A few weeks ago, the National Uniform Claim Committee- the organization that, among other things, assigns taxonomy codes for insurance reimbursement- decided that doulas are healthcare providers worthy of receiving third party insurance reimbursement! On Thursday, I applied for my National Provider Identification number and received it yesterday. Now, my clients can send a copy of my invoice to their insurer and maybe, possibly, god-willingly, their insurance will cover some or all of my bill. I already know of one doula who was paid by an insurance company.
This is a fantastic step for doulas towards gaining recognition as legitimate providers of healthcare services. I explain this on my website, but I think Debra Pascali-Bonaro, doula, childbirth educator, and doula trainer (my trainer in fact!), says it even better: "When we look at the data, we know that having a doula is not only nice, it shortens labor, makes it easier, lowers the cesarean birth rate, lowers the use of all interventions and actually helps the baby have a healthier birth. We often say, with that data, if the doula were a drug, we'd all be scrambling for it. It would be unethical to without it." If the doula were a drug, insurance companies would cover it like nothing else.
One small step for the insurance industry, one giant leap for doulas!
Saturday, December 19, 2009
Tuesday, December 15, 2009
Bellevue, Birth Center No More
A few weeks ago, I attended a birth at Bellevue Hospital in downtown Manhattan. A warm, smart, and unassuming couple from Queens, Regina and Jason (names changed, of course) were incredibly knowledgeable about their options for their prenatal care and birth. They had decided early in her pregnancy that Regina would deliver their first daughter in Bellevue Hospital's Birthing Center, a section of the hospital staffed by midwives and equipped with queen-sized beds, bath tubs, birth balls, and birthing stools, all in the name of allowing the process of birth to unfold undisturbed. Now, this couple didn't choose the birthing center because it was the delux suite, the "spa" version of birth. (Although, I'm not denying that it is better to cuddle with your husband on a queen-sized bed than a regular hospital twin). They choose it because its outcomes for low-risk women were incredible, with a c-section rate of 4%. Because it was an incredibly safe place to give birth.
Regina and Jason also chose the birthing center because, like Elan McAllister of Choices in Childbirth said (in the GritTV link I introduce below), it was a "culture of faith." When midwives and nurses allow birth to progress undisturbed, as they do in the birth center, they are displaying to mothers their faith in birth, their faith that birth can progress undisturbed. Their actions proclaim their faith that it is actually possible for a woman to have a baby without an IV line, constant fetal monitoring, and supplemental hormones. With every touch, every glance, they are telling these women that they can do it.
Now, this is what happens when you, a woman with a low-risk pregnancy, like the vast majority of pregnant women, enter your delivery room for the first time in a traditional labor and delivery ward. Your nurse brings over an IV line and begins examining your veins before you can even say you don't need it, you're low-risk and you won't be receiving any extra medications through the line. Simultaneously, another nurse applies the fetal monitors to your belly, before you can ask that you only be monitored occasionally, because again, you're low-risk and your baby doesn't need constant monitoring. Then a nurse asks, "Do you want an epidural?" when the thought of pain relief hadn't even crossed your mind yet. Three very simple actions. But these three simple actions send a strong message: we don't think you can do this. So, Regina and Jason chose the birthing center, because, well, they thought Regina could do it.
If you noticed earlier that I was speaking about the Bellevue Birthing Center in past-tense, good job! Bellevue Birth Center officially closed on October 1st, 2009, without much warning or explanation. Its closing received the attention of the New York Times, WNYC, and GritTV, and not to mention, Regina and Jason, about five weeks before Regina's due date. In their response, the media highlighted something about the birth center that I think is the most important: the birth center at Bellevue was the only in-hospital birthing center in Manhattan to accept patients with Medicaid or without any insurance whatsoever. So this notion of birth centers and undisturbed birth as a celebrity trend, or only for those who can want the "spa" birth? Not at Bellevue. Like the New York Times article says, the birth center at Bellevue "was the only one of its kind dedicated not to Manhattan's trend-conscious set, but to poor, mostly immigrant women on Medicaid."
