Homebirth Backup

There are a variety of care provider options for parents during their perinatal stages.  Deciding which care provider to use isn't a cut and dry choice.  As midwifery becomes more regulated, we're seeing birth become more and more medical, where medicine was never intended.  Take the "joint care" perspective that many parents have.  They hire a home birth midwife, but they also hire an OB and see both on a regular basis.  My opinion?  If you believe you NEED the care of an OB, then you probably want to really consider if birth at home, or with a midwife, is really for you.  I'm not sure you trust the process as much as you might think.  (Although, there are circumstances where a need arises that you prefer a few labs specific to this pregnancy to confirm you're still good to birth at home).  Same concept of believing you need to be your own midwife - or have anyone act as a midwife - if you plan to birth unassisted.  Having someone with less skill because they're cheaper, or "do the same things" - is not the same thing... at least not in this modern world.

But, let's get a few things straight.  There are some midwives who prefer that their clients have a backup OB in case of transfer.  A backup DOES NOT mean joint care... let me explain...  This confusion, I believe, often comes with the requirements of a CNM.  A CNM, in most cases, is legally unable to attend births without a physician backup - someone they can call on for information on their clients... a second opinion so to speak.  Logistically, this should be the same physician that would see the client if a medical transfer was necessary, or some sort of medical need arose, but that isn't always the case.  A backup physician could easily be hours away and no where near the proximity to see the client in those instances.  Therefore, the client sees whoever is assigned to "unassigned" patients should that need arise.  There are some states that also require CPM's to have a physician backup - in the states where CPM's are also regulated (and most DEM midwives are illegal in those states).  Other states with no laws for or against midwifery don't have that physician backup requirement for midwives (other than CNM's).  Because of this, some midwives suggest moms get established with an OB practice in case of transfer... and here is where the confusion sets in...

The recommendation [usually] doesn't come from the perspective that moms need JOINT CARE, but just to know someone (to be comfortable) should they need to transfer.  Think about it - you have a medical transfer during a homebirth...although rare, the situation may lead to a stressful one, and knowing your attendant can be beneficial.  Additionaly, it may have also developed from the perspective that most mothers have, in that they need labs and tests during pregnancy, in which many midwives often don't provide (those practicing with the belief that midwives are not medical providers).  While I don't believe that moms *need* this situation, I see no harm in having an OB backup just in case if the mother desires it.  This is NOT joint care... there is a difference here; let's take a look.

1.  Midwife's backup or Consulting Physician - A physician that talks with the midwife - in which case they are communicating with the midwife, and it is typically a relationship created by the midwife and this physician has agreed to "backup" or "consult" for all the midwife's clients.  This backup, ideally, would see the client in case of transfer, but in cases of distance issues, the mother would get the provider assigned to "unassigned" patients, or may hire a backup herself (like #2).

2. Mother's backup - A physician that agrees to see the patient should medical care be needed, in which case the mother creates the relationship, and this physician may differ for each of the midwife's clients.    While most mothers don't assume the physician is responsible unless there is a transfer - in a court, this wouldn't fly. If a mom doesn't hire a "backup," she'll just get the physician assigned to "unassigned" patients (and should also keep in mind that most OB's have a backup themselves so they aren't on call all the time, and the mother may not get their hired backup anyway).  If the mother hires a backup, she may choose to ALSO have joint care, (like #3), but this isn't the initial reasoning

3.  Joint Care - The mother sees the physician throughout the pregnancy, either in part or on a regular basis along with her midwife and is essentially responsible for the health of the mother and baby no matter where or with whom she births.  The mother may believe she needs this, or she just may prefer it.  Again, keep in mind that your OB likely has a backup themselves and you may not get this OB in the case of transfer if they're not on call.  Nevertheless, it doesn't matter what kind of midwife you have (nurse or not), this joint care really isn't necessary unless you may need medical care for some reason, but prefer midwifery care for the basic needs of pregnancy and postpartum (I know I would if I needed to birth in a hospital for some reason).  ALL midwives are checking for the health of the mother and baby... If you believe you NEED medical care during pregnancy, birth, or postpartum - then I question if you are as comfortable with your home birth as what you should (or we would like you to) be...  If you're getting joint care because you're afraid to talk to your midwife about your wishes... I would hope your level of comfort rises over the next weeks and you can be open about your birth, otherwise, you're giving up your control anyway.  Every provider practices in their own way, finding one that practices compatible to you is ideal, but no one will be 100% - though they could be if you speak up.  However, this joint care/backup confusion is where you lose most physicians' willingness to be involved at all with the home birth.

