Friday, June 27, 2008
Midwives Brace for Future Battle - Post Dispatch
Legalization of Midwifery...a technicality that began with a tuck
press release from Friends of Missouri Midwives and The Big Push that addresses this "smear campaign."
Tuesday, June 24, 2008
As we reported previously, in Missouri an amendment included in a big insurance bill that was passed last year would give CPMs legal, unregulated status in Missouri, but was challenged by the Medical Association. When the first court upheld the ruling, midwives and midwifery advocates appealed to the state supreme court. Now, finally, the supreme court has ruled: they essentially threw the case out on the basis that the Medical Association did not have any standing in the case! The Medical Association has 10 days to petition for a re-hearing, so there could still be a reversal, but this is unlikely.
The meaning: Once the 10 days are up (on July 4, Independence Day!), if a re-hearing is not granted, CPMs will be free to practice legally in Missouri!!
Here is a brief news account and another.
You can read the opinion and summary here.
Here is a press release from Friends of Missouri Midwives.
The appeal involved attorneys that cost money. If you are excited about this amazing victory, consider a donation to help with the remaining $33,000 still owed. You can go to Free the Midwives to make a donation -- every little bit counts!
As you are likely aware, midwifery advocates in Missouri have fought very long and hard to achieve legal status. They were extremely close to passing licensing legislation this spring, only to fall victim to hardball tactics by the medical lobbyists in the final hours of the legislative session.
Legal, unregulated status will allow midwives to practice openly and thus increase the pool of midwives and home birth advocates, a very positive development for midwives and mothers in Missouri!
Kudos to all in Missouri, who worked very hard, pushed through discouraging times, and never gave up!
Susan Hodges, “gatekeeper”
Saturday, June 21, 2008
Some blog comments referencing CfM here (this one urges people to join CfM, which we appreciate!) and here.
Friday, June 20, 2008
"This is the statement ACOG would file if facts interested them: We at ACOG recognize that, according to our most recent poll, none of our members have homebirth practices and, therefore, making a homebirth statement is unnecessary since this subject is outside the expertise of ACOG members. For the purpose of making an informed choice, consumers should not look to ACOG for a statement on this subject."
"Resolutions were recently introduced by the AMA to support ACOG's position against home birth and to 'develop model legislation in support of the concept that the safest setting for labor, delivery, and the immediate post-partum period is in the hospital, or a birthing center within a hospital complex, that meets standards jointly outlined by the AAP and ACOG, or in a freestanding birthing center that meets the standards of the Accreditation Association for Ambulatory Health Care, The Joint Commission, or the American Association of Birth Centers.'"
"Please help send a message to the AMA and ACOG, and to our state and federal legislators, to tell them that we object to these resolutions and we view legislation that would restrict a woman's right to choose a home birth as a being contrary to scientific evidence and a violation of women's basic human rights."
Thursday, June 19, 2008
Wednesday, June 18, 2008
You can read the blog and comments so far here.
You do have to sign up/log in before you can post comments. However, after you have read some of the more ignorant/hostile posts, you may feel moved to sign up! This is a place where you can speak up for facts that support midwife-attended home birth, and point out that the issue is not making “all” women have natural childbirth at home, but that the AMA does not have any business dictating that “all” women give birth in hospitals (or specifically accredited birth centers which are few and far between).
There probably are other blogs where this discussion is going on, but this is the first one pointed out to me.
Some thoughts to consider:
The AMA and ACOG are the health care professionals who have brought us the highest cesarean section and induction rates ever in the US, along with the worst standing yet for perinatal mortality and worsening rates for maternal mortality. Furthermore, rates for premature birth have been increasing, and recent studies have connected this increase with the increase in cesarean sections (for example, see here). The same professionals who have brought us these sad outcomes are claiming their way is best???
Many complications in labor and delivery actually are caused by medical practices and interventions, and are not common problems of pregnancy, labor or vaginal birth. Denying food and drink during labor, preventing or discouraging mothers from walking and other physical activity during labor, using drugs to "start labor” (ie, induction) or hasten labor (augmentation)
One has to ask if modern obstetricians are even competent to attend normal birth, as they seem unable to resist meddling with the process and causing problems in so many ways. There is no question that sometimes interventions, even cesarean sections, are needed and can be life saving. However, it is likely that many fewer mothers would have complications if typical routine obstetrical practices did not interfere with the normal process so much.
