Wednesday, September 22, 2010

It Happened on the Way to the Midwife, Part 4.

 As promised, here is Collin's letter to Dr. Miller.  He's much more subtle than I am.

I understand that you no longer act as a contingency physician for home births, as you have in the past.  I have no qualms with your decision to provide care in the best manner you see fit; that is wholly within your purview and I commend you for your carefully considered philosophy of care.  That being said, my wife clearly communicated to your staff that she intended to have a homebirth, and rather than inform her of your recent change in policy, they nevertheless scheduled an appointment with you, a needless appointment for which she waited one and a half hours.  I hope that your staff was ill informed rather than deceptive by omission.

The decision to have a non-hospital birth is one that we have made with deliberate risk management, weighing with great gravity the risks and benefits of both hospital and non-hospital births.  The extremely high rate of caesarian births at Ridgecrest – at 22% for a low-risk pregnancy, versus 10% for Bakersfield Memorial, per the Census Bureau  – gave both of us pause.  Hearing that Ridgecrest categorically does not conduct VBACs, contrary to the recently revised (August 2010) guidelines issued by the American College of Obstetricians and Gynecologists, makes me think that the OB/GYN standard of care in Ridgecrest is less than what it should be.  If we lived in a city with a birthing center affiliated with a hospital, we would have preferred that, but given the option between a well-briefed home birth with a certified professional midwife versus a birth in a hospital in which one in five women with a normal, healthy pregnancy leave having had a c-section, I am compelled to think that the two options are at worst equal in terms of risk, to say nothing of other factors.  I am supported in my opinion by the paper “Outcomes of planned home births with certified professional midwives from the British Journal of Medicine, volume 330, which I commend to your reading.

Although she may not have presented her reasons for non-hospital births so succinctly, my wife nevertheless articulated her decision to have a home birth, a decision that you should have respected.  Rather than politely informing her of your disinclination to provide care under the circumstances, you continued with what was in essence a sales pitch in an attempt to change her mind.  Clearly, what transpired was a mutual waste of time, a waste that certainly could have been obviated by early, clear communication in what you do and do not provide and a respect for her articulated wishes.

Your comparison between appendicitis and pregnancy summarizes the gulf between our respective views of pregnancy and childbirth – pregnancy as a malady to be cured rather than a process to be observed and in most cases allowed to follow its natural course to fruition.  I wish you well in your practice, and that you may better inform your staff of the care you have elected not to provide.

Saturday, September 18, 2010

It Happened on the Way to the Midwife, Part 3.

Since this is the part where Dr. Miller gives me a sales pitch for himself (who is one of only three OBs in Ridgecrest) and the hospital, I think I should give you a few stats about the hospital.  They do not do VBACs.  Even though this isn’t a concern for me, it tells me they are seriously behind the times.  As of 2007, their overall c-section rate was 40%.  Their c-section rate for normal, low-risk pregnancies is 22%.  Compare that to 10% just two hours down the road in Bakersfield.  I have other reasons for being suspect of this hospital, but I think the statistics are enough to give one pause.

At this point, I’m pretty well shocked.  I had no indication that the meeting would wind up like this.  I wasn’t really sure what to say.  If he’s already made his decision, what point is there to arguing.  I’m hungry, tired, and ready to leave, but that wasn’t going to happen any time soon.  So I mostly tried to stay quiet and listen to his spiel until I could get out of there.

He starts giving me reasons he doesn’t do this.  He says (and I quote) “1 in 100 babies died before hospitals.”  I don’t have internet right now so I can’t check the accuracy of this statement.  But I do know that a statistic like that doesn’t apply to modern home births attended by professional midwives.  I also know that some of the darkest days of maternity care were the early maternity wards that were unsanitary.  Doctors didn’t even wash their hands and antibiotics hadn’t been discovered to treat infections.  But I digress.

He tells me he can’t be sure about some of the midwives “around here.”  He says that there are a lot of midwives in the area practicing without licenses or even any training.  In case you were wondering, my midwife is licensed by the state of California.  Since he has worked with her before, he should know this.  However, it’s fairly easy to check that kind of thing.  We do live in the information age, after all.