Even though a mother may prefer to not have joint care, and just use a backup - if they are not dismissed from the care of the pregnancy formally, a court could easily argue that they took responsibility for the birth - especially if something goes wrong (although rare) - yes, even if they weren't present.  Sure, we'd all like to think that people aren't sue-happy, but with all the lawsuits out on midwives right now (and all the other ridiculous lawsuits out), can you blame people practicing defensive medicine?  There are definitely numerous cases of iatrogenic complications, but there are also a LOT of people who will sue for just about anything, which is a big chunk of increased malpractice costs and modern medicine.  They can't get sued easily for doing an emergency cesarean, but they can get sued easy for not doing one.  They're paying bills and putting food on the table with this job - and they likely have a lot of them; it would be hard to expect someone like that not to think about money and livelihood.  I hate that our culture is like this, but people take less and less responsibility for themselves as the years go by (and providers are also forced to take the responsibility, even if it is the mother's health and life choices that had a big hand in the situation), and therefore, right, wrong, or a little gray, I simply can't deny that I understand why this perspective of care exists.  Additionally, this is why mothers lie about their birth wishes.

Mom wants a simple backup, but the physician is leery about the end result and doesn't want to be responsible.  They often don't trust home birth, so they're less likely to support the situation.

The midwife may also be worried about her licensure or legal issues (in case something happens, she doesn't want to be sued or lose her profession either) or she sees a backup (only in case of transfer) as a nice thing to have to keep the mom's comfort levels in check.  But, moms can't get a physician to agree to this situation, so they lie and get joint care (only, the OB doesn't know its joint care - they think you're planning  a hospital birth).  They see the OB as much as they see the midwife (usually a stressful situation since they're getting better care at home), don't tell them they're planning a home birth, and then "OOPS," just don't show up.

For your sake, and the sake of all mothers and babies, please do not lie!

It does nothing to help yourself (you know, you can get in "trouble" for this in a court, too), or other mothers who want a different birth experience.  Somebody has to do the legwork somewhere along the line, and if we do to birth what we've done to every other aspect of our culture and believe that someone else will always take care of everything for us, then, well... do you see where birth will be in 20-30 years?  There are already countries where most of the mothers are asking for cesareans; we won't be far behind (only, we could experience more of a "forced for the health" reasons).  We see change when people speak up - and we need to truly understand the implications of what we're speaking up against (the hidden ones - because not everything is as it seems).  Right now, mothers are speaking up for giving up their responsibility to someone else and having induced and medicated births, whether they know it or not.  When the majority of the society is birthing that way, and the majority of the other  [1% of] mothers are lying about it... how in the world do you expect to change the face of birth and turn it back to biological?  We have enough lies in our politics, culture, mom groups, and everywhere else - please don't complain about the state of birth and do nothing about it... or even worse, harm it.

If you change providers - tell them why.  If you don't want to tell them to their face, write it on the forms to transfer your records.

If you are preparing for a home birth, sure - I can understand not telling your life story to the receptionist, but please be honest about your intentions to birth.  The more they hear it, they may start listening.

The change usually starts with opposition - but if moms keep speaking up & demanding better care - it can make a difference. If you don't speak up - they think you're OK with being treated like a patient and receiving less than optimal care... you are PAYING them to do this to you and saying nothing about it.  They're making you happy, obviously... Do you really think they're going to magically "see the light?"

Yes, this can involve some headache on your part.  It involves some frustration being told you're being unsafe or you won't be cared for... I've been there myself.  But, when you cater to them, they don't cater to you anyway - so please at least help the future of birth.

I do think you need to ask yourself one question when choosing the style of care you want.  Are you likely to sue?  Are YOU taking responsibility for your birth, or are you hiring someone to take responsibility for you?  If YOU are in control... if you understand that YOU are responsible for ALL outcomes, this may help you pick the best provider.  There are things that happen in either direction... but when you hire someone to take care of you, you are hiring them to do the job that they know how to do - and unfortunately, people make mistakes... and sometimes, some things simply just happen.  Don't assume because you're in a hospital everything can be fixed... remember that birth is as safe (and often with less interventions) in a home birth as it is in a hospital.  Not everything is perfect, so choose wisely.

A with-woman midwife does not believe that a healthy expecting mother needs medical care.  She is an attendant at the birth who is there to be with you during this stage of your life.  Because of this, some midwives don't provide medical services - they don't provide lab work, ultrasounds...etc., even though many mothers still want those things, because they don't believe that is a midwifery service - they believe its a medical service.  I believe it is important to separate the understanding of this, regardless if you choose medical care during your birth or not.  Years ago - a midwife was simply a woman who had been there before and did so little to disturb the birth process that no one would have ever expected her to know so much about the medical side of birth, like many midwives know today - and there are still midwives who hold true to that ancient form of with-woman care.  She more or less supported the emotional needs of the woman (because birth is, more than anything, emotional) and trusted that the body would do its natural function naturally (with all outcomes in mind).  We, of course, know more techniques to improve birth outcomes so attendants are doing more than what they did many years ago... but what is often failed to be understood by even the majority of midwives, is that not all progression in perinatal care are improvements.  Every step you move in the direction of medical care during the birth process, the more medical all providers become, regardless of their title.  You really need to ask yourself what you believe about birth, and what provider is truly providing you with the care you desire.