If there is going to be legislation, maybe it should require obstetrician wanna-be’s to complete midwifery training before their OB specialty training. In my personal opinion, ACOG and the AMA have no business trying to restrict women’s choices when it comes to birth.
Susan Hodges “gatekeeper”
Tuesday, June 17, 2008
You can find AMA's many Resolutions here (scroll down). Two especially egregious resolutions are:Resolution 205 Home Deliveries (32KB), Resolution 239 Midwifery Scope of Practice and Licensure (38KB).
Resolution 205 includes a resolve to develop model legislation in support of the concept that the safest setting for labor, delivery, and the immediate postpartum period is in the hospital, or a birthing center within a hospital complex, that meets standards jointly outlined by the AAP and ACOG, or in a freestanding birthing center that meets the standards of the Accreditation Association for Ambulatory Health Care, The Joint Commission, or the American Association of Birth Centers.
As usual, the AMA has provided no scientific evidence to support the statements or intent of the resolutions.
Clearly, the medical profession is getting desperate!
The Big Push for Midwives has issued a press release. For a version on Big Push letterhead (that you could download and print) go here.
Susan Hodges gatekeeper
Sunday, June 15, 2008
Thinking about Father's Day and birth and this film reminded me of Pam England's article On Becoming a Father and the need in our culture for "fathers to mentor and initiate [new] fathers" and how we can try to "...support the emerging father's birth as a father." I hope that this film will help to serve in that role.
At my Holistic Moms Network meeting last week we took turns sharing our favorite memories of our husbands/partners during the births of our children and in early postpartum. This topic was inspired by a post at the mamaroots blog in honor of Father's Day. It was a moving meeting and it was beautiful to hear the accounts of the tenderness, courage, strength, and nurturing that these men had offered to their wives and new babies. It was also a time for us to honor men and the value of males and of the role of father which is sometimes overlooked by our emphasis on women and on mothering. I was surprised to find my eyes filling with tears are I shared my own precious memories of the irreplaceable support my husband gave me during the births of our sons and the beauty and intensity of his connection to his newborn children.
Last month, I was interested to read a sidebar called "Biochemical Changes Help Drive Fathers Forward" in the Spring issue of the International Journal of Childbirth Education. Men also experience hormonal changes in preparation for birth and the weeks following birth. Research indicates the following changes in fathers-to-be:
- Stress hormone cortisol doubles in the 3 weeks prior to birth (to intensify response to baby's cries and a protective instinct).
- There is a 20% increase in prolactin levels (enhances instinct to care lovingly for the baby).
- "A 33% drop in testosterone in the 3 weeks following birth and a bounce back to normal at 4-7 weeks postpartum" (diminishes sex drive and enables strong focus on bonding with the baby).
Friday, June 13, 2008
The tone of the report seems to be that this issue is all about politics and not about any real issue of safety/concerns. Given the experiences of the tireless advocates at the Capitol, the admission of using "hardball" tactics is interesting, because that's certainly how it FELT, but it was denied by opponents of the legislation.
The year in review discussion does not discuss evidence or anything about real outcomes -- it discusses turf and beliefs and also about how the legislative efforts across the country
“complicates” ACOG's work.
An article called "It's Your Birth--show up for it!" on Coastal Point.The article covers local (Delaware) options for giving birth at a freestanding birth center, birth with a midwife in a hospital setting, and midwife attended homebirth and references CfM several different times.
The article opens with a nice section and mention of the differences between the midwives model and medical model:
"Women are increasingly at the center of their own health care and many argue that they particularly need to be their own advocates about how and where they will give birth. One thing to remember while pregnant and planning the birth of a baby is that the care provider a woman chooses can have a lot to do with her birth experience and ultimately, how she will feel about it.
Although certified nurse-midwifery got it start in this country in the 1920s, women have been helping other women deliver their babies since the beginning of time. The word “midwife” means simply “with woman.”
The midwifery model of birth is completely different from the medical model, in that it sees birth as a natural physiological event, not an “accident waiting to happen,” said Kathleen McCarthy, CNM, MSN, and co-owner of The Birth Center in Wilmington."Second, CfM is referenced on Kim Wildner's blog Fearless Birthing in her post regarding The High Cost of Health Care.
Finally, there is an interesting post at Independent Childbirth called, "Time for a 'Second Class' of Midwives?" written in response to the ACOG Midwifery Year in Review statement that I will post about shortly.
