2009 REPORT OF CIANE TO THE EUROPEAN NETWORK OF CHILDBIRTH ASSOCIATIONS
SUMMARY OF 2008 REPORT AND FOLLOW-UP FROM PREVIOUS AFFAIRS
Last year, apart from the ‘‘routine’’ activities of CIANE, we focused on three main topics:
- The Ariege case: the death of a baby after a homebirth attended by an American lay midwife and the way it has been used to launch an offensive against doulas, as the lay midwife had been portrayed as a doula.
- Cross-border births: Health Insurance refused to reimburse expenditures linked to childbirth care given to women living close to the border in a German free-standing birth centre. Eudes Geisler, one of these women, engaged into a law battle with the support of CIANE and private donators.
- Non-Invasive prenatal diagnosis: the CIANE developed a series of actions in order to attract public attention on the fact that the clinical validation of a non-invasive diagnosis for Down syndrom was blocked by a conflict between public institutions owning the patents and their industrial partner.
How have these topics evolved during the last year?
- No real evolution on the status of doulas, even though attacks apparently decreased. The court inflicted to the lay midwife a suspended sentence of 12 months jail, on the motive that the umbilical cord had not been cut right after the birth, which may have caused the death. This seems very surprising, for no evidence can be found in the literature confirming this interpretation. In press releases concerning this case, homebirth and doulas were quite stigmatised, but in contrast to the first episode – just after the birth – this case did not mobilize the media and remained probably quite invisible for the general public. At about the same time, a TV program was devoted to homebirth and presented it as a possible option, as safe as hospital birth if correctly prepared. There is no clear picture emerging from what appears as contradictory images; with a bit of optimism, we would say that this constitutes a progress: it is now possible to publicly support the homebirth option without being immediately disqualified.
- A very recent judgment from the Cour de cassation stated that the previous judgment (sentencing Eudes Geisler to a fine on the motive she should not have claimed the reimbursement and stating that the Health Insurance was right in not reimbursing her) is not legally justified. Apart from this case, Health Insurance does not seem to be willing to facilitate things for parents choosing ‘‘alternative’’ childbirths: for example, a woman recently complained that the reimbursement she received covers only 343,87€ out of the 489,04€ she paid for care during childbirth and postnatal visits, This amount is about 10 times less than the cost of hospital childbirth.
- This is certainly the domain in which the CIANE action proved to be the most effective: one of its representative participated in a TV documentary on the topic; the CIANE president wrote an open letter to the Minister of Health and to the President of the Republic, B. Bel published a paper in an independent medical journal. Short after these interventions, the industrial partner accepted to negotiate with public institutions sheltering the scientist who invented the patented process: she managed to retrieve their right to exploit the patents in order to develop prenatal diagnosis tests, a technology on which the company had not invested any effort.
Towards a “normal birth” statement
Apart from the already mentioned success on non-invasive prenatal diagnosis, the most significant achievement of this year is probably the agreement reached between professionals, the Health Ministry and CIANE on the definition of appropriate care for ‘normal’ (physiologiques in French) pregnancy and childbirth. However, this success should be considered with modesty for two reasons: first, the document leaves apart the issues of homebirth and free-standing birth centers; second, it has not yet been published despite the fact that this agreement was reached a year ago. This initiative has been taken by the president of the National Childbirth Commission: this commission has a consultative and advisory role for the ministry of Health and gathers representatives of obstetricians, paediatricians, midwives, anaesthesiologists, hospital directors, Health administrations and ’users‘. After a few years of interaction with users, the president began to believe that they could make sensible propositions; he also felt dismayed by the fact that after more than 10 years of discussion, the experimentation of free-standing birth centres has been abandoned as it proved impossible to reach a consensus concerning the elaboration by the HAS of guidelines for ’normal pregnancies‘. Therefore, he decided to create a special group dedicated to physiological pregnancies. After a few meetings, a document was drafted and discussed in a few subsequent meetings.
