When Research is Flawed

I just wanted to bring attention to the Lamaze Institute for Normal Birth's excellent online article, "When Research is Flawed." This resource provides brief critiques on some key research studies that have shaped maternal-fetal health care in both policy and practice.

Penny Simkin article

Thanks to a link on the Passion for Birth blog, I just read a really great article about Penny Simkin that was in the Seattle Times on Monday.

Towards the middle of the article, Simkin makes the point that it isn't necessarily what happens during birth that makes women feel satisfied with their experiences, but how they are cared for and supported during labor and birth. A quote:

"'We can't control labor, whether it's hard; that's a leap of faith,' Simkin says. 'But we can always control how we care for her.'"

"Even though it's only one day, women are more vulnerable, Simkin says. There's pain, exposure, dependence on others, possibility of physical harm, authority figures who may, or may not, be sensitive. One in four women today describes birth as having been traumatic."

A Book for Midwives

Last year I got a copy of A Book for Midwives for Christmas. This book is published by the Hesperian Foundation and is available for FREE download on the Hesperian site. (Personally, I appreciate having the professionally printed, purchased version of the book because I think it would cost about the same in ink to print it myself, but without the nice cover! It is so fantastic that they make this available for free. What a resource. You can download chapters separately, if you have a specific interest in one over the others.) Hesperian is well known for its other publications, Where There is No Doctor and Where There is no Dentist, but they have a number of other excellent resources availabNe as well (all as free downloads and then also for purchase).

A Book for Midwives is so excellent, a true community resource, but also somewhat disturbing in its honesty and straightforwardness. It is basically a textbook for midwives or health care workers working in third world countries with very limited resources. I appreciated how it makes information/material available that is sometimes "hidden" in other books--it is simply written and extremely blunt. There is no fluff and nothing "romanticized" about pregnancy, labor, and birth. In a way, it was hard to read a book that makes it so very clear how very, very difficult things are for midwives and women in impoverished areas (living in the US, I am used to the "normal, healthy pregnant women" approach to midwifery care). The book covers a wide range of information from preventing infection, treating obstetrical emergencies, pelvic exams, and breastfeeding to HIV/AIDS, testing for STDs and cervical cancer, IUD insertion. There is also a section in the back of the book about medications, medication administration, giving injections, and things like that. It is very comprehensive. (Just a side note, in the section on contraceptives, the book is heavily in favor of hormonal methods such as pills and also very in favor of IUDs and sterilization.)

When I said it was "disturbing," I mean that it is a very sobering look at the reality of women's health and health care in other countries. It contains reminders such as "do not hit or slap a woman in labor" and other things that make you cringe.

Grassroots Network: Healthy People 2020 Meeting, Atlanta

From Susan Hodges:

On March 17 I attended the first regional planning meeting (in Atlanta) for the development of Healthy People 2020, a federal document outlining public health goals for the US. Will maternity care even be mentioned in HP 2020? You can be involved, because ANYONE can comment on-line regarding HP 2020. Read more below.

First, take a look at the site to get a brief idea of what this is about.

Here are some of the things I learned at the Atlanta meeting. First, unlike previous Healthy People documents (such as HP 2000, HP 2010), this time there is a concerted effort to solicit input from the public and from public health workers in this early planning stage. This input includes what health areas or topic should be included, how many should be included, and how to organize them. Some work has already been done to come up with a suggested framework. There is a lot of concern about disparities or inequities in health care especially with regard to minorities and also demographic groups such as people living in rural areas and low-income people. There is concern that HP 2010 had too many objectives (ie, specific goals, such as reducing the c-section rate to 15%) and that HP 2020 should have fewer objectives.

There are Regional Meetings coming up between April 1 and May 28, in San Francisco; Ft. Worth, TX; Chicago; New York, NY; Bethesda, MD. Find out more information here.

The Atlanta meeting included presentations about the project, the preliminary work that has been done regarding a suggested framework, etc. There were several sections of time for public comments (limited to 3 minutes per person), and a panel of people from several organizations and city government who shared their experiences of actually using HP 2010 to work on specific objectives. In the afternoon we were divided into breakout groups each for one of four over-riding topics: Developmental States, Life Stages, and Health Outcomes; Environment and Determinants of Health; Priorities and New and Emerging Issues; Health Equity and Disparities. Each group had a facilitator and brainstormed and discussed several questions to do with how HP 2020 might be used, and how issues and goals might be defined and prioritized. At the end of the afternoon the facilitators presented the main points from the breakout sessions. I would say that there was at least some concern that reducing the number of objectives would not be good, and there was at least some concern about the need to have more “teeth” so objectives could be achieved (although this is beyond the purview of the CDC etc.). It is likely that the other regional meetings will be organized similarly to this one in Atlanta.