Why did it close? HHC, Bellevue's parent company, is suffering a staggering deficit. So cost is probably the first problem that would come to mind. But undisturbed birth is CHEAP. No meds to pay for, no expensive monitoring machines. No epidurals, which cost the hospitals anywhere from $1000-$2500, plus no staffing the extra anesthesiologist who must be there to administer it. And, with a 4% c-section rate, Bellevue is saving $10,000-$20,000 on each c-section the birth center avoids.
Decreased demand? Elan says that yes, Bellevue was experiencing a decrease in demand for maternity services, but ONLY on the traditional labor and delivery ward, NOT for the birth center. What was changing however, was how many women were cleared as low-risk and could use the birthing center. And this, ladies and gentlemen, is where we enter the dreaded field of medical-legal practice. In a survey conducted by the American College of Obstetricians and Gynecologists in September, 29% of obstetricians agreed that they are conducting more c-sections out of fear of liability issues, not out of safety needs. In other words, as the report of the survey says, "As the negative state of the medical liability environment continues, OBGYNs across the US are forced to make changes across their practice that ultimately hurt patients" (quoted from the WNYC report above). Because when you get sued for malpractice, and you didn't document that you did everything, monitored constantly, gave her every medicine possible, that you were constantly waiting for and expecting the birth to go wrong, you lose a staggering amount of money.
So it actually is about cost: the cost of malpractice insurance, the anticipated cost of some staggering malpractice suit lost. (But let's not forget, Bellevue was actually saving money by allowing more of their patients to use the inexpensive birth center). So the closing had a lot to do with cost, but it's more about fear. Fear that birth almost always goes wrong, fear that women can almost never do it, and fear that the hospital will be punished for trusting birth and women's abilities. But in this case, the hospital survives as if nothing happened, and women, mostly low-income women, are punished.
Regina and Jason decided to stick with Bellevue Hospital, and gave birth on the labor and delivery floor. They walked in and were greeted with an IV, a fetal monitor, and an offer of an epidural. But Regina was already doing it. Fully dilated once she entered the hospital, Regina began pushing and, with the gentle assistance of her fantastic midwife, gave birth to a completely gorgeous little girl only a few hours later. She did it.
Regina and Jason also chose the birthing center because, like Elan McAllister of Choices in Childbirth said (in the GritTV link I introduce below), it was a "culture of faith." When midwives and nurses allow birth to progress undisturbed, as they do in the birth center, they are displaying to mothers their faith in birth, their faith that birth can progress undisturbed. Their actions proclaim their faith that it is actually possible for a woman to have a baby without an IV line, constant fetal monitoring, and supplemental hormones. With every touch, every glance, they are telling these women that they can do it.
Now, this is what happens when you, a woman with a low-risk pregnancy, like the vast majority of pregnant women, enter your delivery room for the first time in a traditional labor and delivery ward. Your nurse brings over an IV line and begins examining your veins before you can even say you don't need it, you're low-risk and you won't be receiving any extra medications through the line. Simultaneously, another nurse applies the fetal monitors to your belly, before you can ask that you only be monitored occasionally, because again, you're low-risk and your baby doesn't need constant monitoring. Then a nurse asks, "Do you want an epidural?" when the thought of pain relief hadn't even crossed your mind yet. Three very simple actions. But these three simple actions send a strong message: we don't think you can do this. So, Regina and Jason chose the birthing center, because, well, they thought Regina could do it.
