nurse midwife. And nurse midwives are prime our first nurses who then receive additional training in midwifery with from you know, with it from their nursing educators, and then their direct entry midwives who do not go through nursing to Midwifery, but are trained directly as midwives and go directly into midwifery. In the United States, most of the midwives who offer out of hospital birth services are direct entry midwives. I think almost no or maybe no direct entry midwives are granted privileges to work in the hospital because they are not, or they're not trained within the medical system. So they're sort of the more most outside of that system and and marginalized from it. So they generally work exclusively in the out of hospital setting. While nurse midwives most of them work in the hospital setting, there is a credential in some states called the certified midwife and direct entry midwives can be licensed, they can get licensed and will be regulated, I think in 35 states. So direct entry midwives are legal, as CPMs in you know, I think is 35 states and then they are not legal in the remaining states. And then in all states, there are midwives, direct entry midwives who simply do not choose licensure, even if it is available to them. So they can be there can be unlicensed traditional midwives in a state that does not offer any licensed or to midwives. Anyway, so they couldn't become licensed even if they wanted to, but some choose to remain unlicensed as traditional midwives. So So in theory, all of these different provider types should be available and accessible locations for childbirth include the hospital, include the home, and include freestanding birth centers that are neither homes nor hospitals. And so the human right to choose the circumstances of childbirth, if it would, if it's operating correctly, and is supported by the state should mean that a person can really survey all of these provider types and, and locations and choose the one that is the best for their pregnancy for their family and for their needs. And again, that's a real patchwork around the United States. So how midwives are allowed to practice both si and AMS CPMs. And direct entry midwives really varies across straight state lines in a way that can lead to a lot of confusion for consumers.

Absolutely. I mean, it's very hard for women to know what what they can choose what is legal, what is legal. It's it's very complicated and complex system for women to navigate.

So So Trisha, you are a certified nurse midwife trained at Yale University, which is one of the strongest midwifery programs in the United States, of course, so So I think it would be wonderful to hear a little bit about your experience, Trisha in choosing where you wanted to offer your midwifery services and whether you perceive there to be a difference in sort of your security as a certified nurse midwife based on that decision.

So in college, I in undergraduate school, I went to the University of Michigan and I had an incredible professor there who was a certified nurse midwife, I had no idea that nurse midwives existed. I had always been fascinated by pregnancy and birth and wanted to know everything and anything I could know about it. But had no intention of ever going to medical school, I was not interested in pathology, I was not interested in medicine, I was not interested in hospitals, just wasn't for me. So when I learned of Midwifery, I thought, oh my gosh, wow, like, here's a path that I can take that that is all about physiologic birth and then supports the normal healthy pregnancy but still gives me you know, the ability to practice wherever I want to practice that gives me the ability to work in a hospital if I wanted to. It gives me the ability to write prescriptions, it gives me the ability to work independently. I then learned so that I could become a certified nurse midwife through the master's program offered by Yale University. I was fortunate in my third year of graduate school to have one of our professors actually be a home birth midwife, and she had one of the first certified nurse midwife owned home birth practices, certainly in Connecticut, and probably in the country with very few nurse midwives actually practice Humbert. Only about 10 to 12% of births are attended by midwives, certified nurse midwives in general. And less than 1% of births are at home. And the statistic for how many of those are attended by certified nurse midwives is tiny. So it seems like a great opportunity to explore home birth and then I found myself pregnant in my third year of graduate school. And I realized that there was no way I was going to have the type of birth experience that I wanted for myself through what was offered through the male health plan. And so that led me to home birth and once I had my home birth, I realized that this was basically the only way that I was going to feel like I was providing the kind of care that I wanted to provide as a midwife. But it wasn't an easy decision because there are a lot of barriers to practicing homebirth as a midwife in general or a certified nurse midwife. So the first thing is your it's just not that well supported. I mean, you get a lot of, I don't want to say criticism, but you know, people question what homebirth they mean, even nurse midwives can look down on homebirth. It's very hard to have collaborative care with obstetricians, it's hard to get this Pour to have an obstetrician who will back you in case you need a hospital transfer, we know that the continuity of care for a woman who's transferring from home to hospital is very important to having her birth be as safe as possible. And if you're having to drop women off at the emergency room, or you're having to just show up at a random hospital with a random Doctor Who doesn't know anything about this patient's medical history, pregnancy history, desires for their birth, they're less likely to be treated in the way that would support their birth goals. It's not good for women, it's not good for care. And it's not easy to practice as a nurse midwife in that environment, you just described the treatment or perception of, of a woman who's now transferring from an out of hospital birth to the hospital, because she needs some medical care. I mean, let's remember, those who choose for out of hospital birth are those who are choosing to save medical intervention for the event that it's actually needed. And so now they've shown up at the hospital, because medical intervention of some kind is needed. It might be emergent, it might be non emergent. But can you describe that it's can sometimes feel like they're being treated like, I mean, how many times you will hear obstetrician say, you know, we just get all the, you know, we just get all the cases that have gone wrong, or we just get all the all the mistakes that you made along the way or basically, you know, we get the garbage cases like, now I have to clean up your mess is what's is what is said.

