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2008-2009 REPORT OF CIANE TO THE EUROPEAN NETWORK OF CHILBIRTH ASSOCIATIONS

GENERAL BODY MEETING OF CIANE

On 20 September 2008 a new governing body of 13 members has been elected in CIANE. In compliance with the society's regulations it comprises a minority of 3 men and 1 health professional. The general body expressed a consensus on the issue of funding: CIANE should avoid seeking financial support from public or private agencies and it should tely exclusively on the voluntary participation of its member societies. Conversely, CIANE will not send delegates to any commission unless their travelling expenses are covered by the institution hosting the meeting. With respect to affiliated societies CIANE demands more active participation. The result is that there are fewer members with a stronger self-commitment of their representatives.

THE ARIÈGE CASE

At the end of August 2008 the press published the sad story of a home birth that turned dramatic in Ariège, a rural area in the south-West of France. The baby died for no known reason three hours after a peaceful waterbirth. This birth was attended by a lay midwife who practised for 37 years in the USA and attended more than 1000 births with no casualty. The local press quickly picked up bits of information to spread the rumour that a ‘doula' was “killing babies in cold water”, thereby misinterpreting the statements of the midwife and other witnesses. Ms S. has not yet been granted a certification for attending deliveries from the Order of midwives. This provided an opportunity for its council (CNOSF, Conseil national de l'Ordre des sages-femmes) to launch a campaign against home birth and doulas regardless of the facts that the midwife never introduced herself as a doula and there is no evidence that the baby died because of her malpractice. Still, her case is desperate as the highest punishment for unlicensed midwifery practice in France is up to 15 000 euros fine and 5 years jail.

CIANE published a press release pointing out inaccuracies and mediatic manipulation of this case, reminding readers of statistics on the safety of home births attended by trained midwives:
CommuniqueDecesAriege

DOULAS

The Ariège case again produced effects when the National committee on health (CNN, Commission nationale de la naissance) initiated discussions to issue a statement in response to the application of Doulas de France for the recognition of their professional activity. They commissioned the National medical academy (Académie nationale de médecine) to write a report on doulas. The report contained inaccuracies and arguments unsupported by scientific evidence. CIANE complained about this report in a public letter and the Academy agreed to amend it:
texte de la lettre

On the same day, CIANE complained to CNOSF for having stated in its journal that CIANE is ‘opposing doula practice':
LettreCnosf231008

CNOSF replied mentioning the Ariège case as a typical case of doula malpractice. CIANE pointed out that this case has nothing to do with doulas nor malpractice.

These interventions may be helpful in highlighting the confused state of mind of health professionals and general media regarding the attendance of out-of-hospital births and non-medical support to expectant mothers.

CROSS-BORDER BIRTHS

Because of the lack of options for the attendance of low-risk births in France an increasing number of parents are hiring midwives from neighbouring countries. A few Belgian and German midwives attend home births in France as they have access to insurance at a reasonable fee, which is not the case for French midwives. (Currently the best offer is not less than 19 000 euros per year!)

Women may also decide to deliver babies in free-standing birth centres or near the home of an independent midwife across the border. In all these situations European regulations allow them to get a refund of expenditures on the basis that the same service is not available in France. In addition, it is significantly cheaper than any conventional hospital birth in France. Despite this, a few women who followed the legal procedure have been denied the reimbursement. Eudes Geisler, one of them, sued the health insurance for not applying European regulations. She lost her case and was fined 100 euros. A support group was initiated by CIANE and it is now growing on both the French and German sides:

NON-INVASIVE ANTENATAL DIAGNOSIS

The screening of pregnancies at risk of Down syndrome is currently based on two steps (serum markers + ultrasound examination) and proposed to all women in France. Women considered ‘at risk' are offered invasive diagnostics (amniocentesis and chorionic-villous sampling) that produce a 1-2% miscarriage rate. Thus, out of 850,000 births 500 to 700 fetuses, mostly unaffected, are lost every year. Since 2003 the CIANE coalition has been supporting research work aimed at reducing the rate of invasive tests or shifting to non-invasive methods. An innovative cell isolation process (ISET) able to enrich from maternal blood the very rare circulating fetal (trophoblastic) cells has been successfully developed by the U807 team of INSERM directed by Prof. Patrizia Paterlini-Bréchot. The ISET test has already been (phase-III) clinically validated for the prenatal diagnosis of spinal muscular atrophy (SMA) and for cystic fibrosis, but its distribution to parents of risk groups has been impeded. The clinical validation of the same test for the non-invasive diagnosis of Down syndrome had been programmed in a project funded in 2006 by the French national research agency (ANR), but it was stopped by a conflict between public institutions owning the ISET patents and their industrial partner, Metagenex, as the latter allowed the commercialisation of an unvalidated ISET test for cancer by the Lavergne laboratory in Paris. Today CIANE is trying its best to bring this sad state of affairs into a public debate so that the clinical validation of the non-invasive prenatal diagnosis of Down syndrome may be successfully resumed, and clinically-validated tests put at the disposal of parents in replacement of invasive methods.
DossierDiagnosticPrenatal