Probably because the Atlanta meeting was the first of the regional meetings, we didn’t receive much information until the last few days before the meeting. For example, we did not know whether or how oral comments might be made, and on-line comments that could be made in the last few days were limited to about 400 words. So CfM submitted an on-line comment prior to the meeting, we later wrote a more detailed comment with supporting documents to hand in at the meeting (when we found out that was possible), and I made a 3-minute oral comment at the meeting. Virtually everyone who made oral comments was representing some kind of interest group (oral health, elder care, mental health, etc.) and basically presenting the public health importance of their issue. While some of these may have been more specific than the organizers desired, hearing the concerns about specific issues or health topics surely will help to inform the final decisions about the framework and scope of HP 2020.

I was the only speaker at the Atlanta meeting who brought up maternity care (though there were at least two people who spoke about breastfeeding). I did my best to address public health themes (health outcomes, evidence-based care), name “midwives” as an important part of the solution, and request that HP 2020 have more “teeth” for achieving objectives -- HP 2010 goals for reducing the rate of cesarean section and increasing VBAC have been completely ignored, with both rates going sharply in the opposite direction from the objective rates.

If you are thinking about attending one of the regional meetings, here are some suggestions.

• Do read over the information about the planning process that is available on-line (and I am happy to forward documents that were sent to me right before the Atlanta meeting). Think about the overall aspects of the suggested structure and questions regarding HP 2020 and how any comments you make can address those issues that are the focus in this planning stage. Probably, the more that remarks from birth activists also relate to the framework/vision/mission planning topics, the more likely the remarks will be read and noted at this stage.
• If you comment, on-line or orally, consider that your “audience” for these comments are public health officials. Therefore, it is a good idea if your comments about maternity care and midwives are oriented around one or more public health issues such as: access to care; health disparities; having fewer low birth weight and premature babies; healthy mothers and babies (which means not using unnecessary interventions); evidence-based care (most maternity care is not evidence-based); how midwives experienced in out-of-hospital birth would be an asset in the event of pandemic flu, drug resistant infections, and/or bio-terrorism; etc. If there is one particular aspect of the maternity care issue that you feel most passionate about or are most knowledgeable about, by all means focus on that.
• I think it would be great for at least a few birth activist people to attend each regional meeting in person, especially individuals who represent an organization or a practice. (For oral comments, only one person per organization was permitted.) Hearing the oral comments and participating in the breakout group will give you insights into the development process and how maternity care might fit into the overall plan of HP 2020.
  
• In my opinion, it is not necessary (or even advisable) to have more than one or two birth people making oral comment, since only a relatively few participants get to speak (in Atlanta it was first come first served to sign up, and the total number was limited by time). In Atlanta it was pretty obnoxious to hear the same thing from multiple people. Therefore, if there is any way to coordinate so that if several birth people want to speak, it would be useful if they can each acknowledge agreement with the one before, but address a different aspect. Be ready to rethink, rewrite, or rearrange your remarks to take advantage of what has already been said, etc.
  
• Keep in mind that maternity care is just one of many, many important issues and health topics.
• Keep in mind that disparities in health care is a major important topic that WILL be part of HP 2020.
• The time is so short, it is important to bring up the big issues. I spoke about the lack of evidence-based care in hospitals and how that is harming women and babies, and that we already have a solution: midwives. I did not address birth centers or OOH births these were too detailed to get into. I also did not address the AMA’s Scope of Practice Partnership. While this is a big issue, it is not really within the purview of HP 2020; however, if someone figures out a useful way to present this issue, all power to you!

Meanwhile, ANYONE and EVERYONE can make comments online. Right now they are specifically interested in comments relating to the overall framework, vision, mission, overarching goals, more or fewer topics, etc. They are not seeking comments on specific objectives now, but will in 2009. However, suggesting that an issue (like the problems with maternity care) be included is not the same thing as suggesting a specific objective (such as: increase the % of VBACs to a specific number). One would think that if HP 2020 receives many thoughtful comments about the problems with current maternity care, why these problems are a public health challenge, and the need for more midwives as a way to address some of those problems, the more likely it is that health objectives relevant to improving maternity care just might be included. It can’t hurt, anyway!

