Birth is a big part of Melissa Cheyney’s life – especially right now. As a new mother, having given birth in May of this year to a beautiful girl, as well as a practicing midwife and homebirth advocate, Cheyney has devoted much of her life to bringing new life into this world. In fact, the weekend after we conducted this email interview, Cheyney attended her first birth as a midwife since her daughter’s arrival. But it is her work as a professor of medical anthropology and reproductive biology at Oregon State University that recently caught my eye.
In this capacity, Cheyney and her research partner, doctoral student Courtney Evans, explored the effect of midwife-attended homebirths on elevated rates of prematurity and low birth weight in babies born in a particular county in Oregon between 1998- 2003. And though their research disproved the notion that homebirth yields poorer birth outcomes (in fact, just the opposite was true - all of the homebirths studied resulted in successful health outcomes for the newborns), they did uncover something else in the process. When results of their study hit both the hospital provider and homebirth/midwifery communities, “antagonism was…considerably amplified” between the two; leading Cheyney and Evans to examine the ways in which the hospital/ homebirth provider relationship could be improved.
It is no surprise to Direct Entry Midwives (also known as DEMs) or homebirth advocates that many in the hospital-based birth practitioner community believe homebirth to be unsafe and inferior to in-hospital birth. Both ACOG and the AMA have issued statements proclaiming as much. But Cheyney and Evans discovered a “deep mistrust” between the two communities that led Cheyney to want to do something to ameliorate some of the hostility in the relationship. Cheyney worked with her own back-up physician, obstetrician Dr. Paul Qualtere-Burcher, to create a pioneering protocol guiding the midwife/doctor relationship with the goal of creating optimal experiences for both providers and patients alike. The document, “Proposal for Increased Collaboration between Direct-Entry Midwives (DEMs) and Obstetricans for Homebirth Clients,” is grounded in a series of foundational ideas: homebirth is a viable alternative to a hospital birth particularly when facilitated by a skilled DEM with a physician back-up; research supports the idea that homebirth is a safe option for low risk pregnant women; obstetricians and hospital care represent a “safety net,” as Cheyney and Qualtere-Burcher propose, that can contribute to healthier birth outcomes for both mother and baby if complications arise during a homebirth.
Professor Cheney graciously agreed to answer some of my questions about her groundbreaking protocol, her research into the hostility between both home and hospital-based birth practitioners and why it’s critical to women’s health that these issues are addressed.
Newman: Do you know if there are there similar protocols being developed in other parts of the country between DEMs and physicians (in those states where midwifery is legal!)? If not, would you like to see this replicated?
Cheyney: To my knowledge, this is really the first of its kind, at least one that is being formally implemented and studied. However, in areas where midwifery is legal, these kinds of arrangements exist more informally between individual midwives and physicians that have developed relationships usually over years of working together. I would love to see these protocols replicated and modified to meet the specific needs and goals of the given area. We know that homebirth is safest when it is planned, a trained midwife is present and medical back up is available if needed. It’s really that third criterion that needs streamlining and strengthening in our country.
Newman: Oregon seems to have progressive rules and regulations regarding DEMs - unlicensed midwives are able to practice. Has this been supported by physicians? Has there been resistance, active or otherwise, by OB/GYNs to Oregon's policy?
Cheyney: Most OB/GYNs in the state of Oregon are unaware of the distinction between unlicensed and licensed midwives. Many refer to us all as “lay midwives” – a term that most DEMs find insulting because it suggests very little or no education. Voluntary licensure is thus, rarely an issue for obstetricians. Place of delivery is much more contentious. Many obstetricians are opposed to homebirth regardless of the practitioner type. However, in my capacity as the state legislative liaison for the Oregon Midwifery Council this year, I did find a few legislators that are concerned about voluntary licensure and they have called for a study session this summer to explore the feasibility of mandatory licensure. I will have a lot to say about that. In addition, a small group of labor and delivery nurses at Oregon Health Sciences University recently addressed the health licensing agency’s board of direct-entry midwifery which I serve on, requesting that the protocols that govern the practice of LDEMs be tightened to exclude breech, twins and VBACs. They are also advocating for mandatory licensure. With these exceptions, I would say that the vast majority of practitioners remain unaware of voluntary licensure status and just oppose homebirth in general.
