Tag Archives: Atlanta

Stand up for those who stand up for you

Dr Bootstaylor demonstrating breech skills

Dr Bootstaylor demonstrating breech skills

Update, 24 August 2016: Following protests from the local and international communities, Dekalb Medical has reinstated the ability of Dr Bootstaylor and the See Baby Midwifery team to support planned vaginal breech births. Thank you to all who stood by the team and helped achieve this important result. More information.

21 August 2016: Within the past two weeks, restrictions have been imposed on two highly experienced breech birth providers, suddenly, and without apparent cause. They are currently not allowed to attend breech births in hospitals where they have done so successfully for many years. These restrictions have been imposed by others who hold power within the institutions. The providers who have stood by women now need women, families and other professionals to stand by them.

On 7 September, a protest will be held in Los Angeles, California, at Glendale Adventist Medical Centre, which recently issued an outright ban on vaginal breech birth – The Rally Against Vaginal Breech Birth Ban. Glendale’s Dr Wu is a highly experienced breech birth attendant who supports not only women but other providers to gain skills.

If you attend the rally, or write a letter of support, and you tweet, use #bringbreechback – I will link to these tweets within this post.

Other related blogs:


The See Baby team of Atlanta, Georgia, have also been restricted. Their ban includes water birth and VBAC, as well as breech birth. Read more about their situation on the See Baby Blog. To support the See Baby team, I have written the letter below, sent to the Director of WI Services at Dekalb Medical. Please add your voice to protest this backward decision, addressed to the Director and copied to Julia Modest of the See Baby team, so that they are aware of the support of the international community.

On July 21, 2016, John Shelton issued a press release congratulating 83 of Dekalb’s physicians for being named as “Top Doctors” in Atlanta magazine — including Dr Brad Bootstaylor.

PLEASE WRITE TO ADD YOUR VOICE

20 August 2016

To: [The Powers that Be, names and addresses removed now that resolution has been achieved]

 

I am writing to express my concern and disappointment at the recent, sudden decision of Dekalb Medical to issue a blanket ban on water births, breech births and vaginal births after caesarean section (VBAC), facilitated by the internationally regarded See Baby team. Such a decision directly contradicts the recent, positive movement to recognise birthing women’s agency and autonomy, as summarised in this recent statement from the ACOG Committee on Ethics:

“Forced compliance – the alternative to respecting a patient’s refusal of treatment – raises profoundly important issues about patient rights, respect for autonomy, violations of bodily integrity, power differentials, and gender equality.” 1

The ban on water births and VBACs contradicts practices throughout the developed world, in which the tide is flowing very much in the opposite direction. My area of specialist knowledge is breech practice, where the tide is also turning, as reflected in the recent ACOG Practice Bulletin No. 161: External Cephalic Version, which also acknowledges the renewed interest in vaginal breech delivery as part of the movement to reduce the primary caesarean section rate.2 The change around breech birth is much more dependent on the skills of people like Dr Bootstaylor to light the way, due to many obstetricians having abandoned the art of obstetrics over the past several decades in favour of surgical deliveries.

The most recent ACOG Committee Opinion concerning “Mode of term singleton breech delivery,” written in 2006 and reaffirmed in 2016 makes clear, “The American College of Obstetricians and Gynecologists recommends that the decision regarding mode of delivery should depend on the experience of the health care provider.”3 This is also reflected in the FAQ information ACOG provides publicly to women.4 Dr Bootstaylor is one of the most experienced breech delivery providers in the country, and satisfies every criteria associated with a lower risk of adverse outcomes for vaginally born breech babies 5,6. I was privileged to teach breech skills alongside Dr Bootstaylor at a seminar hosted by Dekalb Medical in May of this year, which was attended by obstetricians and midwives from several surrounding states. This sudden decision will undoubtedly have local ramifications for the women whose birth plans revolved around Dr Bootstaylor and his very competent team of midwives. The restrictions will also have historic ramifications. Dekalb’s actions remove the option of vaginal birth from women pregnant with a breech fetus, and they also remove the option of health professionals to learn breech skills in a responsible and sustainable way, in a hospital setting with a highly experienced mentor.