I have posted both the short and long versions of the testimony I submitted for CfM at the Atlanta meeting, along with some additional “tips” in the files section of the Grassroots Network yahoo page.

Sincerely,
Susan Hodges, "gatekeeper"

High-Tech Birthing

The January/February 2008 issue of the Journal of Obstetric, Gynecological, and Neonatal Nursing contains an extensive article on "The Emergence of High-Tech Birthing." You can read the full text of the article on the Birthfriend blog. The article urges nurses to find ways to support normal birth within a high-tech environment and also urges them to strive for balance between both aspects of care--providing "high touch" components along with technology "as needed" (not "routinely"!).

A suggestion from the article that I particularly liked was: "Become a vocal advocate for normal birth in your community. Share positive messages about childbirth with the young women in your life before they become pregnant. Begin these discussions with your daughters, your granddaughters, and any other young women in your life. Nurses have the power to begin a campaign of 'social marketing' in their communities to counter the negative impressions given to women by the media. Social marketing has worked to promote change in other areas of perinatal care(importance of prenatal care, prevention of preterm labor, and breastfeeding), so a campaign to promote normal birth also could work."

Another interesting point made in the article is with regard to the current generation of birthing women's experience with, familiarity with, and reliance on technology: "The iGeneration is used to and comfortable with technology. They have known nothing other than fast-food restaurants, microwave cooking, drive-through banking and pharmacies, and fast easy access to communication and information. A technologically managed labor and birth that can be fast and efficient is not a negative concept [to them] and is not likely to be challenged." (emphasis mine. I think this is an important concept to keep in mind when we as birth advocates strive to reach pregnant women with evidence based information and support.)

Thanks to the Woman to Woman blog for the link to this article in the first place. Lots of food for blog-thought!

MotherBaby

Mamatoto is a Swahili word meaning "motherbaby"--reflecting the concept that mother and infant are not two separate people, but an interrelated dyad. What impacts one impacts the other and what is good for one is good for the other. The midwifery and birth communities have used this concept for quite some time and more recently some maternal health researchers have also referenced the idea of the "maternal nest" (that even following birth, the mother is the baby's "habitat").

Reflecting this inseparable connection between mothers and babies and the birth-breastfeeding continuum, the International MotherBaby Childbirth Initiative launched at CIMS in Florida this year (preliminary work towards the Initiative began in 2006). Since 1996, there has been International Mother-Friendly Childbirth Initiative and there is also the WHO/UNICEF Baby Friend Hospital Initiative. The term MotherBaby was chosen for the new Initiative "to draw attention to the mother and baby as one integral unit, a dyad that should not be separated, and because the IMBCI places a great deal of emphasis on the impact of birth practices on breastfeeding....The instrumental purpose of the IMBCI 10 Steps is to put into worldwide awareness and practice the MotherBaby model of care--a woman-centered, non-interventive approach that promotes the health and wellbeing of all women and babies during pregnancy, birth, and breastfeeding, setting the gold standard for excellence and superior outcomes in maternity care."

Reading about these initiatives reminds me of a quote from a Midwifery Today editorial by Jan Tritten:

"You will have ideas, options and paths to ponder, but you will also have a sense of possible directions to take as you consider midwifery, childbirth education, or being a doula or an activist. Your path may be circular or straight, but meanwhile you can serve motherbaby while on the path, with a destination clearly in mind." She also says, "I use the word midwife to refer to all birth practitioners. Whether you are a mother, doula, educator, or understanding doctor or nurse you are doing midwifery when you care for motherbaby."

As long as I'm discussing the concepts of motherbaby and mamatoto, I wanted to mention a really interesting book called Mamatoto: A Celebration of Birth published by The Body Shop in the 1990's. This book is a fascinating look at birth around the world. Lots of great photos and content that you do not find anywhere else!

50 Ways to Scare a Mother

Some birth educators from Independent Childbirth put together some creative and interesting musical slide shows on YouTube.

In 50 Ways to Scare a Mother we hear that some of those ways are by sharing awful birth stories, having endless prenatal tests, have her lie perfectly still, tell her she is getting too fat, that her baby is too large, her fluid is too low, that she is "too late, Kate" (overdue) and so forth. The video ends with a message that I think that women need to see: "If your care provider says something that scares you--ask questions, do research, and make informed choices."