I think it was around this time that I finally interjected and told him that I wish he would have told me this over the phone so that I wouldn’t have had to spend an hour and a half waiting to find this out.  He says, “Well, we didn’t know what you wanted.”  Liar, liar, pants on fire.  I said, “Yes, you did.  I told the nurse on the phone that I was having a home birth and looking for a back-up physician.”  He didn’t really have anything to say to that.  Now, I know there’s a chance that this was a miscommunication among his staff, but if you have a hard and fast policy regarding home births, I would think you would communicate that to your staff.  But I would have to remind you that I left a message telling them what I was looking for.  I reminded them twice on the phone when I made the appointment.  And when the nurse brought me to the exam room, she knew what I was there for even though I hadn’t mentioned it that morning.  I never asked for a consultation on home births versus hospital births.  If I had known he wasn’t going to accept me as a patient, I wouldn’t have made the appointment.

I mentioned that I have a friend who had a home birth in May with my midwife, and he was her back-up physician.  He didn’t really have much to say to that either.  It seemed like he really wanted to pretend that this is always the line he’s walked, and he can’t remember ever doing anything differently, even if it was only four months ago.  He continued to act like he doesn’t know anything about my midwife. 

He says he doesn’t like backing-up home births because then he “misses out on all the fun.”  He says he likes to develop relationships with his patients.  He would meet my husband, and we would do ultrasounds together.  First, I never declined having a relationship with him.  In fact, I think it would be great to have a relationship with my back-up.  That’s part of the point, right?  So that if your care has to be transferred or you do have an emergency, it’s not a stranger working on you.  Second, I don’t want a bunch of ultrasounds, thank you very much.  They’re unnecessary and haven’t been proven to be completely safe.  Once again, the fact that he sees this as central to my care shows me that he is not be on the same page as me.

I mentioned that in Jacksonville, the midwives and the OBs work together so that you have a relationship with both (I could be totally off on that, but it seemed like it worked that way from what I saw).  He told me that Jacksonville is a big city, and they do things differently.  Thanks, I needed another reminder of why I hate Ridgecrest and miss Jacksonville.  I don’t really think I should have to sacrifice standard of care because I live in a small town.

I pointed out that some people who are planning a home birth also go to an OB but don’t tell the OB about their plans.  I told him that I was trying to be honest and upfront with him.  He told me he could tell when someone was planning a home birth.  Of course, you can.  (As a side note, I wouldn’t do that.  Part of the reason I’m going to a midwife is because I want joyful prenatal care that is in line with my beliefs.  But even if I did, I wouldn’t be with him because he’s not the OB that my insurance approved.  I’m certainly not going to pay out-of-pocket to be berated and treated like my pregnancy is a disease that needs to be cured.)

I think it was around this time that I told him I felt like I was wasting his time and keeping him from his actual patients.  That didn’t seem to concern him.

Then he offered to help me with a home birth if I did all my prenatal care with him.  I told him that was ridiculous.  Not that it’s something I would even consider to start with, but what midwife is going to do a home birth with someone who has received all of her prenatal care elsewhere?

He told me he wouldn’t charge me all the extra fees my midwife charges me.  What?  I’m paying my midwife a flat fee that covers all of my prenatal care, the birth, and postpartum care.  Maybe he’s talking about the cost of the birthing kit?  Yeah, that $60 is really going to put us in the hole.  Or the birthing tub rental?  Not required and wouldn’t be an option at the hospital.  I don’t know how much he charges, but I know that between OB appointments and the cost of a hospital birth, a midwife is a bargain.  Of course, why should I worry about that?  Tricare and the tax payers foot the bill for the hospital birth, right?

He told me getting a birth certificate would be easier.  And that’s the rubric by which I measure everything.  Sure, just go ahead and do a c-section.  As long as the birth certificate is easy to get.