Monday, June 9, 2008
There are quite a number of measures included. The NQF has a specific framework, and many people have put a lot of time and effort into drafting these measures, which are specifically to measure quality of maternity, including care when there are problems. You may not agree with, or even understand, all of the measures, but this is a situation where we need to look at the glass have full rather than the glass half empty.
It is hoped that many individuals and organization will provide comments.
For excellent background information, read Childbirth Connection’s analysis and comments.
Next, go here. At the end of the brief article on that page, find a link to a pdf of “National Voluntary Consensus Standards for Perinatal Care”. This is the actual document, and includes information about the framework the NQF was working from, and some discussion and rationale for each measure considered, including those not included in the final draft.
While this may seem like a somewhat daunting task (the NQF document is 36 pages, double spaced), it did not take me long to look through it especially after reading the information on Childbirth Connection’s page.
Finally, you can comment on the report as a whole, and/or on individual measures, (see links in the left hand menu on the NQF site) and you can read the comments already submitted, including the excellent comments submitted by Childbirth Connection. Comments are quite limited in length, but there is nothing to say you can’t refer to a comment already submitted, or submit more than one comment on a particular measure.
Also, you can comment on just one or two items you don’t have to comment on everything. For example, the NQF had reasons why they did not include either proposed measure regarding VBACs, which is disturbing, and something you might want to comment on (see the last comment category “19. Measures not recommended”)
Keep in mind that these proposed measures represent a lot of work, and are the FIRST TIME measures to assess the quality of perinatal care in the US, which is a good thing! In general, few projects like this are “perfect” on the first go, and it is good to remember that people who have worked on a project respond best to a combination of appreciation and constructive suggestions!
Susan Hodges “gatekeeper”
The MA ACOG letter contains a number of completely inaccurate statements, especially regarding the CPM credential. The North American Registry of Midwives has addressed these points specifically, as follows:
The MA ACOG letter states:
“The academic standards for certified professional midwifery (CPM) are remarkably lower than the academic standards for training and certification of physicians, as well as for nurse-midwives certified by the ACNM. Moreover, CPM training requirements fall short of internationally established standards for midwives and traditional
Certified Professional Midwives are neither physicians nor nurse-midwives. Their education is specific to risk assessment and management for normal births in out-of-hospital settings. They recognize and refer, but do not diagnose nor treat, pathologies best suited for physician management. The education of the CPM is sufficient for this task as evidenced by the outcomes of the CPM2000 study published in the British Medical Journal, and as evidenced by the acceptance of the CPM by many states that license direct-entry midwives. Twenty-two states license midwives with requirements similar to or equivalent to the CPM; many have been in existence for over 20 years, and all have found the training to be sufficient for the task.
The MA ACOG letter states:
“An individual without a high school degree could be licensed as a CPM if he or she passed the certifying exam, observed 20 deliveries, and participated as the primary attendant in 10.”
Because the CPM is a midwifery credential, it does not set pre-requisites for non-midwifery education. The curriculum and training have been determined by the NARM Job Analysis according to procedures established by the National Commission for Certifying Agencies. The numbers in the above paragraph are false. In addition to the didactic education of over 750 competencies, the CPM candidate must complete 20 births as an assistant (not observer) and 20 births as the primary attendant, all under the supervision of a qualified preceptor. Additional verification of skills and knowledge is verified by a hands-on practical exam and an 8-hour written exam.
The MA ACOG letter states:
“CPMs have not adopted a set of criteria based on generally accepted medical evidence or public safety for patients who may be appropriate candidates for home birth, relying instead on the decision of the individual midwife and patient.”
Certification, by definition, defines the knowledge and skills necessary for attainment of the credential - indicating that the midwife has demonstrated the ability to make appropriate decisions for the practice of midwifery. The North American Registry of Midwives (NARM), which issues the credential, does have a mechanism for addressing complaints about the practice of a CPM. NARM does not, however, regulate the practice of midwifery. Regulation is a function of state licensure, and varies from state to state.
The MA ACOG letter states:
“The curriculum, clinical skills training, and experiences
of CPMs have not been approved by any authority recognized in certifying knowledge and skills associated with the practice of obstetrics, including the American Board of Obstetrics and
Gynecology, the American Midwifery Certification Board (AMCB), and the American Board of Family Medicine.”
Neither the American Board of Obstetrics and Gynecology nor the American Midwifery Certification Board approves the curriculum or sets clinical requirements for their own certificants, much less for the applicants for any other certification program. Each certification program sets its own prerequisites and conditions for application without approval from a completing or complementary certification board.
