28 July 2006

In childbirth, the new makes way for the old

By Eric Jansson
Published by askdrmanny.com, 27 July 2006

Few women in labor, awaiting the birth of a baby, spare a moment to think of their state legislature. But they might be surprised to learn that, increasingly, state legislatures across the United States are thinking of them.

Following the passage in April of a reform bill legalizing the supervision of home births by certified professional midwives (CPMs) in Wisconsin, similar reform efforts are now underway in no fewer than nine states.

Alabama, North Carolina, Idaho, South Dakota, Illinois, Kentucky, Georgia, Missouri, and Indiana all await legislative debates that could lead to the licensure of certified professional midwives, says Ida Darragh, chairman of the board of the North American Registry of Midwives (NARM), the national organization that tests and registers CPMs.

Legalization and licensure of CPM practices in all these states would represent a massive legislative victory for advocates of traditional home birth.

It would also be a startling rebuke to the many physicians who have long maintained that such practices are unsafe, despite growing statistical evidence that suggests CPM-supervised home births are as safe – sometimes safer – than hospital births.

Well-organized opposition within medical lobbying groups makes such a one-sided result unlikely within the next two years, Ms. Darragh says. But, when asked if the flurry of activity in the nation’s statehouses is indicative of a national trend in support of traditional childbirth methods, she adds: “We certainly hope so.”

As with many health issues, the debate about CPMs may seem arcane to non-experts. The debate is a minefield of acronyms, and home births account for just 1 to 3 percent of all births in an average year, with similar percentages in each state.

Yet the debate casts in sharp relief a philosophical tug-of-war over the nature of childbirth that powerfully affects how expectant mothers approach the ordeal of birth.

Elsewhere as in Wisconsin, this tug-of-war pits midwives and physicians who support “natural childbirth” outside the hospital setting and with minimal intervention against the many physicians and nurses who view medical birthing techniques as safer.

When Wisconsin’s reform takes force in May 2007, Wisconsin will become the 23rd state to institutionalize a way for expectant mothers to reject a medical birthing culture entrenched since the 1950s.

Activist midwives say the Wisconsin reform adds bulk to a growing body of circumstantial evidence that America’s popular view of childbirth is in flux, with parents adopting new perspectives on labor and the role of modern medicine in it. CPMs describe labor and birth as “natural” events rather than medical emergencies necessitating medical intervention.

“I think it is a trend,” says Katherine Prown, legislative chair of the Wisconsin Guild of Midwives. “We have seen Minnesota, Utah, Virginia and now Wisconsin all pass laws since 1999. There is a lot of momentum behind these bills.”

Traditional midwifery is struggling to reemerge from the obscurity in which it has languished since passage of Medical Practice Acts (MPAs) by all 50 states, in the 1950s. These acts criminalized the “practice of medicine” by unqualified individuals. They need not have impacted traditional midwifery, but they did in 49 states because only Mississippi offered an exemption for midwives, Ms. Darragh says.

Yet whatever the movement’s momentum, there is also powerful opposition. The American College of Obstetricians and Gynecologists (ACOG), a well-funded proponent of childbirth in the hospital setting, opposed the Wisconsin reform, publishing a position paper stating that CPM-supervised home birth “cannot be considered safe”.

ACOG also urged state officials to take “immediate aggressive action” against “unsafe birth practices”.

Such action was seen earlier this year in Indiana, where state prosecutors earlier this year charged Jennifer Williams, a CPM, with practicing medicine without a license. Ms. Williams, who says she helped 1,500 women give birth safely before she faced any charges, pled guilty. She has since filed a lawsuit against the state attorney general, asking an Indiana circuit court to distinguish between midwifery and “the practice of medicine.” Ms. Williams is also part of the group campaigning for legalization and licensure of CPM practices in Indiana.

The divergence in approach between Wisconsin’s legalizers and Indiana’s prosecutors shows the wide variety of options available to legislators and regulators. States have essentially three options: to legalize, license and regulate the work of CPMs as Wisconsin and 22 other states now do, to prosecute CPMs as Indiana and some others have done, or to turn a blind eye as Mississippi does.

Democratic pressure on statehouses throughout the country could one day yield a consensus, either in CPMs favor or against them. In the meanwhile, those embroiled in the debate are confronted with a growing body of scientific research.

One study frequently cited by CPMs was published last year in the British Medical Journal, an academic publication, by Kenneth Johnson, senior epidemiologist for the surveillance and risk assessment division of Canada’s Center for Chronic Disease Prevention, and Betty Anne-Daviss, a project manager at the Ottawa-based International Federation of Gynecology and Obstetrics.

The study reviewed records of all CPM-supervised home births in North America in the year 2000 and led Dr. Johnson to conclude that “planned home birth for low-risk women in North America using certified professional midwives was associated with lower rates of medical intervention but similar intra-partum and neonatal mortality to that of low-risk hospital births in the United States.”

Asked to provide any statistical evidence contradicting such studies, for the sake of this story, ACOG sent none but e-mailed two policy statements further explaining the organization’s position on the certification of midwives.

15 July 2006

Whiffs of mystery, visions of glory

By Eric Jansson
Published by the Financial Times, 15 July 2006

"Just be quiet for a moment. Try to smell it," whispers Milan, a black-robed novice at the monastery church of Jesus Christ the Pantocrator in Decani, western Kosovo. So I close my eyes and inhale.