He told me he could give me if I had nausea, he could give me a prescription.  Okay, this is another one of those “how different could our philosophies be” moments.  First of all, I already told him my morning sickness was mostly over.  Secondly, I don’t even take Tylenol for my headaches or Zyrtec for my allergies.  I don’t do prescriptions unless it’s a continual quality of life issue and even then, not during pregnancy unless it’s absolutely necessary.

He said he could help me pick out a pediatrician.  I informed him that we have Tricare Prime; my pediatrician is at the base clinic.  “You don’t get to choose?”  Um, no.  That’s how Tricare Prime works.  (Besides that, I have a two year old.  Shouldn’t I already have a pediatrician picked out???)

I think by this time my face was red, and I was shaking.  I was incredibly frustrated with him.  He told me I was just upset because I wasn’t getting what I wanted.  It’s at this point that I started having flashbacks to my pediatrician who used to diagnose my stomach problems and severe allergies as “schoolitis.”  If you want to treat a seven year old like a silly little girl, that’s understandable.  But I’m a twenty-nine year old, college educated, second time mom; I think I deserve a little respect.

Then he told me I should go home and discuss it with my husband.  I informed him that my husband is 100% behind my decision to have a home birth.  He said, “Well, I’d really like to talk to your husband; I respect what he does.”  That was the point where I blew my top and left. 

I know that some of this may seem inconsequential, but it was really upsetting to me.  I was not interested in being sold on the hospital or transferring my care.  I wanted to add him as part of my birthing team.  What really irritates me is that it all could have been avoided.  If he doesn’t back home births, he shouldn’t have made an appointment with me.  I feel that if nothing else, he was deceitful and treated me like I was an idiot.  And maybe because I didn’t really feel like spending my morning chewing the fat with a doctor who just declined me as a patient, he didn’t get the chance for me to prove him wrong.

I still feel that a home birth is the best chance I have for a safe, natural birth, and that’s what I’m doing.  But I am deeply disappointed that I have to do it without a “back-up plan.”  I was already uneasy with of the thought of having anything to do with Ridgecrest Regional Hospital or the OBs associated with it, now I’m terrified.  It is really unnerving to have to spend the next two and a half years of my life in a town where going to the hospital is such a scary prospect.

Friday, September 17, 2010

It Happened on the Way to the Midwife, Part 2.

I know some of these things are going to seem nitpicky, and under other circumstances, I wouldn’t bother with them.  But rather than try to make this super interesting by trying to decide what’s important and what mundane, I’m just going to tell you what happened.  So here it is...

I got there.  I filled out paperwork.  I wasn’t sure what to think when the paperwork asked me question like “What is the nature of my problem? How long have I had this problem?  Is there pain associated with this problem?”  I think you get the idea.  I’m filling out paperwork for a pregnancy and nowhere did I answer questions like “When was the date of your last menstrual cycle? When is the estimated date of conception?  When is your projected due date?”  Oh, wait.  I’m not supposed to know these things, right?  Heaven forbid I know what my due date is before the almighty doctor gets out his magical wheel or gives me an ultrasound.  (See what I mean about being nitpicky, but things like this drive me crazy!)

While I was waiting, I heard the receptionist (Or is it a nurse?  I don’t know.) on the phone with a lady saying, “I know you’re getting big, but the hospital isn’t scheduling any more inductions this week.”  Okay, I know I don’t know the whole story here, but I’m still amazed that people ask for inductions!  I could go on about this, but I won’t.

So after waiting over an hour in the waiting room, I finally get back to the exam room.  They weigh me, but I’m not sure why since they didn’t take any vitals.  The nurse gets out her magical due date wheel and calculates my due date.  Then she says, “So you just want to get Dr. Miller’s opinion on homebirth, and ask him to be  your back up doctor.”  This is where I started to suspect things were not going to go as well as I hoped.  I didn’t get that degree in Literature for nothing; I know foreshadowing when I see it.