If you noticed earlier that I was speaking about the Bellevue Birthing Center in past-tense, good job! Bellevue Birth Center officially closed on October 1st, 2009, without much warning or explanation. Its closing received the attention of the New York Times, WNYC, and GritTV, and not to mention, Regina and Jason, about five weeks before Regina's due date. In their response, the media highlighted something about the birth center that I think is the most important: the birth center at Bellevue was the only in-hospital birthing center in Manhattan to accept patients with Medicaid or without any insurance whatsoever. So this notion of birth centers and undisturbed birth as a celebrity trend, or only for those who can want the "spa" birth? Not at Bellevue. Like the New York Times article says, the birth center at Bellevue "was the only one of its kind dedicated not to Manhattan's trend-conscious set, but to poor, mostly immigrant women on Medicaid."
Why did it close? HHC, Bellevue's parent company, is suffering a staggering deficit. So cost is probably the first problem that would come to mind. But undisturbed birth is CHEAP. No meds to pay for, no expensive monitoring machines. No epidurals, which cost the hospitals anywhere from $1000-$2500, plus no staffing the extra anesthesiologist who must be there to administer it. And, with a 4% c-section rate, Bellevue is saving $10,000-$20,000 on each c-section the birth center avoids.
Decreased demand? Elan says that yes, Bellevue was experiencing a decrease in demand for maternity services, but ONLY on the traditional labor and delivery ward, NOT for the birth center. What was changing however, was how many women were cleared as low-risk and could use the birthing center. And this, ladies and gentlemen, is where we enter the dreaded field of medical-legal practice. In a survey conducted by the American College of Obstetricians and Gynecologists in September, 29% of obstetricians agreed that they are conducting more c-sections out of fear of liability issues, not out of safety needs. In other words, as the report of the survey says, "As the negative state of the medical liability environment continues, OBGYNs across the US are forced to make changes across their practice that ultimately hurt patients" (quoted from the WNYC report above). Because when you get sued for malpractice, and you didn't document that you did everything, monitored constantly, gave her every medicine possible, that you were constantly waiting for and expecting the birth to go wrong, you lose a staggering amount of money.
So it actually is about cost: the cost of malpractice insurance, the anticipated cost of some staggering malpractice suit lost. (But let's not forget, Bellevue was actually saving money by allowing more of their patients to use the inexpensive birth center). So the closing had a lot to do with cost, but it's more about fear. Fear that birth almost always goes wrong, fear that women can almost never do it, and fear that the hospital will be punished for trusting birth and women's abilities. But in this case, the hospital survives as if nothing happened, and women, mostly low-income women, are punished.
Regina and Jason decided to stick with Bellevue Hospital, and gave birth on the labor and delivery floor. They walked in and were greeted with an IV, a fetal monitor, and an offer of an epidural. But Regina was already doing it. Fully dilated once she entered the hospital, Regina began pushing and, with the gentle assistance of her fantastic midwife, gave birth to a completely gorgeous little girl only a few hours later. She did it.
Saturday, December 12, 2009
Now, for an introduction
Like I said, my name is Leda and I am a birth doula. I live in Brooklyn and I attend births wherever my clients take me.
To date, I have attended twelve births of thirteen babies (one woman had twins). One woman gave birth at home, one woman gave birth in an out-of hospital center, and one woman labored in an in-hospital birthing center and delivered on the hospital's traditional labor-and-delivery floor. All of these women, totaling three, gave birth with the assistance of one or more midwives. Nine women gave birth in hospitals, and of those nine, four gave birth with the assistance of obstetricians, four with midwives, and one with a family practice physician. Let's summarize the care provider breakdown: 12 women, seven midwives, four obstetricians, one family practice physician.
Ten women gave birth vaginally (and if that word makes you giggle, you might want to just stop now, because it's going to get worse for you. But I promise I"ll try to avoid talking too much like Julianne Moore in The Big Lebowski), and two women gave birth via c-section. Six women labored with epidurals, six without. The longest birth I attended lasted about 36 hours and the shortest lasted about three hours.
Now, to explain why I might have a shred of clout, of relevance, of reason for others to read this blog, I guess some resume touting is in order? I guess? Ok, let's do it.