So you've just described, you know, one aspect of the danger that both providers and consumers who choose out of hospital birth in the in a system like the United States face is the possibility of like, being treated punitively, if they go into the hospital looking for care, and another aspect of punitive ly punitive treatment is negligent treatment, you're not going to be heard your midwife isn't going to be listened to. And that, of course, can lead to death. Because when you show up at the hospital needing medical treatment, you need to be heard in order to get the effective treatment. And if they're purposely even unconscious Nila bleah not listening as a result of prejudice, then that increases your risk of dying. But the this point about, you know, the the train wreck, you know, one of the stories that we hear from hospital providers is, well, these out of out of hospital providers of cases, they bring us our train wrecks, there's a couple of things being said there one, when the doctor says, well, you're bringing us something when something goes wrong in an integrated system that shouldn't be seen as a problem. That is their job, you know, so like they're supposed to be there to help if they are needed. And they're only needed if physiology went wrong, you know, and so so that that shouldn't be a problem.

If they believe that home birth is safe. If they believe that women should have that choice, then they should happily receive the cases that come in whether it's urgent or emergent. Most of the time hospital transfers from home are non emergent, meaning they're not an emergency, they're urgent, meaning the woman needs some support and care and that can't be provided at home. Sometimes they are emergent just like sometimes there are emergencies in the hospital. And the midwife is doing obviously the exact correct thing by bringing the woman to the place where she can get emergency care. And if it were more supported, the receiving obstetrician would treat it differently.

The receiving obstetrician should not care for you quote because they believe your choice was safe, whether they believe your choice was safe or not, should have no effect on whether you get non negligent care at the hospital. Why do they believe it's unsafe? Because they have biases and prejudices that have not been corrected? Not because that's based in fact, but because their medical bias is being allowed to actually direct their behavior. And that's negligence. Whatever perception a provider has that causes them to give you negligent care is not justifiable, you have a right to non negligent care when you transfer.

Another concerning aspect of that, that I know neither of you is overlooking in this conversation, but I still just want to emphasize is we also don't want that judgment and attitude and approach to be a deterrent to any midwife in making the decision to to do a hospital transfer. I can tell you that it is sometimes I'm sure it is I'm sure that it is and right there. That is an increased risk.

Yes. It's not that the midwife is ultimately not going to do it. They're gonna make the right call but sometimes it is delayed and it's also the woman the mother knows that she is going to potentially be poorly received poorly treated. And so sometimes it's a combined it's always a combined decision. But sometimes it is delayed because of that if the and that's what I mean by the continuity of care. It's so integral to the safety of birth.