See our forthcoming paper in English and more European languages: Non-invasive prenatal diagnosis of genetic diseases: a painful ‘delivery' of innovative obstetrical care.

PARTICIPATION IN COMMITTEES

CIANE delegates are active in several new committees of the health system, notably:

  • An evaluation of “Plan Périnatalité” (The perinatality policy) 2005-2007
  • The organization of care for physiological pregnancies and deliveries in maternities
  • The organization of care for pathological pregnancies and deliveries in maternities
  • The drafting of information fliers for pregnant women, in the framework of ‘patients education' under the banner of the National institute for prevention and health education (INPES, Institut national de prévention et d'éducation pour la santé).

THE FRENCH MEDIA

In September 2008, AFAR launched a campaign to raise concerns about the situation of home birth midwives who are denied access to professional insurance and subject to a ‘witch hunt' by their Order. Parents are invited to send letters to the Order of midwives complaining that no midwife is available for attending home births in their area which will force them to look for alternative (non-medical) assistance. At the moment more than 30 letters have been sent and they are available on a website. A more radical action has been taken in November 2008 by the Dechaînées ‘humour-terrorist' group. They issued a manifesto “for the right to birth at home assisted by a midwife” inspired by the “Manifesto of the 343 Bitches” (1971) admitting to have practiced illegal abortions, and therefore exposing themselves to judicial actions and prison sentences. Women signing their manifesto declare that they already had an unassisted home birth or they plan to have one in the future. This action has been quite successful as it already prompted more than 2900 signatures (with real names, professional status and cities) plus 625 support signatures, among whom many health professionals, thereby proving that this trend is not merely the fashion of a “group of hippies”.
http://dechainees.easy-hebergement.info?page=q0e

On 10 April 2009, E. Phan, a member of the CIANE governing body, sent a commentary to the authors of a paper in Gynécologie Obstétrique & Fertilité 37 (2009) regarding low-risk pregnancies and deliveries, to highlight their misuse of data published by Mori R, Dougharty M, Whittle M. in their paper An estimation of intrapartum-related perinatal mortality rates for booked home births in England and Wales between 1994 and 2003, BJOG 2008, 115:554-9. Basically, the authors are using statistics collected from hospital and home births to draw their conclusions on free-standing birthing centres.
http://ciane.net/Ciane/ImprecisionsSurArticleMori

In a similar way, E. Phan, M. Akrich & B. Bel sent a letter to the editor of Journal de Gynécologie Obstétrique et Biologie de la Reproduction: “Delivering in The Netherlands: A must?” – a patient organisation's viewpoint. Their letter has been published by the journal in response to an earlier editorial paper claiming that the statistics of perinatal deaths and a no-choice policy in the Netherlands should discourage consumers' demands for promoting home birth in France. CIANE's letter points out to flaws in the author's reasoning and concludes that it is manipulative to systematically oppose the demand for a diversification of care offers against the optimisation of security. It further argues that whereas Dutch women might face a limited choice other than home birth in normal pregnancy, French women have strictly no other option than hospital birth regardless of medical pronostic.
http://www.em-consulte.com/article/209274

In the beginning of 2009 two French newspapers, Le Figaro and Politis, published excellent papers on home birth. It is meaningful that these newspapers belong to opposite sides of the political scene: conservative and radical leftwing.

The first April was again an opportunity to generate buzz around CIANE and birth-activist societies. An anonymous supporter of CIANE circulated a fake issue of the INPES Journal claiming that this 1st April would be the day of ‘doctors education', thereby reversing the motto of ‘patients education'. An exhilarating article explained patients how they should educate their doctors and help them to reduce stress that may result in compulsive writing of prescriptions... INPES called CIANE office saying that they would sue the author of this foregery, but the guilty persons have not yet been traced by experts.