The eyes of a thousand painted saints watch us as we stand silently in the central nave. White light pours in through a high window, then glows blue as it bounces off the 14th-century church's richly frescoed arches and walls. Directly above, the intense face of the Panto­crator - the omniscient Christ - stares down from the interior of the great dome.

"Now do you smell it?" Milan asks. The sweet odour of the wax candles burning behind us mingles with what must be the scent of myrrh. "Yes, that's the smell of incense left over from this morning's service," I reply.

"No. It is almost exactly like incense but it isn't that," he says. "I have learnt to tell the very slight difference between the smell of incense and the smell of the king."

Every Thursday the monks raise the body, clad in crimson and gold and lain in an ornamental sarcophagus, and venerate it. Since the death of King Stefan Decanski in 1331, his majesty's complexion has darkened somewhat and the royal hands have thinned. Even Milan, faithfully in awe, admits that the old monarch looks "like he has lost some water". But the "miracle" of the saintly monarch's uncorrupted body, housed in Decani's magnificent, Unesco-listed monastery church, still powerfully fuels the faith of the monastery's Serbian Orthodox believers.

"God has kept his body from decay to show us that saintliness and holiness are possible, to show us that the kingdom of heaven is here," the novice says.

The emanation of the scent of myrrh from the king's body is one of many enduring medieval marvels in Kosovo that strike the modern heart and mind like unwelcome lightning - flashbacks from a rejected age of faith. Do they illuminate, or do they blind? They certainly disarm and dazzle the visitor, just as the holy places in Serbia's breakaway province have always done, by defying the spiritual pretensions of the outside world and demanding an answer.

One could stomp out through the monastery gate, cursing, and drive away, calling it all a hoax. But standing toe to toe in that glorious nave with gentle Milan, the mere thought of such a reaction seems flagrantly presumptuous, wildly proud.

He asks me if I believe in the uncorrupted body of the saint. Pressure. Either it is a hoax or it is real. Either the shaggy-bearded brothers working quietly in the monastery yard outside the church's walls are liars or they are deluded or they are guardians of a genuine holy relic. I am tempted to cop out. Relativist instincts whirr into motion and suggest a noncommittal reply: "Why shouldn't we believe it when the universe is full of so many wonders?"

But discipline kicks in. A leap of faith is a truer option. "Yes, I do believe it," I say, looking Milan straight in the eyes. He looks back with a mild, sceptical grin.

Now am I the liar? It is something to ponder as I walk out of the monastery grounds, past the group of Italian soldiers stationed at the whitewashed stone gate.

I drive past the tank traps and barbed wire that protect Decani against the Albanian militants who would see it burnt down. I go back out into the anguished secular landscape of this pretty land of fertile fields, grand mountain ranges and exotic fables.

The Orthodox monasteries of Kosovo are diamonds scattered in this moral scrapyard. They count among the places, so rare in the present age, where one's agnosticism and relativism seem to blow away. These places demand focus and reckoning.

If for some visitors the uncorrupted body of Stefan Decanski fails to force the big issue of personal faith, then the constant state of danger in which the monks live inevitably does. These havens of prayer and joy have become the most threatened places in Kosovo since the 1998-1999 war.

On any ordinary day, profound peace prevails in the cloisters. Order becomes beauty as life moves to the rhythm of bells and the low tone of the semantron, a wooden board that strikes the call to prayer. The patterns, colours and shapes of Byzantine, Romanesque and Balkan aesthetics fuse seamlessly in ancient buildings and immaculate gardens amid the muffled clamour of labour from the workshops.

The sheer pleasantness of the scene causes some visitors to doubt that these communities live in genuine danger. But no one can dispute the reality of the routine attacks against Orthodox religious communities in Kosovo, none worse than the 2004 pogrom in which more than 30 churches were destroyed and Decani came under mortar attack.

The diamond metaphor comes to mind again, for the gems are formed under massive pressure. So is the kind of peace that prevails here. The monks and nuns speak no ill word of the ethnic Albanians outside their cloister walls and some even dare to muse, in unreason­ably good humour, that someday the monasteries in Kosovo may all be overrun by militants. "Temples fall. It happens. What matters is that we preserve the community of prayer," a monk says.

So fearless and infectious is this disposition - tempered by what the monastics call harmolipi, "joyful mourning" - that the modern western traveller who ventures here risks departing as a pilgrim, even if he has arrived as a tourist.

I drive onward to the famous monastery at Gracanica, two hours from Decani. The road crumbles into a wilderness of potholes as I cross into the small Serb enclave where the 14th-century monastery stands. The location means security is a smaller problem. A lone Swedish soldier at the modest gate, a member of the same Nato force to which Decani's Italian guards are attached, dreams away the hours with a rifle cradled in his arms.

Admirers call Gracanica "the queen of Kosovo churches". Standing in the middle of her broad yard, she appears regal but petite. Yet beneath her multitude of little domes is a vast blue and gold universe of iconography in which to wander.

Beneath an image of the Hebrew prophet Elijah, fed by ravens in the desert, I am greeted by a nun. Sara approaches me, clad in black from head to toe, bubbling with enthusiasm and keen to chat in whatever combination of Serbian, English and French suits me best.

"What's in the golden box next to the altar?" I ask.

"The relics!" she exclaims. "One of them is a bone from the body of St George. You know it is the saint because it still smells beautiful!"

Surprised, I ask: "St George, the famous one? The dragonslayer?"

"Yes," she says. "Come on St George's Day. You can see it for yourself."