Again, this is getting to What is the role of the law in protecting the human right to choose the circumstances of childbirth. And one important role of the law is to recognize that women are making this choice. And given that they're making the choice, ensuring that the system isn't punishing them for that choice in a way that increases their risk of dying, but is instead ensuring that they are received. So back to that issue of, you know, if a if a midwife is working in a state or a country where medical bias against out of hospital births and midwifery is being allowed by the state to run rampant, so that she knows if she and her client transfer to the hospital, they face risk at that hospital her client is facing, it affects her risk analysis, right. So the the midwife is actually trying to make us decision about whether to transfer based on safety for the client, the client needs a medical intervention. But if she knows that client faces a risk of marginalization, of abuse of trauma at the hospital that must necessarily rationally come in to her risk analysis. And, you know, I mean, given that we're in a maternal health system that excuses Oh, Bs for giving women C sections because they say of their liability risk, right. So we're letting Obeah say, my fear of legal risk for me is making me make a treatment decision for this client that is less safe for her because I'm now imposing a surgery on her that increases her risk of of death, then we need to understand and excuse that midwives, first of all, face their own legal risk, I mean, recognize their own legal risk as irrelevant. Even if it's unconscious, just like obese, I think it's probably mostly unconscious when they're weighing their own legal risk into a treatment decision, which shouldn't be something they have to worry about. But also, in the case of out of hospital birth, and this is not the case in the in the situation where the obstetrician is imposing a C section, because of liability risk, that in the case, where the midwife has to make a hospital transfer to a hospital Hospital, which is the case for many midwives, working out of hospital until she actually has to recognize that there is a safety risk to sending that client to that hospital. And that can skew that that can get her to make a different analysis than the whole everybody in that system would want her to make if she's making a pure analysis of what is this client's clinical need. And so what we have to recognize is that it's unfair for the law to blame her for that situation, because she has no power to affect how her client is received at the hospital, the role of the law is to ensure that the providers at the hospital don't punish her client that way, often, midwives, they make that transfer, they see the client abused or marginalized, they come out of it, afraid that they're going to face a complaint on their license from that doctor. So the doctor came in lectured them about they shouldn't allow this or that the doctor is completely wrong and has no idea what they're talking about, because they have no expertise or understanding about a hospital birth. And but the midwife is still afraid that she's going to face some sort of punitive complaint. And in fact, there are hospitals where their official policy and there are doctors working at the national level in the United States who have told every hospital to file a complaint on every home birth midwife that makes a transfer. And there are hospitals that do that. So again, back to the midwife having to weigh her own legal risk. She's there are places where she knows she will face a licensing complaint that will cost her 1000s of dollars and take months out of her life.

And that's the scenario where the midwife is actually dropping the woman at the emergency room doors and running away because she or she also drops him at the emergency doors and runs away when she is when her state hasn't licensed her. So she's not even the illegal provider. She's a midwife, she's trained, but her state has allowed medical bias to run so rampant and to have so much power that that system won't even recognize her as a midwife. And so she can't come in, she won't be recognized as a provider, she has no choice but to drop the woman in. But again, then this is some tries to turn around and blame her for that, which then only perpetuates. But I want to finish this point on the complaints. Very often midwives are coming out of this story on the defensive, you know, they're just waiting for that complaint to be filed, when in fact, they know that what just happened at that hospital either created risk or actually caused harm. Sometimes actually, it's actually somebody died, or something bad happened as a result of that punitive transfer, file a complaint every single time even if nothing bad happened as a result, because how else is that going to change? File a complaint with the medical board the licensing board the nursing board on every single person that endanger your client through their own prejudice?

What On what grounds? Can they file a complaint on any home birth transfer to a hospital? What if it's just prolonged labor? That's the number one reason for transfer to a hospital in the first place? I mean, are you saying they're being encouraged to just by rote file complaints on any transfer? But on what grounds?

I don't on the grounds that they think that what you did is negligent per se, that is as if those medical providers filing those complaints are implying seeing every home birth midwife should be successful. And if every single one isn't? It is by definition, negligence. Yes. I mean, I know, the whole idea is to discourage homebirth midwifery in the first place. But that very policy of filing complaints is to imply that it should have otherwise been a perfect home birth. I don't I don't understand. Can they just file a complaint because there was a transfer?

