Who do you want on your birth team?

Here's one Q & A exchange — the last one, in fact — from an interview Tara Parker-Pope, who writes the "Well" blog for the New York Times, conducted last year with Randi Hutter Epstein, physician, mother of four and author of the 2010 book on childbirth, Get Me Out: A History of Childbirth from the Garden of Eden to the Sperm Bank.

Q (TPP)  Should the care of women during childbirth be reserved for other women?

A (RHE)  I look at it as a doctor-patient relationship history, more than a man-woman kind of thing. When you hear women say, “I’d much rather give birth with a midwife than a doctor,’’ I think, “Why?” I love my ob-gyn. It’s sad people think you’ll have a nicer person if you avoid the medical system. That’s the feeling you get when you talk to women. I think if women had better relationships with their doctors, I think that would help. They would be more informed. They would believe the information their doctors tell them.

I agree with some of what Dr. Epstein is saying. I loved both my ob-gyns, too. I believe, though, that to choose a midwife for a birth attendant instead of a doctor is to opt for, or at least to attempt to have, a qualitatively different experience.

It isn't just a hope to deal with a nice person. It's embarking on a whole different journey.

What do you think? I would love to hear from you.

Pushing back against home-birth critics

British and Australian midwives are pushing back against a recent editorial in The Lancet, a British medical journal, which builds on a study released last month that appears to show that home births are less safe than those that occur in a hospital.

"Women have the right to choose how and where to give birth, but they do not have the right to put their baby at risk," stated the unsigned editorial from July 31.Pregnant Graffiti

In an interview today with the Guardian, a British newsaper, Cathy Warwick, the general secretary of the Royal College of Midwives, said that midwives believe home birth is "being unfairly pilloried by some sectors of the global medical maternity establishment."

Hannah Dahlen, the president of the Australian College of Midwives, weighed in as well. "Intense medical lobbying and strategically released journal articles" had put midwifery in her country "in the hands of the medical profession," she said.

Warwick said, "What shocked us about The Lancet editorial was its language and tone and how it pumped the hype about the dangers of home birth, and made sweeping and misogynistic statements."

"The Lancet said it stood by its editorial," wrote Randeep Ramesh in the Guardian article.

The impetus for the piece in The Lancet was a meta-analysis scheduled for release next month in the American Journal of Obstetrics and Gynecology, a peer-reviewed journal published jointly by a number of organizations that includes the Society for Maternal-Fetal Medicine. The meta-analysis was presented at the SMFM meeting in Chicago in February.

The article, published on-line last month, "provides the strongest evidence so far that home birth can, after all, be harmful to newborn babies," according to The Lancet editorial.

Home births account for about 3 percent of births in the United Kingdom, according to the article in The Lancet; in the United States, the figure is about 1 percent.

American midwifery groups and out-of-hospital birth advocates like The Big Push for Midwives have already questioned the findings of the AJOG article.

The Coalition for Improving Maternity Services called the report a "poorly designed and methodologically unsound study," expressed itself "outraged" that AJOG accepted it for publication, and suggested the report was rushed on-line as a ploy to stop legislation then pending (since signed into law) in New York that will make the practice of midwifery easier in that state.

"Pregnant Graffiti" by Petteri Sulonen

New York delivers for midwives

Last Friday, New York's Gov. David Paterson signed into law A8117b-S5007a, the so-called Midwifery Modernization Act, which removes the requirement for midwives to obtain a written practice agreement from a physician or hospital to practice in New York State. The bill will take effect in three months.

Paterson's signature was by no means a sure thing — the Democratic governor, who is not seeking re-election in the fall, vetoed thousands of bills this summer, and he waited until the very last possible day to sign the midwifery bill.

Not only that, but the American Congress of Obstetricians and Gynecologists, the new political arm of the American College of Obstetricians and Gynecologists, lobbied against the legislation. The group argued that it would make midwife-assisted birth less safe, as midwives who did not have formal relationships with doctors might not be able to access medical care in an emergency.Pregnant Graffiti WPAs have been a condition of practice for midwives in New York since 1992.

But old certitudes and worst-case-scenarios fell flat in Albany this summer.

The closing of St. Vincent's Hospital in New York City last spring created a crisis for those relatively few women seeking home birth with midwives, and provided an object lesson in the difficulties the requirement for a written practice agreement could create. By June, seven midwives who had had WPAs with St. Vincent's were still scrambling to find doctors willing and/or able to formally partner with them, and hundreds of mothers who had been planning to deliver at home were in a state of limbo.

Beyond the immediate concerns, though, the ease with which the bills sailed through the New York legislature — the vote was unanimous in the Senate — suggests that midwifery has attained a mature level of acceptance in New York, which has perhaps 900 midwives, more than any other state.

Assemblywoman Amy Paulin, for example, one of the bill's sponsors, had her children with midwives, including two home births.

Groups that represent midwives emerged as effective lobbyists for the bill, mustering thousands of calls, emails and signatures on petitions.

Meanwhile, ACOG's efforts were notable for gaffes like a quote in the New York Times from Donna Montalto,  executive director of ACOG's New York division, who said physicians might balk at providing emergency care without a WPA.

“What obstetrician who has never seen the patient, doesn’t know the midwife, and happens to be at home at their son’s baseball game is going to say, ‘Sure, I’ll come in and take care of your patient,’?” Montalto said.

Perhaps most importantly, the new act affirms the view that birth is a natural event, and not necessarily a medical one. New York legislators have given midwives a vote of confidence, one that could portend a significant shift in attitudes about childbirth.

"Pregnant Graffiti" by Petteri Sulonen

Specialists in women and babies

The American College of Obstetricians and Gynecologists was founded in Chicago in 1951, the latest in a line of associations that has sought to serve the organizational needs of specialists in medicine for women.

By the time the organization was founded, the controversy over whether the two specialties should be practiced separately or together had been largely resolved, which reflected an improvement of the status of obstetrics. (One 19th century proponent of keeping the two disciplines together had characterized obstetrics as "the portal to the temple of gynecology.")

Obstetricians are not the only doctors who deliver babies — family physicians attend about 20 percent of births nationally, and midwives, mostly nurse-midwives, handled about 8 percent of births in 2004. Still, obstetricians deliver the majority of American babies.

ACOG membership is voluntary. The group, now headquartered in Washington, D.C., has 52,000 members, more than 90 percent of board-certified OB-GYNs. Important ACOG activities include the annual meeting, continuing education and the publication of the monthly journal Obstetrics and Gynecology, the so-called Green Journal.

Some of  ACOG's members are specialists in maternal-fetal medicine, gynecologic oncology, reproductive endocrinology, and other areas.