This document is divided into two parts:
- In the first one, it states a number of key principles that should guide the organisation of care for physiological pregnancies and childbirths. In particular, it declares that it is possible to discriminate between physiological pregnancies/childbirths and pathological ones, and that taking care of the first ones as if they were potentially equivalent to the latter has detrimental effects. It also declares that any organisation should provide more space for the expression of preferences by parents. These may seem rather tiny progresses. However it should be remembered that, a few years ago, the idea that it is not possible to declare childbirth as normal before two hours after the delivery was dominant amongst obstetricians and served as a justification for massive medical interventions.
- In the second part, it gives examples of the way maternity wards can be organized in order to favour a more physiological approach. It mainly distinguishes between two approaches: one which tries to develop a more respectful approach to childbirth in the whole maternity ward and for all childbirths even if some pathology appears at some point. The second one is based on a separation of the maternity ward in two parts: the ’business as usual‘ part and the physiological pole.
This document has been approved by CNGOF (Collège national des gynécologues obstétriciens français) and equivalent organisations for midwives, paediatricians, and CIANE. It should normally constitute a kind of French equivalent of the British Normal Birth Consensus, even though it is still a ’pale‘ copy in the sense that it does not specify any objectives in terms of medical interventions: episiotomy, induced labor, acceleration of labor etc.
CIANE also invested a great amount of time and work on improving the quantity and quality of information it delivers to its members and general public:
- a subsequent part of the wiki is devoted to ’activist education‘. It is meant to provide all the necessary information on the functioning of the Health system and all opportunities offered to citizens for improving it (thanks to their legal representation), plus feedback on their experience and suggestions for initiating formal collaborations etc.. Unfortunately, there is an on-going important reform of the system and it will require new efforts for understanding and explaining the system.
- The wiki has been migrated to a new architecture using more stable software (PmWiki) in an implementation that is easier to adapt to different editorial groups. In addition, its layout has been revised in depth to facilitate access to its content via many sorts of queries.”
Disseminating ideas and positions
CIANE members gave a number of public interventions and publications in order to disseminate the ideas it defends. Among these, it started publishing papers in Revue de médecine périnatale (A journal on perinatal medicine):
- a French translation of Lauren Plante’s paper L. A. Plante, 2009, Mommy, What Did You Do in the Industrial Revolution?: Meditations on the Rising Cesarean Rate, International Journal of Feminist Approaches to Bioethics, 2, 1, 140–147. http://wiki.naissance.asso.fr/index.php/Articles/2322
- a series of papers explaining the role of customers/citizens in challenging and changing medical practice with respect to pregnancy and childbirth, see here.
- A paper on the so-called “demand” of women for cesarian section. S. Heimann, 2009, La césarienne sur demande maternelle: quelle est la vraie demande de la mère ?, Revue de médecine périnatale, 2, 1, 8–11. http://dx.doi.org/10.1007/s12611-009-0050-3. Cesarean delivery by maternal request: what is the mother really requesting? Abstract: Cesarean delivery by maternal request is a loosely defined concept and includes many cases, which cannot be reduced to simple convenience. A mother stating that she wishes a cesarean may also do so because of a previous trauma, or because she received biased information. Dialog between the mother and the practitioner is then crucial to understand the mother’s true needs and define the best solution, which is not always a cesarean.
Ensuring our mission of representation
Currently CIANE receives more and more calls from institutions announcing vacant posts for representatives of customers in their committees. This is a consequence of a 2002 law stating that customers should be represented in all decision-making committees of the Health system, and the fact that CIANE is the only coalition of childbirth societies that has been granted the certification of Health ministry for nominating representatives. In order to cope with this increasing demand (which is an indication of a growing ‘heath democracy’), CIANE is taking steps to enroll more non-profit societies and train their members to play this important role.
Homebirth in France
In France homebirth is legal. However, midwives attending homebirths are no longer covered by insurance because of its very high cost. In the same time, the Order of Midwives is regularly publishing warnings that this insurance is mandatory for midwifery. Instead of trying to deal with Government and insurance ccompanies, they are having a case against a midwife whom they want to ban because of her lack of insurance. As a result, about 60–80 midwives are attending homebirths in this semi-licit position and an increasing number of parents are opting for unassisted birth for this wrong reason.