Yeah, if you transfer a woman who has been laboring at home for 24 hours, and she's tired and needs an epidural and need some IV hydration, it's very easy for them to look at that and say, Well, you letter labor to law. That was they don't even have to get into the details, you guys, it gets to a fundamental paradigm difference in how they perceive childbirth itself. Right. So the medical model of childbirth that American obstetricians worked so hard to develop is one that childbirth is risky and dangerous. By definition, you only survive it in retrospect, you can only call it safe on any way, if you survived it in retrospect, right, that childbirth, like the attitude of, say, the Dutch, so I gave birth in the Netherlands and I and in the Netherlands, their whole system was always based on the idea that childbirth is a normal physiological family event with the potential to become a medical event, because they perceive it as a normal physiological event with the potential to become a medical event, they saw it as appropriate for normal physiological childbirth to happen in the home. So the whole Dutch system has been based on healthy women give birth at home with midwives, and you save the doctors and the hospitals for the event, they're actually needed. And they've always had better outcomes in the United States. So they explode the story that American obstetricians worked so hard to sell, which is that childbirth is a medical event, by definition, from start to finish, that you only safely survive through the management of doctors and hospitals. So when that's your model, that child is as a medical as a dangerous emergency almost by definition, then when you look at what homebirth midwives do, treating it as a normal physiological event that looks to you like dangerous, like negligence, right? It's a paradigm clash. But you know, like, there's a real, and it will be fine to have two different ways of looking at it, right, like getting back to free choice, great. If I if I see it as a medical event, then I'm going to go to an obstetrician and I get to get a system of care that's going to shepherd me through it in that way that makes me feel safe. But what about my choice? What if I see it as a physiological event with the potential to become a medical event? Do I have the ability to choose for that the problem we're facing here is that we've got this paradigm difference in the United you know, we have a paradigm difference, but the the doctors have the power over the midwife. So they're having the power, they've had the power for the last century and, and although midwives have made headway, you know, it's only headway that still within the system, OB is still have the power to set that frame, and the states reinforcing it every time it validates that frame.

So let's talk through the alternatives scenario when homebirth is well supported with collaborative care. And, and I was fortunate to practice in a state where I was able to have a backup position and I did have that continuity and that collaborative collaborative care and we had a very, very successful home birth practice because of that. And basically what that looks like is you join your home birth midwife, you join the practice. At some point in your third trimester, you make an appointment to meet the covering physician, the backup OB they have your chart, they know you they know your face, they know your goals, they know your preferences, and therefore if you end up transferring from home to hospital in labor, you can call that OB you can say I'm bringing in so and so this is her information she she or he the OB already has all the data in their in their records. And they're welcoming and receiving of the transfer and the birth those much more smoothly in a woman is respected. And the midwife was treated with respect. And even in the case of my practice, we were able to have hospital privileges at the hospital that we transferred to so I could even continue to provide her care. I could transfer from home to hospital and I could still be the one to help complete the birth process with her. I Connecticut you for baby. Yes.