The other is called 50 Ways to Birth More Safely. The first half of this one focuses more on ways to "dump your doctor" and "avoid the strife, hire a midwife." It goes on to suggest doulas, viewing birth as a rite of passage, having freedom of choice, and trust in birth "is the key."

Gestational Diabetes Research

From the most recent version of DONA's e-newsletter: "Canadian researchers have determined that the presence of gestational diabetes does not necessarily indicate that the woman will develop diabetes later in life. However, there was an increased risk for subsequent development of diabetes if the gestational diabetes was severe enough to warrant insulin therapy, pre-pregnancy weight was greater than 86 kg (189 lbs), the infant suffered from low blood glucose levels or if the woman also developed gestational diabetes in her other pregnancies." You may read the abstract here.

Our Bodies, Ourselves: Pregnancy & Birth

I was lucky enough to review the brand new book Our Bodies, Ourselves: Pregnancy & Birth for the upcoming issue of CfM News!

This book would be an excellent addition to the library of most pregnant women (particularly those who connected with the original Our Bodies, Ourselves book and its approach to women's health and empowerment). This is a basic, introduction to pregnancy and birth book geared primarily towards the first time mother. It goes beyond the scope of most basic pregnancy books though in its willingness to address important, though uncomfortable, topics such as domestic violence, sexual abuse, depression during pregnancy, HIV, STDS, & substance abuse that are often neglected or ignored in other books.

The book clearly addresses the differences between the Midwives Model of Care and the medical model (you can also read about the differences according to the OBOS authors in their excellent online article). A main strength of the book is that it is balanced—not in the sense that some people mean the word (that all options are presented as equal), but in the sense that it provides information on just about everything. It is also very evidence based and true—it does not present only “party line” and likewise not only one philosophy.

The conclusion of my review is as follows:

Many of the most popular pregnancy books are rooted in medical model, conventional wisdom, and a climate of fear and doubt. This book is rooted in an empowerment oriented, woman centered midwifery model in a climate of confidence and competence. This book is a basic introduction to pregnancy and birth and is primarily directed towards the newly pregnant first time mother. I hope it finds a comfortable home on bookstore shelves next to (or in place of!) books about “what to expect” during pregnancy.

I have much more to say about this book and will share those thoughts in future posts. You may also join CfM in time to receive the spring issue of CfM News and read my full review there as well as many other interesting articles about midwifery, birth, and women's health care!

Primate Birth

Some time ago I posted about an orangutan in the zoo being given a cesarean. I wondered about the impact of the zookeepers standing by watching her labor had on her labor and eventual birth outcome. I recently finished reading a very interesting book by Tina Cassidy (Birth: The Surprising History of How We Are Born) that happens to touch on this issue and so I wanted to share what it said.

"Monkeys in labor often stop contracting when they know a human is watching them. Women aren't necessarily different. After laboring at home for hours, many find their labor stalls when they arrive at the hospital, surrounded by the unfamiliar...For women, being among strangers can retard labor."

Birthing Project USA

Birthing Project USA was founded in 1988, but I only heard about it for the first time this week!

"Birthing Project USA is the only national African American maternal and child health program in this country. We are a volunteer effort to encourage better birth outcomes by providing practical support to women during pregnancy and for one year after the birth of their children."

This Project pairs volunteer "SisterFriends" who are trained to navigate the health care system and provide one-to-one mentorship for a woman through pregnancy, birth, and her baby's first year. The founder believes that supportive friendships and a sense of community can improve health outcomes for mothers and babies. (She also notes that babies born to women with SisterFriends have higher birth weights and are more likely to be born at 40 weeks instead of at 36 weeks which is the average for African American women.)

Birthing Project has helped more than 10,000 women and has a presence in 86 communities and 3 countries. What a wonderful, creative, inspiring program!

Recent VBAC Research

From Susan Hodges:

VBAC should be widely available and is low risk for many VBAC hopefuls.

A just-published large study found that a woman with a prior cesarean but who has since given birth vaginally is at low risk for complications for herself and the baby, and with increasing number of prior VBACs has a greater likelihood of successful VBAC as well as lower risks for complications such as uterine rupture and perinatal complications for the baby. (Brian M. Mercer, et al. Labor Outcomes With Increasing Number of Prior Vaginal Births After Cesarean Delivery. Obstet Gynecol 2008;111:28591).

