June 14 - Corvallis Science Pub


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Power Poijnt slides from Melissa Cheyney's presentation at Corvallis Science Pub. The Politics and Science of Being Born: Location, Location, Location

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  • In the United States, institutionalized racism and biomedical hegemony heavily structure a woman’s right to choose where and with whom to give birth. Political-economic factors position obstetricians and hospitals as the only “appropriate ” options, even though a large body of literature supports midwifery care both in and out-of-hospital as a safe and viable option. In this paper, we describe an experimental program designed to remove one of the main barriers to homebirth care -- access to supportive and respectful medical back-up. We discuss the difficulties and triumphs involved in creating a policy that facilitates mutual accommodation across the home/hospital divide.
  • In 2006, the American College of Obstetrics and Gynecology (ACOG) published an official policy statement on OOH births, asserting: “The hospital, including a birthing center within the hospital complex is the safest setting for labor, delivery and the immediate postpartum, ” and that, “ACOG strongly opposes out-of-hospital birth” (American College of Obstetricians and Gynecologists [ACOG], 2006, p. 1). The executive board’s statement is based on the belief that, although “labor and delivery is a physiological process that most women experience without complications, s erious intrapartum complications may arise with little or no warning, even in low risk pregnancies ” (ACOG, 2006, p. 1). ACOG’s perspective clashes overtly with the APHA recommendation that efforts should be made to increase access to out-of-hospital maternity care services and the range of quality maternity care choices available to consumers, through recognition that legally regulated and nationally certified direct-entry midwives can serve clients desiring safe, planned, out-of-hospital maternity care services ” (APHA, 2001, p. 2).
  • June 14 - Corvallis Science Pub

    1. 1. The Politics and Science of Being Born: Location, Location, Location Melissa Cheyney, PhD, CPM, LDM Oregon State University
    2. 2. Background: Homebirth in the United States <ul><li>Two Categories of Midwives in the U.S.: </li></ul><ul><ul><li>- Certified Nurse Midwives (CNMs) </li></ul></ul><ul><ul><li>- Direct-entry Midwives (DEMs) </li></ul></ul><ul><li>Licensure of DEMs is state-specific </li></ul><ul><ul><li>- Oregon and Utah have voluntary licensure </li></ul></ul><ul><li>Even in legal states, DEM status is highly marginalized </li></ul><ul><ul><ul><li>ACOG statement </li></ul></ul></ul><ul><ul><ul><li>APHA statement </li></ul></ul></ul><ul><ul><ul><li>MacDorman et al. 2010 </li></ul></ul></ul>
    3. 3. “ Numbers and Narratives”Community Based Participatory Research Project <ul><li>Vital records </li></ul><ul><li>Hospital data bases </li></ul><ul><li>Participant-observation at perinatal task force and Oregon Midwifery Council meetings, peer reviews, transports and transfers of care in my practice, enforcement committee for the Oregon Health Licensing Agency </li></ul><ul><li>Open-ended, semi-structured interviews - collection of transport narratives </li></ul><ul><li>Focus group discussion of findings and reciprocal ethnography </li></ul>
    4. 4. #1Intrapartum home-to- hospital transports tend to fuel the home/hospital divide <ul><li>Compulsory interactions that occur during transports bring biomedicine’s ascendant knowledge system into contact with the devalued and marginalized knowledge system of homebirth midwifery. This contact can function either to entrench and solidify divisions or to begin healing the gap. </li></ul>
    5. 5. <ul><li>Robbie Davis-Floyd (2003) describes three possible outcomes of interactions during home-to-hospital transports that she terms disarticulation, fractured articulation and smooth articulation. </li></ul><ul><li> - Disarticulation occurs when there is no overlap in or correspondence of information between the midwife and the hospital staff. - Fractured articulation of knowledge systems result from partial or incomplete correspondence of perspectives, and </li></ul><ul><li>- Smooth articulation results when the interactions between midwife and medical personnel involve mutual accommodation or the respectful sharing of knowledge and power. </li></ul>
    6. 6. Six themes help to explain the perpetuation of the home/hospital divide <ul><li>Hospital-based providers: </li></ul><ul><li>- 1) the belief that home delivery is substantially more dangerous than current studies suggest; </li></ul><ul><li>- 2) the fear and frustration generated when physicians must assume the risk of caring for another provider’s transported patient; and </li></ul><ul><li>- 3) the belief that midwives make high-risk situations more dangerous by being difficult to work with due to poor charting and their defensive, antagonistic personalities </li></ul>
    7. 7. <ul><li>Homebirth Midwives Perspectives: </li></ul><ul><li>- 1) the defense of holistic and co-negotiated assessments of risk; </li></ul><ul><li>- 2) physicians’ tendency to judge homebirth midwives by “the exception, rather than the rule”; and </li></ul><ul><li>- 3) the failure of physicians to take responsibility for their roles in contributing to poor maternal-child health outcomes. </li></ul>
    8. 8. #2 Providers are well positioned to identify strategies for bridging the divide <ul><li>Homebirth Midwives: </li></ul><ul><ul><li>1) Midwives requested that the hospital staff show respect for them during transports and in dialogues over the best course of treatment. </li></ul></ul><ul><ul><li>2) M idwives cautioned hospital staff against assuming that someone who has attempted a home delivery will necessarily decline hospital procedures. </li></ul></ul>
    9. 9. <ul><li>Hospital-based Providers : </li></ul><ul><li>-1) E xpressed the need for &quot;timely transport with clear charting,&quot; along with a desire to assist with “complications, not crises. ” </li></ul><ul><li>-2) R equested that midwives make a greater effort to prepare all clients for the possibility of transport, with the expressed intent of demystifying and de-vilifying interventions such as epidural pain relief, pitocin augmentation, and cesarean section. </li></ul>
    10. 10. #3 Change will not be made without institutional policies that facilitate cross-cultural communication <ul><li>1) Three “take-home” messages: </li></ul><ul><ul><ul><li>Every conversation is a cross-cultural conversation. </li></ul></ul></ul><ul><ul><ul><li>Cultural competency is medical competency. </li></ul></ul></ul><ul><ul><ul><li>There are multiple markers of difference. </li></ul></ul></ul><ul><li>2) Group and one-on-one trainings - models of care, safety research </li></ul><ul><li>3) Participant-observation of “the other” </li></ul><ul><li>4) Formal transport protocols endorsed/enforced by the hospital </li></ul><ul><li>5) Mixed oversight committee and quarterly discussion groups </li></ul><ul><li>6) Taking responsibility for initiating a cultural shift </li></ul>
    11. 11. Summary and Conclusion <ul><li>Intrapartum home-to- hospital transports tend to fuel the home/hospital divide </li></ul><ul><li>Providers are well positioned to identify strategies for bridging the divide </li></ul><ul><li>Change will not be made without institutional policies that facilitate cross-cultural communication </li></ul>