GRN: The Access to Certified Professional Midwives Act of 2011

Grassroots News Message 2011-03-18 no 2

Historic news from the MAMA Campaign: “The Access to Certified Professional Midwives Act of 2011” introduced in Congress. Citizens for Midwifery is a coalition partner in the MAMA Campaign and has been working hard to increase access to midwifery care for families through federal recognition of CPMs. We are thrilled to have reached this historic milestone. Read more from the MAMA Campaign below.

CPM Bill Introduced: A Milestone for Mothers and Midwives!



Join the Celebration for HR 1054
!

We are thrilled to announce that Congresswoman Chellie Pingree (D-ME-1) has introduced HR 1054, the “Access to Certified Professional Midwives Act of 2011” in the U.S. House of Representatives.

Photo of Rep. Chellie Pingree



“I believe it’s important that women are able to have the birth experience they want, regardless of where they live and how much money they make. That is why it’s important that women with Medicaid coverage have the same access to high quality, safe, and cost-effective services,” Congresswoman Pingree said. The Congresswoman is known in Maine and Washington, DC as a sensitive, independent voice for social and health issues that affect families everywhere. 



The Midwives and Mothers in Action (MAMA) Campaign expresses our sincerest appreciation to Congresswoman Pingree and celebrates this milestone in the history of direct-entry midwifery in the United States.

MAMA is also deeply grateful to Rep. Gwen Moore (D-WI-4) and Rep. Jim McDermott (D-WA-7) for their support and leadership in co-sponsoring HR 1054 with Representative Pingree.

Increasing women’s access to the care of CPMs will support better outcomes for mothers and babies, reduced disparities in outcomes for vulnerable populations, and provide significant cost savings for Medicaid and the health care system.

We are most grateful to Representative Pingree for her vision and support for childbearing women and their families. 



This is Your Milestone!


Your support, your letters to members of Congress, meetings with your legislators in Washington, DC and in-district, and all of the dollars that you have contributed to this cause have made possible the introduction of HR 1054. You should be proud of yourselves – the MAMA Campaign Steering Committee thanks you!

Now the Work Begins….

MAMA will be counting on your energy and involvement in the coming weeks and months as this train gains steam and we forge ahead to garner the support of Congress for enacting HR 1054 into law. Our next steps include securing additional co-sponsors, obtaining support from the leading advocates for change in maternity care, raising the funds, and motivating the volunteers necessary to see this campaign through to victory. Together we will steadily move this important piece of legislation forward, Congress member by Congress member, for the benefit of women and babies.


Coming Soon From MAMA:

• Letter-writing guidelines for soliciting your Congress members to become co-sponsors
• Invitations to participate in visits to the Hill in Washington, DC and organize in-district visits to your Representatives
• Advice on how you can become more involved as the MAMA Campaign gathers support in key Congressional committees



MAMA’s New Look

MAMA is getting a “make-over” with a new color scheme, updated logo and website and a fresh look to our materials. Check MAMA out at www.mamacampaign.org. We’re also implementing a new web platform that will make it easier for us to stay in touch with you and for you to post your thoughts, write your representatives, and make donations to the campaign.



MAMA Is Growing

With the introduction of HR 1054, MAMA is seeking to hire a self-starting, energetic, and driven team member as Administrative Assistant to the Campaign. Take a look at the Job Posting and help us find the right person to provide this support to the Campaign.



Keep MAMA Going in 2011!

Just one year ago, MAMA celebrated a significant victory in our campaign for federal recognition of CPMs! Since that time, we have been working quietly to secure the initial sponsors of HR 1054 and solicit support from major donors who understood the need to invest in MAMA’s long-term success. As a result, we are already halfway toward meeting our expenses in 2011! Now we need the support of our grassroots – mothers and fathers, grandparents, midwives, doulas, and other advocates – to keep our momentum going. Please celebrate with us – show Congress you care, too – by making your contribution today. We will put your dollars to work, making a difference for mothers and babies! Together we can move mountains!

 Donate Today!