Another recently published study concluded that: A history of multiple cesarean deliveries is not associated with an increased rate of uterine rupture in women attempting vaginal birth compared with those with a single prior operation. Maternal morbidity is increased with trial of labor after multiple cesarean deliveries, compared with elective repeat cesarean delivery, but the absolute risk for complications is small. [emphasis added] Vaginal birth after multiple cesarean deliveries should remain an option for eligible women. (Mark B. Landon,et al., Risk of Uterine Rupture With a Trial of Labor in Women With Multiple and Single Prior Cesarean Delivery Obstet Gynecol 2006;108:1220).

With each successive cesarean section, the risk of increasingly serious complications in the future rises. (Robert M. Silver, et al. Maternal Morbidity Associated With Multiple Repeat Cesarean Deliveries Obstet Gynecol 2006;107:122632). For women who were traumatized by their initial cesarean section experience or felt betrayed by their doctor or hospital staff, the hospital may be the least conducive setting for a successful VBAC, especially if the doctor or staff are unsupportive or unskilled in providing appropriate emotional support and encouragement. Furthermore, in many hospitals it is routine to induce or stimulate labor with drugs, even for VBACs, which significantly increases the risks of uterine rupture and other complications. (Brian M. Mercer, et al. Labor Outcomes With Increasing Number of Prior Vaginal Births After Cesarean Delivery. Obstet Gynecol 2008;111:28591).

Mother-Friendly Childbirth Forum

As I write, three CfM Board members are at the Coalition for Improving Maternity Care Services (CIMS) Forum in Florida. Today was the opening day of the Forum and I'm sure there is lots of great stuff going on!

Watch for an update on the Forum after the Board members return! They are definitely going to be busy this weekend. They are each co-presenting sessions at this event. Carolyn is presenting during the session, “Learn to Gather Intervention Statistics and Market The Birth Survey.” Susan will help present “Using the Evidence Basis for the Ten Steps of Mother-Friendly Care in Your Community,” and is participating in a plenary discussion on “Making Mother-Friendly Care a Reality.” She will also be on the panel discussion following a screening of The Business of Being Born. Nasima, who is also a leader on the CIMS Grassroots Advocates Committee (GAC) and worked on the Planning Team, has perhaps been the busiest preparing for the Forum. She and the other GAC leaders are presenting a plenary session on “CIMS Grassroots Advocates Committee (GAC): Transparency in Maternity Care Pilot Site Results and National Launch.” Nasima is also presenting a workshop on “Creating Birth Change: Grassroots Advocacy Effective Resources and Tools.”

You can read more about each of their presentations in follow-up articles in the fall issue of CfM News. These Board members are working so hard on behalf of Citizens for Midwifery as well as for women everywhere who are seeking access to mother-friendly, maternity care!

From the Forum press release:

"The United States spends more on healthcare than any country in the world, $79 billion in 2005. Pregnancy and delivery and newborn care are 2nd and 3rd most expensive conditions treated in U.S. hospitals and the two most expensive conditions billed to Medicaid and private insurance. Despite these burdensome costs fewer newborns die in countries like Lithuania, Slovenia, Israel, Greece, and Portugal. One in 4,800 women in the U.S. are likely to die from pregnancy-related causes compared to 1 in 9,600 in Kuwait, 1 in 17,800 in Denmark, and 1 in 47,600 in Ireland. The CDC estimates the true level of U.S. maternal deaths may be 1.3 to 3 times higher than the reported rate. At the 2008 Mother-Friendly Childbirth Forum hosted by the Coalition for Improving Maternity Services (CIMS), March 6-8 in Kissimmee, Florida, expert speakers will address this issue and explore solutions for what can be done to reduce the maternal and infant mortality rate while enhancing care for the nation's most vulnerable populations - mothers and babies."

Update from Missouri

Missouri advocates have posted a press release, excerpted below (read the full text on their website). The case will be heard in the MO State Supreme Court on Wednesday, March 5! (For background about current efforts to have legal CPMs in MO, see Grassroots Network Message 706014 (you can find all messages under Messages in the yahoogroup).

The American Medical Association filed an Amicus Brief in this case, and as noted below, midwifery advocates filed an Amicus Brief in response, addressing the points the AMA brought up basically the same tired old refrain we have been hearing for quite a long time. (If you are interested, you can read the case documents, including all of the various briefs (the AMA amicus brief and the “Citizens for Midwifery” amicus brief are the last two) here. Just scroll down a bit to see the links.) The CfM amicus brief did not address the legal arguments (about whether or not the sentence in the Insurance Bill violated the single topic rule) as these issues were addressed in other briefs, but focused on the specious AMA arguments regarding safety. The writing and filing of this brief was an amazing effort by a collection of people in various parts of the country, all done by phone and e-mail!