My first foray into actualizing my interest in women's healthcare (which was born long before I can remember) was an internship with NARAL Pro-Choice America during my last year of high school. Fast forward to college, when the birth light bulb went off, and I began writing as many papers as possible on birth and maternity care (from the first one on the transition of birth from the home to the hospital to the last one on breastmilk kinship in rural Islamic communities). I traveled to India for my semester abroad, and for my "independent study project", I studied the nature of maternity care in Varanasi through interviews with 25 mothers of different ages, castes, and religions. I came home and began conducting research for world renowned midwife Ina May Gaskin on maternal mortality in the US, to support her Safe Motherhood Quilt Project (like the AIDS quilt, a quilt for women who have died of childbirth-related causes). Then I continued that research for Amnesty International USA, supporting their project on maternal health as a human right. And the piece de resistance, my sociology major thesis! 102 pages of blood, sweat, and tears on midwifery, midwives' feminist ideology and how knowledge is produced. Or you might say, "Midwives and the Ideology of Empowerment: The Relationship Between Ideology, Practice, and Knowledge Construction". It's pretty sweet.
Now, I doula. For private clients, and clients I meet through organizations like Birth Focus and Birth Day Presence. I also doula for teen mothers residing at Inwood House, and soon, I hope to doula for women giving their babies up for adoption through The Doula Project. Also through The Doula Project, I abortion doula, meaning I help women during termination procedures, and I doula for women who face miscarriage, stillbirth, or fetal anomaly.
Now, I blog. About birth. Birth work. Birth health. Birth news. Birth rights.
Birth. Strong beautiful birth.
To date, I have attended twelve births of thirteen babies (one woman had twins). One woman gave birth at home, one woman gave birth in an out-of hospital center, and one woman labored in an in-hospital birthing center and delivered on the hospital's traditional labor-and-delivery floor. All of these women, totaling three, gave birth with the assistance of one or more midwives. Nine women gave birth in hospitals, and of those nine, four gave birth with the assistance of obstetricians, four with midwives, and one with a family practice physician. Let's summarize the care provider breakdown: 12 women, seven midwives, four obstetricians, one family practice physician.
Ten women gave birth vaginally (and if that word makes you giggle, you might want to just stop now, because it's going to get worse for you. But I promise I"ll try to avoid talking too much like Julianne Moore in The Big Lebowski), and two women gave birth via c-section. Six women labored with epidurals, six without. The longest birth I attended lasted about 36 hours and the shortest lasted about three hours.
Now, to explain why I might have a shred of clout, of relevance, of reason for others to read this blog, I guess some resume touting is in order? I guess? Ok, let's do it.
My first foray into actualizing my interest in women's healthcare (which was born long before I can remember) was an internship with NARAL Pro-Choice America during my last year of high school. Fast forward to college, when the birth light bulb went off, and I began writing as many papers as possible on birth and maternity care (from the first one on the transition of birth from the home to the hospital to the last one on breastmilk kinship in rural Islamic communities). I traveled to India for my semester abroad, and for my "independent study project", I studied the nature of maternity care in Varanasi through interviews with 25 mothers of different ages, castes, and religions. I came home and began conducting research for world renowned midwife Ina May Gaskin on maternal mortality in the US, to support her Safe Motherhood Quilt Project (like the AIDS quilt, a quilt for women who have died of childbirth-related causes). Then I continued that research for Amnesty International USA, supporting their project on maternal health as a human right. And the piece de resistance, my sociology major thesis! 102 pages of blood, sweat, and tears on midwifery, midwives' feminist ideology and how knowledge is produced. Or you might say, "Midwives and the Ideology of Empowerment: The Relationship Between Ideology, Practice, and Knowledge Construction". It's pretty sweet.
Now, I doula. For private clients, and clients I meet through organizations like Birth Focus and Birth Day Presence. I also doula for teen mothers residing at Inwood House, and soon, I hope to doula for women giving their babies up for adoption through The Doula Project. Also through The Doula Project, I abortion doula, meaning I help women during termination procedures, and I doula for women who face miscarriage, stillbirth, or fetal anomaly.