Amazing. And and indeed like that's that's what it looks like. But there's a very important, you know, one more element of what a safe integrated out of hospital birth look like. It looks like non punitive transfers, it looks like continuity of care. And an element of that is that the EMTs that is the ambulance people are trained and equipped every single time this is really important because in states that license or allow for out of hospital birth. That state needs to be responsible for making sure that the EMTs are trained and equipped because when they license out of hospital birth, but then they don't require the EMTs to understand a transfer from out of hospital birth babies die work on those cases. And that that's those are cases where babies need a resuscitation, the middle and should it and a hospital transfer, they just need a little help sometimes babies are born then it's hospital help. And midwives are trained to keep those babies stable till they get to the hospital. And so you know, the baby comes out babies having some trouble breathing, midwife gets that airflow go and she gets that oxygen going for baby, but she now needs to get that baby to the hospital so that baby can get some more care baby might even even need some time in the NICU. So So midwife has the bag and mask where she has, you know, there's a special mask for babies that she's now put over the baby's face and, and she's got that baby respirating they call 911. The 911 comes in you guys, this happens too often. They come in, they basically push that midwife off the baby were taken over, they don't even know who she is, they don't really understand what she does. And then they stand over that baby not knowing what to do. They mentioned they don't have an infant mask. They don't have an infant board. They've got none of the equipment. They've got none of the training, but nor are they knowledgeable and respectful enough of the midwife to say, you know, what can you keep doing what you're doing and make sure this baby breathes till it gets to the hospital, they literally push the midwife off the baby and stand over the baby who can't breathe without help. And then the baby dies, y'all. And then they turn around and blame the midwife. And complaints need to be filed every time and beyond complaints, you know. So the EMTs I see as as a incredibly critical missing link. And one approach that midwives have taken to solve this problem is to offer trainings to ambulance guys. And that is really important. Go meet those ambulance guys make sure they know who you are. But if this needs to be non optional, the state needs to take responsibility for ensuring that this has happened every single time because otherwise the state's participating in negligence that causes deaths. I mean, the other thing is when a midwife is not following her client into the birthing room, under the Opie's care, I can tell you that there's a tremendous amount of information that's not being passed on that is relevant to her care. And that could make the difference.

And another way that that happens is either she's not allowed in, which is insane, because she's the treating provider and they need to be listening to her about what has happened until the transfer, or she's she's in the room. But the OB comes in and literally won't look at the midwife literally won't look at the midwife, let alone talk to her talk to the woman as if the midwife is a non human. And the most she'll say to the midwife is to scold, there's a lot of scolding that's happening. And that's not respectful. And it's not collaborative. Because midwives could be scolding OB is to they obviously, we've got a paradigm clash here, right, we see things differently, but we need to be able to get over it and work together. Because like you say, in systems that work, the OB is and the midwives are able to collaborate even despite their differences in paradigms. And in Holland, where I gave birth, I knew that the ambulance guys would be trained, if I needed a transfer. And I knew that when I got to the hospital, my midwife would have privileges all the midwives have privileges, because it's kind of unsafe not to allow them to have that continuity of care once they come in.

And I have to tell you that you know, our situation with the the homebirth practice in Connecticut, it took a tremendous amount of fighting for that. And it didn't, it didn't actually last, I mean it, it's very hard to create those relationships and those arrangements, and it's a disservice to women. And this is what ends up leading women down the path of free birth, because they have no other options. And they know that they're not going into that environment where they're going to be treated that way.

That's right. It also confuses the statistics as to whether homebirth is safe. Because if homebirths can safely and freely transferred to hospitals, and there is continuity of care, and there is good care at the hospital, I no egos and no likelihood for doctors to know that if they perform a C section, they're more likely to be protected in court. And by the way, if we have to mention, they're done in 20 minutes and make a heck of a lot more money and get on with their day. That is how our system is set up. That's not anything personal about those obstetricians who succumb to the conflicts of interest and the pressure, the financial pressure they're put under in their work. That is how our system is set up in this country. And then the big conclusion, well, you know, where does that statistic lie? When that baby ends up dying or something happens? Oh, home birth isn't safe. They rushed to the hospital and the baby died? Well, how about they rushed to the hospital and all of these things happened in order for that to happen? Because, you know, you always have to think of that that phrase statistics lie because they really can be manipulated in so many ways. I mean, we know relative risk, absolute risk, there's so many ways to phrase the same exact thing. There's so much underlying data, but we just always have to go back to the system and when the takeaway is that when all hell breaks loose, only one side is at legal risk and the other isn't just because that's how the culture rolls. That's how the press Nothing has been said in court that it's going to side with the obstetricians or the midwives? Where do we begin to change this system?