The MA ACOG letter states:
“The North American Registry of Midwives™ Portfolio Evaluation Process (PEP) requires midwives to be the primary care provider on 50 homebirths and have three years of experience. The average intern in obstetrics and gynecology gets this much experience
in 1 month.”
The Certified Professional Midwife does not function as an obstetrician/gynecologist. The clinical training for the CPM is similar in number to that of most certified nurse-midwives and is more extensive in vaginal births than the number required for family practice physicians.
MA ACOG could have easily checked their information before posting, but chose instead to post opinion and innuendo as if it were fact…
It is also interesting to note that the letter mentions no health evidence to support the ACOG position, and does not address the needs or preferences of mothers…
NARM’s “Planning for Legislation Handbook” includes lots of info, including factual information (p. 30) similar to the information above addressing the MA ACOG letter, and can be found here.
Susan Hodges, “gatekeeper”
Friday, June 6, 2008
"The alternative method is known as Active Management of Risk in Pregnancy at Term, or AMOR-IPAT, for short. AMOR-IPAT uses "risk-based preventative labor induction to ensure that each pregnant woman enters labor at a gestational age that maximizes her chance for vaginal delivery," says lead researcher, James M. Nicholson, MD, Assistant Professor of Family Medicine and Community Health at Penn....
"Over the past decade, the rates of cesarean delivery have climbed above 30%," says Dr. Nicholson. "Cesarean delivery, when compared with vaginal delivery, is associated with higher rates of postpartum hemorrhage, major postpartum infection and hospital readmission," he adds....
"The findings of this study suggest that the AMOR-IPAT approach to obstetric risk lead to healthier babies and better birth outcomes for mothers. In addition, the results challenge the current belief that a greater use of labor induction necessarily leads to higher rates of cesarean delivery. In order to further explore the potential benefits of the AMOR-IPAT method of care, further research involving larger randomized clinical trials in more diverse populations is needed."
Taking such an intensively managed approach to normal birth is of cause for alarm. Particularly quotes such as this "...labor induction to ensure that each pregnant woman enters labor at a gestational age that maximizes her chance for vaginal delivery." Hmmm. Doesn't a woman's body generally enter labor at the right gestational age for both of them, no induction necessary (or calculation of the "proper" time to induce)?!
There is an editorial called "Association Not Causation" that rebuts the claims of an earlier study on the protocol above. This rebuttal was written by a family practice physician and published in the Annals of Family Medicine.
One of the best portions of the rebuttal is as follows:
"We can learn something about complex care for a complex problem/phenomenon from midwifery. In midwifery care in the hospital or at home, cesarean section rates and other outcomes are as good as or better than those reported in the current study. What is the intervention in midwifery care? It is the totality of the care. It includes a coherent philosophy and an articulated, highly noninterventive approach. Induction rates are low, and women whose pregnancy is post-term are usually allowed to progress to labor on their own much later than in conventional physician practice."
The physician also draws a parallel between this "new best thing" and previous prophylactic intervention techniques that were advocated in previous decades: "An historical example of enthusiasts taking up the challenge of their leader before the intervention was fully examined is what happened when Joseph B. DeLee exhorted his followers to implement the "prophylactic forceps operation," with associated episiotomy. He believed this delivery style could improve outcomes for both mother and fetus at a time when, as today, there was a real problem, when childbirth was indeed quite dangerous. It seemed like a good idea at the time, and it has taken us more than 80 years to recover." (emphasis mine)
Thanks to Kathy of Woman-to-Woman CBE for pointing me in the direction of the editorial referenced above!
And thanks to Jim for noting that the editorial was actually written in regard to an earlier study. The research quoted at the beginning of the post is from a newer study (May 2008).
I wanted to mention two research surveys currently in progress:
A Birth Choices survey examining how pregnant women who participate in online communities make decisions about where they give birth and whom they have in attendance. Participants shuld be pregnant or have given birth in the last 12 months and meet one or more of the following criteria: women who have chosen to give birth either at a birth center, attended by a family physician, or unassisted.
A Beyond the Baby survey studying women's birth experiences and the ways in which women feel impacted by these experiences Participating women must: have given birth within the last three years, be 25 years old, or older, have a high school education, or beyond.
Wednesday, June 4, 2008
A new randomized controlled trial of continuous labor support for middle-class couples looks at the effect on cesarean delivery rates and found significant benefits. From the abstract:
In fact, the study found that the doula group had a significantly lower cesarean delivery rate than the control group (13.4% vs 25.0%).