Many women in the population served by Dekalb Medical go on to have one or more further children. The increased maternal and fetal risks associated with multiple caesarean sections are well-documented7, and removing the ability of this population to make an informed decision to avoid a first or subsequent caesarean section could be considered reckless. The high caesarean section rate is a contributing factor to the fact that the US is the only country in the developed world where maternal death rates increased between 1990 and 2013.8 While the decision to ban water birth, breech birth and VBAC was no doubt based on apparent increased short-term risks, the absolute risks of all of these choices are lower than they have ever been. I would ask Dekalb Medical to consider the increased recognition courts are giving to women’s right to autonomy, informed choice and respectful care9,10. In other settings, coroners and experts have specifically implicated lack of access to hospital-based care in the deaths of breech babies born at home 11,12. Dr Bootstaylor is one of the few obstetricians who truly work in harmony with other practitioners to make sure the door is always open.

Giving birth is a physiological process, not a treatment provided by a medical professional. In no other area of medicine are institutions or professionals ethically able to require patients to undergo surgery in order to access care at a time when their health is at risk. The choice of surgical intervention must always remain informed and freely made, or else it is coercion. As summarised in ACOG Committee Opinion No. 439, Informed Consent: “Consenting freely is incompatible with being coerced or unwillingly pressured by forces beyond oneself. It involves the ability to choose among options and select a course other than what may be recommended.”13

It is reasonable for Dekalb Medical to take a position and issue a recommendation to women regarding these options, if your experts feel they represent a higher risk of which women should be informed. That is the professional course of action. But disabling informed refusal of caesarean section is a clear case of medical coercion. Forbidding water birth is a disregard of the preference and comfort of hundreds of women, which will cause them emotional distress, with no evidence that such action will improve physical health outcomes for them or their babies.

Dr Bootstaylor and his See Baby Midwifery team are shining lights in safe, compassionate, woman-centred care. As Dekalb Medical were issuing this ban, I was writing about this team by invitation for an edited volume on sustainable maternity care. They are an exemplar of safe, sustainable breech care, a model for others to replicate. In my opinion, they still are exemplary and will still be featured. Although now the enduring lesson will be of how politics, power and money can undermine even the best practice and principles in medicine and midwifery.

Please may I ask that you forward this letter to the powers that be involved in the decision-making process to suspend these vital and exemplary services? I look forward to hearing that this dangerous and unethical action has been reconsidered.

Kind regards,

Shawn Walker, RM

  1. American College of Obstetricians and Gynecologists. Refusal of medically recommended treatment during pregnancy. Committee Opinion No. 664. Obs Gynecol 2016;127:e175–82.
  2. American College of Obstetricians and Gynecologists. Practice Bulletin No. 161: External Cephalic Version. Obstet Gynecol 2016;127(2):e54–61.
  3. American College of Obstetricians and Gynecologists. Mode of term singleton breech delivery. ACOG Committee Opinion No. 340. Obs Gynecol 2006;108(1):235–7.
  4. American College of Obstetricians and Gynecologists. If Your Baby Is Breech, FAQ079 [Internet]. 2015 [cited 2016 Aug 20];Available from: http://www.acog.org/Patients/FAQs/If-Your-Baby-Is-Breech
  5. Su M, McLeod L, Ross S, et al. Factors associated with adverse perinatal outcome in the Term Breech Trial. Am J Obstet Gynecol 2003;189(3):740–5.

Summary: The presence of an experienced clinical at delivery reduced the risk of adverse perinatal outcome (OR: 0.30 [95% CI: 0.13-0.68], P=.004).

  1. Walker S, Scamell M, Parker P. Standards for maternity care professionals attending planned upright breech births: A Delphi study. Midwifery 2016;34:7–14.

Summary: An expert panel consensus opinion that attendance at approximately 10-13 vaginal breech births is advisable for achieving basic competence, and 3-6 per year with mantaining competence.

  1. Caughey AB, Cahill AG, Guise J-M, Rouse DJ. Safe prevention of the primary cesarean delivery. Am J Obstet Gynecol 2014;210(3):179–93.

Summary: The risk of maternal death from cesarean delivery compared to vaginal delivery is 2.7% vs 0.9%. Placental abnormalities (such as abnormal adherence, with consequent bleeding and possible hysterectomy) are increased with prior cesarean vs vaginal delivery, and risk continues to increase with each subsequent cesarean delivery.