Newman: What has your experience as a practicing midwife been like as you've developed relationships with physicians? Have you experienced the "deep mistrust?" In other words, were you surprised at your findings that there was antagonism, distrust and conflict between doctors and DEMs?
Cheyney: The vast majority of my personal experiences have been positive, largely because I was fortunate early on to establish a relationship with several local obstetricians through my work as a researcher. For the most part, I feel like I have been treated with respect and as a colleague whenever I have transferred the care of one of my clients. However, about a year and a half ago, I did experience a negative transport that was the result of deep mistrust. I had been caring for a low-risk woman who had a straightforward labor, but experienced a severe complication at birth known as a shoulder dystocia. This is where the head is born, and the shoulders become impacted behind the pubic bone. I responded quickly and was able to extract the baby and perform a successful resuscitation. However, this baby suffered a broken arm, which is the second most common complication from a shoulder dystocia. When we transported to the hospital, the pediatrician in the ER threatened me with child abuse and arrest. His attack on me and subsequently the parents who felt judged during their care made a bad situation even worse. The parents still recount the most difficult part of that day being the interaction with this pediatrician. Later when mom and baby were moved to the postpartum ward, we received nothing but support and compassion from the labor and delivery staff who had recently lost a baby to a shoulder dystocia. Thankfully, this baby made a full recovery and ultimately solidified my relationship with this hospital. My quick action at his birth helped to overturn the misconception that direct-entry midwives are untrained. So while most of my experiences have been extraordinarily positive, my one negative transport experience stands out in my memory and made me well aware of what I might find with this study.
Newman: In your proposal, crafted by you and your back-up physician, you write that "Obstetricians acknowledge that there are twenty-nine studies that now clearly indicate homebirth as a safe and viable option for low-risk women." But with the ACOG and AMA both stating, essentially, that the safest setting for birth is in a hospital, do you find it difficult to "convince" OBs that homebirth is a “safe and viable” option?
Cheyney: In the community where the proposal is now being implemented and studied, half of the practices in the county were represented at the proposal meeting. All of the obstetricians present were willing to concede that homebirth for low-risk women was a viable option. The bone of contention lies with how to define low-risk. As addressed in Cheyney and Everson 2009, midwives tend to have a broader definition of risk that includes psychosocial, emotional and social risk, where physicians are more likely to see risk as simply clinical risk. As a result, a woman may choose a homebirth even when at higher risk for a complication because of a past traumatic experience in the hospital. This can be hard for obstetricians to understand during a transport when they are filled with fear about having to attend a higher risk woman that they do not know well. Dialogue around whether a higher risk woman should still have the right to choose a homebirth tends to be very difficult and heated.
One bad experience may also bias a doctor against all home deliveries. In addition, in my experience, there is often a divide between theory and practice for obstetricians. In theory, they know that their professional organization opposes homebirth. In practice, they are called in with some regularity to assist in homebirth transports. They are also well aware that homebirth, water birth and births with doulas are on the rise. This means that physicians cannot simply ignore homebirthers and continue to vocalize their mistrust of Direct-entry midwives. We are forced, out of necessity, to interact. As physicians come to know the midwives in their community, a grudging respect has the potential to emerge, making it difficult to remain adamantly opposed in some cases.
Newman: How can providers who are already open and amenable to working with midwives help foster a more supportive culture among colleagues, as you suggest in the proposal?
Cheyney: One of the mechanisms for maintaining distrust between midwives and obstetricians is what my colleagues and I have termed “ birth story telephone.” This is very similar to the childhood game of telephone where as the story spreads from one individual to another, it grows in nature and the details change substantially. As home and hospital birth stories are told and retold, and filtered through the lens of the teller, details shift to match the preconceived worldview of the teller. For example, a non-emergent transport for a slow, uncomplicated and non-progressive labor can turn into a mother laboring at home for days with poor heart tones and a uterine infection before the midwife reluctantly brings her in. By the time the story has been passed along, mother and baby who were actually never in danger were saved from a near death experience by the hospital staff.
Conversely, hospital births where a woman feels too many interventions were used can be constructed as abusive or traumatizing to the woman after numerous retellings. These stories effectively maintain the home/hospital divide. Physicians and midwives can work to overturn that divide by refusing to participate in “telephone,” by being committed to accuracy and professionalism; sharing only the stories they have first-hand knowledge of. Midwives and physicians who have positive experiences working with one another also need to speak up regarding those positive interactions.