You can read the abstract here.
Here is the citation:
A randomized controlled trial of continuous labor support for middle-class couples: effect on cesarean delivery rates.
SK McGrath and JH Kennell
Birth, June 1, 2008; 35(2): 92-7.
Susan Hodges, gatekeeper
The Sunday New York Times includes an article documenting that women who have individual health insurance coverage (not group insurance through an employer), are being penalized by some insurance companies with higher premiums, just because they had a cesarean section for any reason.
As the friend who sent me this link wrote:
“Talk about being between a rock and a hard place -- women who have had cesarean surgery are now, on top of everything else, ping-pong balls in a game between the health insurance companies and the malpractice insurance companies.”
You can read the article here. When obstetricians have openly admitted to performing cesarean sections merely to decrease their vulnerability to a lawsuit (and other equally outrageous non-medical reasons), the fact that women are first operated on for non-medical reasons, and then are required to pay extra for health insurance, is just plain unacceptable.
Susan Hodges, “gatekeeper”
Tuesday, June 3, 2008
Many of you already know of the bill wending its way through the MA legislative process: a bill developed by CNMs, CPMs, CMs and consumers, working together. The gist of the bill is that it would create a single midwifery board that would license CNMs, CMs and CPMs, with slightly different licenses that reflect differences in training, and includes prescriptive privileges for CNMs/CMs and administration of emergency and state mandated meds for CPMs.
Of course, ACOG (American College of Obstetricians and Gynecologists) is opposed, as they are opposed to any bill that would license CPMs and allow for legal midwife-attended home births.
Now you can read exactly what ACOG is saying about the bill, and how they are urging their members to actively work to stop passage of this bill. You can read their latest statement here.
I am sure you will recognize the many errors and misinformation, starting with the novel idea that CPMs are what used to be called lay midwives absolutely not true!
Whether you are involved with state legislation for CPMs or not, in MA or elsewhere, it is worthwhile to be aware of what ACOG is telling its members. You never know when you will have a chance to enlighten a physician or other person who has been misled by ACOG's statements!
Susan Hodges, gatekeeper
A study about to be published has found that that singleton preterm births have increased, and that 92% of them were delivered surgically (i.e. by cesarean section). Read about this in the March of Dimes press release.
- C- Sections a Critical Factor in Preterm Birth Increase
- Some C-Sections May Not Be Medically Necessary, March of Dimes Says
- WHITE PLAINS, NY, MAY 28, 2008, Cesarean sections account for nearly all of the increase in U.S. singleton preterm births, according to an analysis of nine years of national birth data.
- Between 1996 and 2004 there was an increase of nearly 60,000 singleton preterm births and 92 percent of those infants were delivered by a cesarean section, (c-section), according to research by investigators from the March of Dimes and the U.S. Centers for Disease Control and Prevention (CDC) that will be published in the June issue of Clinics in Perinatology. While singleton preterm births increased by about 10 percent during this time, the c-section rate for this group increased by 36 percent.
In discussing this issue, it is good to remember that the only study of any kind that has actually asked mothers if they wanted a cesarean is the Listening to Mothers II study by Childbirth Connection which found that extremely few mothers who had cesarean sections actually asked for them, and that most felt pressured to have the surgery.
Susan Hodges “gatekeeper”
Monday, June 2, 2008
"In all cultures the midwife's place is on the threshold of life, where intense human emotions--fear, hope, longing, triumph and incredible physical power--enable a new human being to emerge. Her vocation is unique. The art of the midwife is in understanding the relationship between psychological and physiological processes in childbirth. Rather than being the provider of a technical service to support a doctor, or someone who scuttles around getting ready for an obstetrician and clearing away after him, her skills lie at the point at which the emotional and biological touch and interact. She is not a manager of labour and delivery. Rather, she is the opener of doors, the one who releases, the nurturer. She is the strong anchor when there is fear and pain; the skilled friend who is in tune with the rhythms of birth, the mountain tops and chasms, the striving and the triumph."
The intersection of emotional and biological is exactly why I valued the prenatal care from my own midwife so much--she cared for ME as a person and woman with feelings, plans, thoughts, hopes, and ideas while at the same time that she also checked my BP and the baby's heart rate. Women are much more complicated than a set of biological symptoms or vital signs! This type of care is irreplaceable and is no less than ALL pregnant women deserve.