By the time Dr. Miller comes in, I have been waiting over an hour and a half.  There are a few pleasantries like “Where does my husband work, What does he do,” etc.  He asks a few medical questions like “Am I taking prenatal vitamins?, Was my last birth full term?, Who’s taking care of me?”  Then he asked me why I want a home birth.  This is the part where I’m kicking myself now, because my answer was total crap.  I don’t know why I was surprised that he asked me that.  I don’t know why I didn’t give him a better answer.  Honestly, I don’t think many people have asked me why.  Most people who have known me more than five minutes can figure it out.  So I told him that my first birth didn’t go the way I wanted.  They didn’t follow my wishes.  And of course he gave me the classic OB line, “But it was a good outcome, right?”  Yes, nobody died.  That’s the rubric by which I measure everything, of course.  Seriously, Dr. Miller should be the poster child for “typical bad OB that you always hear about.”  I also mention that I don’t like hospitals.  So he counters, “What will you do if you get appendicitis?”  A little dumbfounded as to how you can compare having a baby to appendicitis (and I speak from experience here, my mom almost died from a ruptured appendix), I told him that I would of course go to the hospital.

So at this point, I’m feeling like I’ve just been presented with a pop quiz, and I’m failing miserably.  This is when he looks at my chart (not at me) and says, “Well, I’m sorry but if you want me to help you with a home birth, I’m going to have to decline.  I don’t think they’re safe.”

I’m going to leave off here for tonight.  But let me just make a quick commentary on what I’ve written so far.  Even though, I can already tell that this man would not, under any circumstances other than a life or death situation, be the doctor I chose to help me with anything, I respect his right to make his decision.  It is how he handled telling me his decision that I have a problem with.  More in Part 3. 

Thursday, September 16, 2010

It Happened on the Way to the Midwife, Part 1.

In order to keep this from being too long, I'm going to assume that you know me.  But if you don't, I would be happy to tell you about my previous pregnancy and birth experience, my strong belief in natural birth, or about how I live in a town where it seems the majority of people (including doctors) don't bother to pick up books and educate themselves or in the rare case that they do, they don't bother to do any research on the credentials of the authors that they are reading.  Where to start?
I am planning a home birth.  In a perfect world, OBs would be willing to work with midwives so that home birthing mothers have a back up OB who is not a complete stranger in the event of an emergency.  But we don't live in a perfect world, we live in a country with a very broken system for maternity care.  Nevertheless, I was advised by my midwife to visit the local OB who has provided unofficial back up for her in the past.

I'll say this right now, I was not excited about having to meet his man.  I'm not excited about anything that takes me onto the property of the local hospital.  Ridgecrest  Regional Hospital scares me.  I was even more apprehensive when I went online to get  Dr. Miller's phone and saw the absolutely terrible reviews of him.  But this was a hoop I had to jump through, so I picked up the phone and dialed.  I left a message with them.  I said, "I am planning a home birth, and I would like Dr. Miller to be my back up physician.  My midwife said that I might be able to just talk to him on the phone."  They called me back a couple of days later and left me a message with their phone number and office hours.  Helpful, aren't they?  I called back and left another message.  The next time they called I was home to answer.  They told me Dr. Miller didn't do phone interviews, and that I would have to make an appointment.  I made the appointment.  The earliest appointment they had was a month from the  day I called.  I reminded them once again that I was having a home birth with a midwife and that I did not want an exam.  They said it would just be an appointment to set me up as a patient and talk to the doctor.  Okay.

I wanted to be prepared for what to expect.  I didn't even see an OB when I was pregnant with my first child.  I saw a nurse-midwife during my pregnancy and a family physician attended his birth (all within the military medical system, so there was no drive for profit - it makes a difference).  So I called my friend who had a home birth with my midwife in May.  She told me he would make you thankful for our midwife.  But he was used to this and would talk to you, offer you a prescription for prenatal vitamins, and an ultrasound.  But overall, he was friendly, and it wasn't that bad.

Since I actually have to leave in a few minutes for an appointment with my midwife, I will go ahead and post this.  I'll get the long story of the actual meeting up as soon as I can.