I want to talk to speak to the stats, and I wanted to go back to the train wreck point. So regarding what you just said about statistics, Cynthia, it's really important. And I think it's easily provable. That when we look at the statistics for, first of all, one thing that needs to be said is that when we talk about risk and safety for out of hospital birth, the way we talk about it reflects something that we've talked about in in our larger conversations about childbirth, which is an undervaluation of the mother. So again, when we're talking about safety on out of hospital birth, generally, the focus is on perinatal mortality, which is, you know, does out of hospital birth, raise the risk for the baby, you know, by point oh, 3%, or point oh, 4%, or no percent? Or is it even a little bit safer for the baby. But what is ignored in these conversations, and here, I'm paraphrasing a bio ethicist from Holland named Elsa line KingMa, who spoke about this at my conference in 2012. So brilliantly, she explained, you know, we focus all the time, she said, You know, there's data. And there's how we talk about the data and how we talk about the data as a function of our cultural values. And we need to recognize that. So the way we talk about the data for out of hospital birth is always focused on perinatal mortality and tiny, tiny numbers. And we're ignoring that out of hospital birth is safer for mothers, and not just a little bit safer, but massively so so that's one important point to make on data. Second, even if we just look at perinatal mortality and the impact on babies, the studies out of the countries where out of hospital birth is integrated, like Holland, where I gave birth, show that it is just as safe for babies as possible. There's no difference for the baby when the system is integrated. So Holland has, you know, because it has so much out of hospital birth, it was able to do a study of half a million births in 2012. That proved that that's an integrated system. England has the birthplace study that shows the same thing because England isn't is a relatively integrated system. Canada has good outcomes because they're integrated. And so when we look at then studies like the American wax study, which isn't already becoming kind of old, or but other studies that show a disparity for out of hospital birth incomes, we need to recognize what is the difference between the United States and the countries where there's no difference in perinatal outcome. The difference is integration and the marginalization of out of hospital midwifery. So what we are literally looking at, in those studies showing poor perinatal outcomes for out of hospital birth is baby's dead from a lack of integration, that should be the priority of the system and trying to address to trying to close that gap not trying to drive the choice underground. Because all you do when you do that is make it more dangerous, not less dangerous.

Absolutely. And I remember a meta analysis was done on this big question we're always asking is home birth or hospital births safer. And when it was done, it was about 10 years ago, Holland contributed 700,000 data points to the meta analysis, and they just left it out. There said, we're not including Holland. And that often happens, they were ranked number one in the world in safety. And by the way, in Holland, I believe there was a period I don't know if it still exists today in which they did they do not allow you to birth in a hospital unless you are high risk. And by the way, they don't rescue out when you're 43 years old, they don't rescue out by age, and they came out number one in the world and safety. While we're the Gayatri were the only developed country with increasing maternal mortality over the decades. So the fact that they could leave out the biggest data set that anyone contributed to that meta analysis, they just left it out. Who would know that when they look at the outcome that says, yeah, it's comparable home birth is about the same as hospital, I hear your point about the integration. And that's fascinating. I honestly never considered that before. But who would ever think that data set was left out? No one would think that that would never crossed our minds.