  1. Schumaker E. Maternal Death Rates Are Decreasing Everywhere But The U.S. [Internet]. Huffingt. Post. 2015 [cited 2016 Aug 20];Available from: http://www.huffingtonpost.com/2015/05/28/maternal-death-rate-in-the-us_n_7460822.html
  1. Birthrights. UK Supreme Court upholds women’s autonomy in childbirth: Montgomery v Lanarkshire Health Board [Internet]. Blog: Protecting Human rights childbirth. 2015 [cited 2016 Aug 20]; Available from: http://www.birthrights.org.uk/2015/03/uk-supreme-court-upholds-womens-autonomy-in-childbirth-montgomery-v-lanarkshire-health-board/

Summary: Women have a right to information about ‘any material risk’ in order to make autonomous decisions about how to give birth.

  1. Pascussi C. Mom Sues for Bait & Switch in Maternity Care [Internet]. Blog: BirthMonopoly. 2016 [cited 2016 Aug 20]; Available from: http://birthmonopoly.com/caroline/

Summary: A jury in Alabama unanimously returned a verdict in favour of a couple who experienced mistreatment and a lack of options in their hospital-based care, with an award including punitive damages of $16 million.

  1. Kotaska A. Commentary: routine cesarean section for breech: the unmeasured cost. Birth 2011;38(2):162-4.
  2. Powell R, Walker S, Barrett A. Informed consent to breech birth in New Zealand. N Z Med J 2015;128(1418):85–92.
  3. American College of Obstetricians and Gynecologists. Informed consent. ACOG Committee Opinion No. 439. Obs Gynecol 2009;114:401–8.

Final Stop: Atlanta

See Baby panel discussion

See Baby panel discussion

From Asheville to Atlanta, home of the SeeBaby team!

Following Sunday’s workshop in Asheville, Dad and I drove to Atlanta, Georgia. I kept him content by taking him out to dinner and buying him a pint of Shock Top. This strategy was successful, and the next morning we arrived at DeKalb Medical, home of the truly wonderful and amazing SeeBaby team. An opportunity to meet one of my obstetric heroes, Dr Brad Bootstaylor!

Dr Bootstaylor demonstrating breech skills

Dr Bootstaylor demonstrating breech skills

Dr Bootstaylor set the tone of this half-day study day by describing the facilitation of breech birth as a “healing force that goes beyond that mother and that birth.” This philosophy, or as Dr Bootstaylor describes it, “a certain headspace,” clearly permeates the See Baby team. SeeBaby Midwifery is dedicated to providing options and support to women and families in this birth community.  Patients travel near and far, for birth options such as Water Birth, VBAC, Vaginal Twin Birth and of course, Vaginal Breech Birth (singleton & twin pregnancies).

We were also joined by Certified Professional Midwife (CPM) Charlotte Sanchez, another breech-experienced midwife in this community, who shared valuable reflections on some of the births she has attended. Charlotte also teaches other health professionals about the safe facilitation of breech births. Hopefully we will cross paths again soon. Thank you for coming along, Charlotte!

My presentations included the mechanisms of breech birth — the key to understanding when intervention is needed in physiological breech birth — and active strategies for resolving complicated breech births, as well as ‘Save the Baby’ simulations, where participants resolve complications in real time with birth videos.

groupFollowing this, the See Baby midwifery team and Dr Bootstaylor led a panel discussion on ways forward for breech in Atlanta and surrounding areas. CNM Anjli Hinman identified one barrier as insurance company’s requirement that providers sign a statement saying that they are ‘experienced’ at vaginal breech birth in order to offer this service. However,  ‘experienced’ remains undefined. This is a persistent problem. Our international consensus research suggest competence to facilitate breech births autonomously probably occurs at around 10-13 breech births attended, although this varies according to individual providers, the circumstances in which they work and the complications they encounter during this period.

Following the workshop, participants took a tour of the SeeBaby facilities at DeKalb. I would have liked to have joined them, but I had a message from Dr David Hayes in Asheville. Jessica’s waters had broken, and her breech baby was on the way. Because he is the best dad in the world*, my old man turned the car around and drove me 3 and a half hours back to Asheville. (* Don’t tell him I said this. He’s already big- and bald-headed enough.)

Tomorrow: We return to Asheville for the birth of Leliana …

Shawn

Thank you to Tomecas Gibson Thomas for use of some of the photos she took during the workshop!