Now, I blog. About birth. Birth work. Birth health. Birth news. Birth rights.
Birth. Strong beautiful birth.
Wednesday, December 9, 2009
Dear Baby, Happy Birthday
My name is Leda and I am a birth doula.
In lieu of a more detailed introduction, I'd like to share a birth story. I have a feeling that I'll have a lot to complain about in this blog, so let's start with some joy and optimism. For each of my clients, I write a letter to their baby detailing the events of their birth, something their parents can read to them as they grow older. But even though I address these letters to their children, I write them also for the parents, to help them remember the experience, even after long hours of intense emotion, physical exertion, and exhaustion may have caused some mild memory loss. The following is a compilation of stories I've written, weaved together to create a fully anonymous yet narrative story. All names of babies, parents, and care providers are (and will be for the rest of this blog) changed.
Laura Anne Cauller's Birth Story
September 19th, 2009
Dear Laura Anne,
While you were being born, I was your mommy's doula. I wanted to write you this letter about your birth because it was so wonderful. The most amazing part of your birth was the overpowering love everyone felt upon your arrival. You are a lucky, lucky girl.
It all started in the late evening of September 18th, 2009. Around 11:00 pm, your daddy started singing to you inside your mommy’s belly. As he sang, your mommy felt something different inside her, so she said to him, “Keep going! I think your singing is starting something!” As daddy kept singing, your mommy kept feeling that something different and soon realized that what she was feeling was probably labor contractions and that you were on your way! Your mommy and daddy
were so happy that you decided to come on your own, because otherwise your mommy would have been induced the next day. We knew right away that you would grow up to be strong and assertive, making decisions all by yourself!
In the morning, after a night of waking up every ten to twenty minutes to a contraction, mommy and daddy decided it was time to call me. I came over to the apartment at around 9:30 am to find your mommy peacefully lying on the bed, with your daddy leaning over her and gently stroking her hair. I knew immediately that no matter what, your mommy would be ok as long as your daddy was there to support her.
In between contractions, mommy was very chatty, chipper, and giggly. During contractions, she would become very quiet, close her eyes, and breath very slowly. She was doing so beautifully. We decided to take a walk to distract ourselves and help mommy’s labor progress a bit. It was very windy, but many people were out walking, too. We wondered what they thought of us, three people walking very slowly, stopping our pace and conversation every so often for your mommy to lean on daddy and get through the contraction.
We returned home, and over the next few hours, your daddy and I took turns giving your mommy massages, getting her food and water, and walking with her up and down the hall to speed her labor. We tried many different positions to help with the labor, and mommy liked this one the best: she would wrap her arms around daddy’s neck and hang down, swaying her hips back and forth while I massaged her back.
When mommy's contractions were three to four minutes apart and lasting one minute, I asked her how she was feeling and what she wanted to do. She mentioned that she might want to go to the hospital and get an epidural so that she could manage the pain better. I was very surprised because she appeared to be managing the challenge of labor with such strength and poise! But she said she didn’t want to be a “rock star” and keep going without the help of an epidural. We assured her that that made a lot of sense, especially since she had been such a rock star since her contractions began at 11:00 the night before! At around 4:30 pm, your daddy and I got ready for us all to leave for the hospital.
When the taxi came, daddy went down to meet the driver and tell him that he was about to make a very special trip, which was taking a woman to the hospital so that she could have a baby and become a mommy. He said, “Drive more carefully than you ever have before!” I helped mommy out of the apartment and into the car. During the drive, I gave mommy some crackers and Gatorade so she could keep her strength up. We told her when bumps and stops and turns were coming and she told us when contractions were coming so that the driver could slow down.
We arrived at the hospital minutes and quickly made our way through a maze of hallways and found the labor and delivery section. Daddy had to fill out some paperwork about mommy, so I helped mommy get some attention from the nurses. I said, “She’s in very active labor!” and a nurse directed us into a small room where the midwives would soon come. Mommy’s contractions were coming closer and closer together and were more and more intense, but she was still doing so beautifully. She even stayed strong and confident when we had to deal with a very rude nurse!