Exactly. And so then when we look at well, recognizing that the systems that integrate out of hospital birth don't have that out, don't have worse outcomes for babies, but the systems that refuse to integrate it, and when that allow medical, you know, bias to dominate the system have worse outcomes for those babies that choose that choice, then it becomes Okay, well, how do you solve that? And I want to circle back to this idea, this assertion that on the part of hospital providers, that what that the cases that show up or train wrecks, you know, one result of that anticipation of hostility at the hospital, is that the midwife and the birthing woman might delay going in until they really, really, really need to go in, you know, until there's no question while they would have gone in earlier if they knew that there was going to be flow that if they knew that they could call ahead to that hospital team, and that you know, they're going to be received respectfully they might have gone in earlier. And so, in Oregon, There's one hospital where the chief OB really made it his business to try to increase safety for out of hospital birth transfers. This was legacy Emanuel Hospital and the chief of OB was named Duncan Nielsen. And so Duncan Nielsen, you know, maybe eight or 10 years ago, made a decision to train his hospitalists in out of hospital birth and midwifery and just take a bunch of policy steps to try to increase that. That continuity of care. And I remember reading an interview with him in Portland monthly magazine, when you know, in 2013, I think it was about these efforts. And Duncan Nielsen said, you know, before we made these changes, we used to see these train wrecks come in here. We don't see that anymore. And I thought that was so interesting, because he used that, that very common metaphor of the train wreck. And what it shows is that like a train wreck happens from two things coming together. You know what I mean? It's not just one thing that arrives as a wreck. And so what he was showing was that when you can eliminate the crash, you know, like if you if they take steps on the receiving end, then the crash doesn't have to happen. So that was so important, because it showed the the responsibility of the hospital in eliminating the things that they're complaining about, which is these messy looking transfers, that they can take steps to make that happen. That's only going to happen if you file those complaints about the times that didn't happen. Trying to eliminate the choice by attacking the providers or terrorizing the women or making it so that they are going to get punched, if they go to the hospital doesn't change the choice as much as make the choice more dangerous. There are studies from around the world on abortion that show that when a nation makes it illegal, drives it underground. It doesn't change the incidence of abortion so much as it makes women die from the choice for abortion, and it drives up maternal mortality.

So highly motivated. And you're highly motivated, you're saying the same thing is happening in birthing under percent. So what we know in childbirth is that, you know, when they drive these choices, underground, women still make them, they just become more dangerous. And when a midwife shows up for her there, it's more dangerous for the midwife to so there are still midwives who will show up for your VBACs for your twins for your breeches for your out for your straight up singleton out of hospital birth in places where they are not legally or you are with a system doesn't support them to do that. But for all the reasons we just described, prescribe that that decision is made more dangerous, both legally and medically. And then when midwives can't offer it, because they've been so frightened that they don't feel safe to offer it. What we are seeing in increasing numbers around the United States and probably other countries too. But certainly the United States is that women are feeling that their safest choice for childbirth at this point is to give birth at home alone with no trained professional to assist them. And when we look at the numbers of women who are making this choice, so much that it has become a quote unquote, movement, a quote, free birth movement that we understand, these women are can't all be just dismissed as insane, right for making a choice at the medical system. Like, you know, everybody knows things can happen in childbirth. And so people look at the choice to give birth unassisted as obviously dangerous. And so when you understand that women are willing to take on those risks, what you really need to look at is, why do the women consider this to be their safest choice. They know what we know about childbirth, they know things can happen quickly. And a lot of them already had a baby in a hospital

100%. So what you need to recognize is that these women consider it perceive it rationally, to be safer to give birth with nobody than to give birth with any of the trained, licensed professionals available to them. And that tells you a lot about the quality of care that they are receiving in it, you know, at the hospital, or through the licensed trained professionals, you know, in the ways in which those those providers hands are tied in the way that they're providing.