Evaluating breech training in North America

ShawnPortsmouthBusy packing … leaving London for the US on Friday. Originally, I planned to attend the celebration of 20 Years of the Kelly Writers House and my college reunion at Penn, as well as the annual ACOG meeting where our film on upright breech birth is being shown, followed by a family wedding. But it turns out the first two conflicted, so instead I will be spending half of my holiday teaching breech in collaboration with other health professionals along the east coast of the US and Canada. With ‘renewed interest’ in vaginal breech birth from the ACOG, and Canadian SOGC guidelines fully supporting planned breech birth since 2009, the will to revive breech skills is in full swing in North America!

Some of the health professionals and birth activists collaborating to provide breech training in their communities include:

  • Atlanta, Georgia – See Baby Midwifery is dedicated to providing options and support to women and families in the birth community.  Patients travel near and far, for birth options such as Water Birth, VBAC, Vaginal Twin Birth and of course, Vaginal Breech Birth (singleton & twin pregnancies). The SeeBaby Team will lead a panel discussion on ways forward in the support of vaginal breech birth, and Dr Brad Bootstaylor is collaborating on the analysis of the evaluation data from this series of training days. (Places available.)
  • Asheville, North Carolina – This is a community which values co-operation, and the study days here have been organised collaboratively by obstetricians, CNMs, CPMs and doulas. Dr David Hayes of Harvest Moon Women’s Health is also contributing to the analysis of the evaluation data. Thanks especially to Kathleen Davies and Jennifer White.
  • Philadelphia, Pennsylvania – Thank you to Julie Cristol, CNM, of Lifecycle WomanCare for enabling this workshop.
  • Tillsonburg, Ontario – Thank you to Christine McGillis and Sheila Stubbs for making this workshop happen in Ontario.
  • Montreal, Quebec – Thank you to Rivka Cymbalist for organising this workshop and raising awareness of the need to increase vaginal breech birth options in this community. (Places available.)

This is a brief welcome message for those attending the Physiological Breech workshops.

The training provided by Breech Birth Network is different from obstetric emergencies training because it is based on physiological birth principles, including the importance of maternal movement in facilitating the birth process. Decisions on when or whether to intervene in a breech birth are determined by careful observation of the unfolding mechanisms, recognition of deviations from the norm and strategies to restore the mechanism. These strategies include maternal movements, as well as hands-on help from birth professionals. In Breech Birth Network training, which follows recommendations outlined in primary research with experienced professionals, birth videos are central resources, enabling both experienced and inexperienced professionals to develop and expand their pattern recognition skills, even in communities where actual breech births remain a rarity. Therefore, the training is supplemented by secure access to the resources and videos, which cannot be downloaded, but can be used to refresh training by those who attend the hands-on workshops when preparing for a birth within their local teams — the Virtual Community of Practice (VCOP).

Thank you to the women, midwives and obstetricians who have made this possible in order to increase the safety of breech birth for others.

Training programmes are often evaluated according to Kirkpatrick’s hierarchy, which has 4 levels:

Kirkpatrick model

Image from : http://www.kirkpatrickpartners.com

Thorough evaluations of breech birth training packages are lacking. Evaluating impact of training on maternal/neonatal outcomes is a longer-term project, easier to achieve when considering the effect of training within one site, rather than professionals working in many different contexts; we have plans to begin such a project later in the year. However, for this series of study days in North America, we are collecting data on how many breech births those participating have attended in the year before and after training (change in behaviour), as well as changes in confidence levels before and after training (change in learning).

networklearningThose attending these training days include obstetricians, CNMs, CPMs, students, and birth activists keen to support cultural change in their communities. The results of the evaluation will help us to determine whether providing breech birth training based on conceptual understanding of physiological principles, within a community of practice/network learning model, will increase women’s access to the option of vaginal breech birth by increasing provider confidence and skills to provide this service.

The evaluation data will also contribute to answering two fundamental questions, which will require on-going research in the future:

  1. How can vaginal breech birth skills be revived within communities which have few or no experienced providers?
  2. How does training based on physiological principles impact the safety of breech birth for mothers and neonates?

Thank you to all the health professionals participating in this training and evaluation. I am looking forward to meeting you and learning from your communities!

Shawn

P.S. Of course, we aren’t the only source of physiological breech birth training. Others include:

We advocate that all professionals including breech within their sphere of practice access breech training from multiple providers, consider the underlying principles and how they fit with your own understanding and experiences of birth, and maintain an open mind.