Stephanie, the midwife, arrived and greeted mommy with a big, warm smile. She checked mommy's cervix to see how far along she was in her labor, and found that mommy's cervix was dilated to seven centimeters. Now, when a woman has a baby, her cervix has to dilate to ten centimeters before the baby can come out. So seven centimeters meant that mommy was almost done and that you were so close to being right here in this world! We were all so proud of her.
Your mommy said she was ready for an epidural, so Stephanie went to get the anesthesiologist. When he arrived, he told your daddy and me that we had to wait in the hallway while he gave mommy the epidural. Your daddy was not happy about being separated from your mommy! But soon after, we came back in and your mommy looked so comfortable and serene. It was definitely the right decision for her.
With the epidural in, your mommy chatted away for the next hour. She was on the phone non-stop with friends and relatives to say that you were coming. We all thought this was very funny. At 10:00 pm, mommy said that she felt an urge to push. Stephanie checked mommy again and found that mommy's cervix was fully dilated to ten centimeters and that you had already come down a little! We were so excited that mommy could begin pushing!
Mommy wanted to find the right position in which she could push and decided that she would sit up and that daddy would sit behind her with his arms wrapped around her belly. And this is when your daddy really shined. He stayed right with mommy, whispering in her ear words of encouragement and love, stroking her hair, and wiping her forehead with cool cloths. The best support, I think, was during the moments in between pushes when he repeated, “I love you, I love you, I love you.”
The minutes passed, and so did more and more pushes. Around 10:45, we began to see your little head. When daddy saw your head and mommy felt it with her fingers, they were in awe. In a few more pushes, we all saw your beautiful face, and at 10:51 pm on September 19th, 2009, your whole body slipped out and you were placed into your mommy’s arms for the first time. The whole room gasped with delight. I will never forget the expression on your mommy’s face: her eyes widened with incredible awe, as if she were viewing a miracle—which, of course, you are. She turned to your daddy with those wide, joyful eyes, who returned her gaze with the happiest of smiles, and then gave mommy a big kiss. Mommy said, "Hello baby! What a beautiful baby girl!"
Stephanie and the nurses were pretty pleased with you as well. You scored a 9 out of 10 on your first physical exam, meaning you were a very healthy baby. We were all so happy to hear you cry, to hear your strength! Almost immediately, you began moving your little head around and sticking out your tongue, telling us that you were hungry. I helped you and your mommy begin nursing, to comfort you and fill your little belly up with mommy’s good milk. It was pretty clear from the start that you two would make a great nursing team.
I left your mommy and daddy to give them some private time with you and to decide on your name. I ran into the waiting room and exclaimed to your Grandma, Grandpa, Nanna, Granddaddy, and Aunt Linda, "She's here!" Everyone was hugging and celebrating and asking us a million questions: “What does the baby look like?”, “What did her crying sound like?” and on and on. They could not wait to meet you.
Soon, Grandma's phone rang and it was your mommy, telling us all to come back in and meet you. We paraded past the nurse’s station without caring that it was past visitor’s hours, and thankfully, they didn’t say a word! When everyone came into the room, mommy was sitting up on the bed, looking beautiful and proud, daddy was holding you, and you were peacefully sucking away on daddy’s pinky finger. With all of your family, the room was full of happy tears, joy, and love.
It was a particularly special moment when your mommy and daddy announced your name. They named you (as you know by now!) Laura Anne, the names of your maternal great-grandmothers (Grandma's and Nanna's mommies), two very special women. You should be so proud to carry such a legacy.
Beautiful Laura Anne, I am so happy for you and for all that life is sure to bring you. Remember how lucky you are to be surrounded by such love. It was a joy and a blessing to share your birthday with you and your family.
With love,
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