Sincerely,
Susan Hodges, “gatekeeper”

Excerpts from the press release:

Missouri Supreme Court to hear Midwives Law Appeal

Court grants motion by coalition of midwife advocates to file a ‘friend of the court’ brief for Mar. 5 hearing

(Jefferson City, MO) The Missouri Supreme Court will hear arguments to reconsider the permanent injunction on the state’s new midwifery law at 9:30 a.m. on Wednesday, March 5 at the Cole County Courthouse, 301 E High Street. A coalition of state and national midwife supporters, midwives and home birth families, led by Friends of Missouri Midwives (FOMM) and mobilized for the appeals process, has learned that the Court has granted their motion to file an amicus curiae (friend of the court) brief, submitted by:

* Citizens for Midwifery (CfM)
* Midwives Alliance of North America (MANA)
* National Association of Certified Professional Midwives (NACPM)
* Our Bodies Ourselves
* The National Birth Policy Coalition (NBPC)

The amicus brief submitted by the coalition supports the lifting of the midwives law injunction and makes the case that increasing access to trained and qualified Certified Professional Midwives (CPMs) and out-of-hospital birth is beneficial to Missouri citizens. In seeking to provide such access, Missouri is following the wisdom of a growing number of states recognizing the benefit of authorizing CPMs, who provide safe and high quality care, to practice.

“If the Supreme Court lifts the injunction, this law will permit CPMs to provide high quality, cost-effective care that will benefit Missouri’s citizens and fill some significant gaps in the state health care system,” said Susan Jenkins, legal counsel to the midwives coalition and steering committee member of National Birth Policy Coalition. “Home birth among low-risk women attended by CPMs does not jeopardize the health of mothers or infants, is authorized in 22 states, and is supported by many highly regarded international and professional organizations.”

Mary Ueland, Grassroots Coordinator for Friends of Missouri Midwives, says she hopes the Court will rule to decriminalize Certified Professional Midwives and remove the threat of prosecution to professional midwives who assist families who choose out-of-hospital birth. "Missouri shouldn't drag it's feet when it comes to allowing mothers to have safer and healthier births options."

The new Missouri Midwifery law was supposed to take effect Aug. 28, 2007, but the Missouri State Medical Association (MSMA) organized a well-financed challenge to the new law and was granted a temporary restraining order on July 3. Then on Aug. 8, Circuit Court Judge Patricia Joyce, who serves on the Board of Directors for St. Mary’s Health Center in Jefferson City, disallowed the Certified Professional Midwives provision contained within HB818 regarding portability and accessibility of health insurance.

Judge Joyce ruled the provision was unconstitutional and unrelated to health insurance, despite hearing from Assistant Attorney General John K. McManus and Midwifery Coalition attorney Jim Deutsch that decriminalizing midwifery does indeed relate to health insurance as they recalled that the Missouri Supreme Court has already ruled health insurance is interdependent on health services, and the two subjects are related.

During the Circuit Court appeal to Judge Joyce on Aug. 2, Deutsch cited nine other states where Medicaid covers home births attended by Certified Professional Midwives and many others where CPMs receive private insurance reimbursement. Both McManus and Deutsch argued that families obviously cannot get health insurance reimbursement for their midwives if their providers are considered felons by the state. They agreed that legalizing Certified Professional Midwives is a first step to home birth families being able to have their maternity care providers covered by insurance. They also cited the lower cost of midwifery care, which in turn could encourage insurance companies to lower their rates for healthy women.

“We’re seeing a strong shift in support of professional midwives as families become more aware of the benefits of CPMs, as well as more alert to skyrocketing c-section rates,” Laurel Smith, President of Friends of Missouri Midwives, said. “Beyond the additional risks for mothers and babies that c-sections create, what effect does a c-section rate of more than 30 percent have on our insurance premiums, and how reliant are doctors and hospitals on these increasing revenues?”

Missouri is part of The Big Push for Midwives Campaign, a nationally coordinated campaign to advocate for regulation and licensure of Certified Professional Midwives (CPMs) in all 50 states, the District of Columbia and Puerto Rico, and to push back against the attempts of the American Medical Association Scope of Practice Partnership to deny American families access to legal midwifery care.