The Dechaînées website got an infuriated paper published in left-wing satirical newspaper Charlie Hebdo after commenting the video of a home birth that sounded quite ‘mystical'. This was an opportunity to discuss the difficulty of accomodating feminism à la française with new claims for freedom of choice and women's ownership of their bodies in the face of medical power. This analysis is in line with Lauren Plante's observations on women behaviour in maternities: In the US, we have heard arguments that women are entitled to autonomy in making their birth choices, and that therefore it is ethical to perform cesarean for no reason other than maternal request. Curiously, this vaunted autonomy stops at the door of the labor room. Women are implicitly allowed, or encouraged, to make only those choices which increase the power of the physician and which decrease their own. (See here)

TOWARDS A BIRTH SURVEY À LA FRANÇAISE?

After 3 years of lobbying in professional circles and recent discussions in our national childbirth commission (CNN), several activists have come to the conclusion that French professional groups are not eager to collaborate in the creation of a new label based on the Mother-Baby-Friendly Initiative of CIMS.

Already a shamefully small number of maternities have adopted the Baby-friendly ‘Ami des bébés' label. Now a few of them argue that being ‘baby-friendly' implied modifying all their protocols, which is contradicted by some testimonies.

The only positive reaction to our label proposal has come from the private sector. They are keen to use it for showing that they do better than the public sector. Howver they prefer to display ISO 9001 certification and environment quality labels (HQE) which have more promotional effets than ‘respect of physiology'... French newspapers still classify maternities putting on the top the ones with the highest rates of epidurals, and most ordinary citizens believe that an increase of C-section rates is a proof of more care for security. For these reasons we were thrilled to hear that a Birth Survey has been implemented in the USA and it is being entirely managed by a consumers' group:
http://www.thebirthsurvey.com

The system that French activists may implement (outside CIANE) shoud be compliant with local rules in terms of storing and sharing personal information. For both ethical and legal reasons we would never issue reports on individual performance. Rather than dealing with individual caregivers the French reporting system will deal with maternity units.

We started this project with a French translation of the Birth Survey questionnaire which is now being discussed for matching the local context. For instance, if a woman is globally insatisfied with the maternity service, did she contact the mediation committee (CRUQ in France), does she plan to do it, does she know what it is, does she plan to file a case etc. Another innovation will be another questionaire for fathers.
See the project: ProjetEvaluation

FREE-STANDING BIRTH CENTRES

The Gyn-obs college and a significant number of midwives supporting the idea of giving access to physiological care for normal pregnancies wish to experiment inside-hospital units that they would name “Maisons de naissance” (birthing centres). CIANE is reacting to the misuse of this terminology as the earlier proposal was to experiment with birthing centres situated at different distances from a hospital and assess whether distance is a risk factor.

Taking example on neighbouring European countries (notably Germany, Belgium and the UK) CIANE claims that the label “Maison de naissance” should be reserved to free-standing birthing centres outside hospital premises.

‘GRASSROOT' PROGRESS

The failure of the launching a “Maison de naissance” experiment prompted parents, birth activists and midwives to reconsider the case of home birth. It is particularly encouraging to see that a number of younger midwives are turning to home birth and continuity of care short after the completion of their studies, despite (or because of) the fact that their training is excessively pathology-oriented.

We published the translation of a joint declaration of the Royal College of Obstetricians and Gynaecologists and Royal College of Midwives in the UK:

We also translated the Normal Birth Consensus of Ob-gyn and midwife organizations in the UK calling for action to increase rates of ‘normal birth' where appropriate in order to minimize morbidity and complication rates:

Even though these actions do not yield an immediate effect on policies endorsed by high-level instances of the health system, we receive increasing feedback from ‘grassroot' actors. Parents tell us that maternities are trying to offer more options for medical care in childbirth and that it generally results in more freedom for choosing (and changing) birth positions. There is also a growing awareness of respecting the first contact between newborns and their parents, in contradiction with the dominant frenzy of medical interventions on babies. This trend is activated by the Maman Blues autonomous group of women encouraging (non-medical) support between mothers suffering of maternal difficulty (including ‘post-partum depression'): http://www.maman-blues.org

Changes are hard to implement. This not only due to bad habits and an inappropriate training of midwives. Health professionals are struggling against economical constraints that result in a drastic reduction of the time they can spend on attending births in hospital. An independent midwife recently pointed out that one of her clients spent 9 hours in a hospital to have only 3 medical tests because of a dramatic reduction of crews. A maternity ward like Les Bluets, which is renowned for its attendance of physiological deliveries in Paris, has been forced to accept too many patients (growing from 1400 to 2000 per year) without any additional staff.


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