I think the key point here that we want everyone to understand is that we're not getting into what is safer. We're not getting into the debate around free birth, we're getting into the fact that we should all agree no one has a greater incentive or motivation to have a safe outcome than the mother of that child. So for those who are having free birth, yes, some choose it because they embrace it. And that's very much the intimate, private experience they want. But for those who feel they have no better choice. Those women have conviction that that is the safer approach to birthing their baby. And that that's that's the issue. How did they get there? How come the system doesn't offer them more safe options when they feel they have no other choice? I mean, look, I've talked many times about the very high VBAC success rate in my own community of couples that I've taught over these past 15 years I'm counting and the vast This majority of all those V backs, including V back after multiple C sections happened at home. Why not? Because those women decided to have a vaginal birth and said, Oh, the heck with the hospital. They tried desperately to get the support that they needed for their V back in the hospital. And most of them were, they just didn't get it. And they said, I can't believe this. But I believe so much in this VBAC, that there's nowhere else for me to do this than home. So I just think it's important for everyone to understand that that is why so much home birthing happens. We make assumptions about people having home birth, we make assumptions about people having free birth, as if women are being reckless, often they are first of all educated because they actually do know when it's safe, and when it's not. But they truly feel they're out of options. They are out of options. No one is being reckless, I think the takeaway is no one feels they're being reckless, and we need to respect that that's what's going on. For women, no one feels they're being reckless with their own birth. And actually, nobody's making a decision based on dogma or philosophy. So it's not that even though they believe so much in VBAC, it's that they want to give their their body a chance to let the baby out of their vagina before it gets cut out of them. So essentially, what we're seeing in our maternal health system is that as it becomes harder and harder for women to access support for a normal physiological process in which a baby comes out of their vagina, they have to, they have to work harder, and take on more risks in order to even have a chance at Physiol physiology even have a chance at a healthy birth. We know that the healthiest birth for the mother and baby is one that happens on pure physiology, that they get the best benefits both mother and baby short and long term. And so all these women want is a chance for a healthy birth. But they they're the options available to them, or not allowing them that and so the only way that they can access that chance is to leave the hospital, and sometimes to give birth alone with nobody, and the system has failed when women are in that position.

So Herman, we need to talk next about solutions. How do we how do we improve this? I know personally, as a certified nurse midwife practicing in a state where homebirth has been fairly well supported. It's still sort of a losing game in the long run, because it's not well reimbursed. It's not supported enough. The lifestyle is exhausting. The burnout rate for homebirth midwives is somewhere between five and 10 years, it's not really sustainable for the long term. So how do we make that? How do we improve that, and that has to come through this better process of integrating the system integrating the different kinds of care in birth and supporting each other in supporting women. Ultimately, in the end, it is up to the woman and we all need to support her choices.

There are so many areas in which advocacy is needed to make the choice for out of hospital birth truly accessible in the United States. But at the end of the day, midwives can't stand up for pregnant women's rights. Pregnant women need to stand up for their own rights and in doing so stand up for their midwives. So the midwives have to be willing to share with their clients what they're going through very often midwives protect their clients from the knowledge of what they're going through, because they don't want them to know how hard it is they don't want to be complaining etc. But your your clients really need to understand what you're facing. And and if if, if we know what you're going through, we're going to show up, we're going to stand up and that is what makes a difference in the US area. So for the consumers and all of us what we need to understand is licensure is only the beginning. When it comes to access for out of hospital birth. There's a lot more that is needed to ensure that the choices is safe and is integrated in all the different kinds of ways we've discussed today. And the people who are going to be most effective at accomplishing those goals are the consumers holding hands with their providers and with the support of legal counsel.

Thank you for joining us at the Down To Birth Show. You can reach us @downtobirthshow on Instagram or email us at Contact@DownToBirthShow.com. All of Cynthia’s classes and Trisha’s breastfeeding services are offered live online, serving women and couples everywhere. Please remember this information is made available to you for educational and informational purposes only. It is in no way a substitute for medical advice. For our full disclaimer visit downtobirthshow.com/disclaimer. Thanks for tuning in, and as always, hear everyone and listen to yourself.

I mean, how many nurse midwives are out there right now wishing they can practice home birth, but they don't, because it's just not well supported enough how many of them are out there practicing, frustrated in the hospital? I know they're frustrated by the policies. By the, you know, the increase in interventions, the high cesarean rates, the limitations on what they can do to support physiologic birth.

Right? They don't they don't feel safe. Just like for the women, it doesn't feel like a safe option to come into the hospital. So we've got again, like we've got this problem with the maternal health system in which lots of people don't feel safe. Right. And like, that's literally the opposite of what we need for childbirth, because what we need for childbirth to work is a feeling of safety for the birthing mammal. And that can really only happen if the people around her feel safe to because if they feel fearful and anxious, that feeling is going to be contagious, and it's going to interfere with the physiology of childbirth.