Newman: What are some of the stereotypes or judgements held by midwives about OBs/physicians?
Cheyney: Let me begin with this caveat, midwives often hold fewer misconceptions about obstetricians because we actually get to see hospital deliveries when we transport. We have first-hand knowledge of the model of care that we often critique. However, very few physicians ever attend a home delivery, and yet feel very comfortable critiquing that option.
That said, because midwives often hear stories of hospital births from clients who are unhappy with the experience and are now seeking an alternative, many maintain an outdated view of hospital deliveries as inhumane and impersonal. The vast majority of women, about 70% in the United States, leave the hospital feeling it was a positive experience. Only about 30% leave with regrets or frustrations about their experience and treatment. We as midwives disproportionately serve that 30%. This can prevent us from seeing the work that obstetricians are doing to humanize and individualize birth in the hospital.
Finally, while obstetricians can envision a world without midwives, midwives cannot envision a world without obstetricians. Thus, midwives have a larger incentive to work towards positive relationships with back-up physicians.
Newman: What if a pregnant woman faced with a VBAC or twins does not want to consult with an OB? Is this protocol suggested or mandated?
Cheyney: It is suggested. Oregon law prevents any clinician from forcing a woman to engage in any intervention or procedure against her will. Midwives can strongly encourage it, and because they have a close relationship with their clients, their suggestion is likely to be followed. Midwives who have agreed to participate in this experimental protocol will have to document in their charts that the physician consult protocol was encouraged.
Newman: What happens now with a transport where the midwife and physician have not previously spoken? Do they get a chance to confer? Is the midwife even allowed in the room or does that depend on the doctor?
Cheyney: Before the protocol, non-emergent transports were highly variable and dependent upon the physician on call for undoctored patient. During emergency transports, there is little time for consultation and that will remain the same with this protocol. However, since the vast majority of transports are non-emergent (more than 95%), there is at least the theoretical potential for midwife and physician to meet in the hall and to discuss the case before entering the room together to propose an agreed upon course of action to the mother. The extent to which this happens in practice varies considerably by facility and by physician. The point of our protocol was to help standardize interactions and to help physicians and midwives to create a culture of interaction and collaboration built on mutual trust and respect. See also our discussion of this in Cheyney and Everson 2009.
Newman: You write in the proposal: “Opportunities are made available for physicians to observe homebirths and for DEMs to observe low-risk hospital deliveries.” This is a fantastic idea and I'm surprised that this doesn't already happen. Are there any classes or opportunities available in medical school, for those who chose to pursue an OB/GYN track, to learn about midwifery and for midwives in training to observe hospital births?
Cheyney: Currently, there are no opportunities for obstetricians to observe home deliveries during their medical training in the U.S. However, this is an option for physicians in the Netherlands; in fact, it is a requirement for all Dutch obstetricians who wish to attend low-risk deliveries. Obstetricians often have exposure to hospital deliveries with Certified Nurse Midwives, however. Because many Direct-entry midwives have been doulas at some point in their lives and because they accompany women who transfer care due to a complication, there is a general understanding among midwives about what happens in a “low-risk” hospital delivery. Further, most transports are for non-emergent cases with low-risk women, allowing them to see many low-risk deliveries in the hospital. The reverse simply cannot be claimed for physician knowledge of homebirth practice.
Newman: On a personal note, you had a baby recently. As a practicing midwife, a researcher of this issue and a mother, do you have any advice for women who are pregnant or looking to have a baby soon and who plan on working with a DEM, about how best to ensure the most comprehensive care for themselves during childbirth? Should they ask their midwife if she has a back-up physician with whom she has an amiable relationship?
Cheyney: Very few DEMs in the United States have formal relationships with particular back-up physicians. As such, if women asks this question, the answer will very likely be no. It may be more helpful to ask what transports are typically like. Because the vast majority of midwives who go into labor intending to deliver at home do so successfully, I would never advise a woman to make a decision about whether a homebirth is right for her based simply on what a transport may be like. It is most important that the woman’s philosophy of care matches that of her midwives. There is a spectrum of homebirth midwifery, from very hands off to more medicalized. Some will do breech births and twins, some will not. Some have antagonistic feelings toward the medical model; others see the relationship as collaborative. It is important for women to take the time to interview the homebirth providers in their area, and when possible, to choose a midwife with a similar perspective.