GRN: ACOG Is Not Qualified to Evaluate the Practice of Midwives

Grassroots News Message 2011-03-16 "ACOG Is Not Qualified to Evaluate the Practice of Midwives" March 11, 2011 Grassroots Network Message ACOG Releases Opinion on Homebirth Hello Friends, After a January press release announcement, the American Congress of Obstetricians and Gynecologists (ACOG) officially issued its current statement on the safety of homebirth in February (ACOG, 2011.). The numerous challenges posed by a physician’s trade organization releasing an opinion about homebirths (which most obstetricians do not attend), based on unsound research, will be explored below. In the statement, ACOG acknowledges that they “respect the rights of a woman to make a medically informed decision about delivery,” but again asserts its long-held belief that hospitals and birth centers are the safest settings for birth. ACOG’s opinion on homebirth is based largely on results from a poorly conducted, scientifically weak meta-analytic review (Wax et al., 2010). This paper has been roundly criticized for its methodological flaws and shortcomings, rendering its conclusions inaccurate at best. You can check out these links for critiques: The Big Push Science and Sensibility Our Bodies Our Blog Midwifery Today Scribd That ACOG would use poor quality science is a testament to the fact that ACOG is a private trade organization, not a scientific organization, whose primary goal is to support the interests of its members (for more on this). Perhaps even more important, ACOG, as a group, lacks any comprehensive knowledge of or experience with midwifery practice. ACOG is not qualified to evaluate the practices of midwives given the vast differences between modern obstetric practice and midwifery practice. Most obstetricians have never observed a single woman labor and give birth without any medical intervention, let alone in her own home. It is essential to keep these considerations in mind when evaluating recommendations from a trade organization such as ACOG. While ACOG’s opinion on homebirth is not surprising, it is important to consider the potential negative impact it could have on the future of women’s access to homebirth. Some may recall the 1999 ACOG practice bulletin recommending that VBACs (vaginal birth after cesarean) only be attempted in hospitals with immediately available emergency surgical teams. This recommendation had an immediate (and long lasting) chilling effect on the number of VBACs occurring in the United States (see the figure below, reprinted from Roberts et al., 2007.). If ACOG’s statement on homebirth is used to set policies in the same way that the VBAC opinion was, access to homebirth could be jeopardized for many women for a long time to come. In the statement, ACOG asserts that several of the current, well-conducted empirical studies illustrating the safety of homebirth cannot be generalized to the United States, given that they were conducted in countries in which midwifery is well integrated into the health care system. In light of this assertion, we call on ACOG as well as national and state medical societies to understand that criticism and to begin to support (rather than obstruct) efforts to license and integrate well-trained professional midwives into main stream health care delivery in the United States. Sincerely, Lauren Korfine, PhD for CfM References: American College of Obstetricians and Gynecologists, Committee on Obstetric Practice (2011). Committee Opinion: Planned Home Birth, Obstetrics and Gynecology, 117(2), 1-4 Roberts, R. G., Deutchman, M., King, V. J., Fryer, G. E., & Miyoshi, T. J. (2007). Changing policies on vaginal birth after cesarean: impact on access. Birth, 34, 316-322 Wax, J.R., Lucas, F.L., Lamont, M., Pinette, M.G., Cartin, A., Blackstone, J. (2010). Maternal and newborn outcomes in planned homebirth vs. planned hospital births: A metaanalysis. American Journal of Obstetrics and Gynecology, 243, e1-8.) From Roberts et al., 2007. Number of births by cesarean section over time. Note the sharp decline in VBACs after 1999, the year ACOG issued its VBAC practice bulletin that lead to VBAC bans in many hospitals.

LEARN MORE ABOUT CFM SIGN UP HERE TO RECEIVE GRASSROOTS NEWS MESSAGES! SHARE WITH OTHERS IN YOUR AREA! Feel free to forward and share on facebook with friends, family and colleagues SEND US NEWS! If you find news, resources, or other valuable information that you think should be posted on the Grassroots Network, please send it to info@cfmidwifery. org... with "For the grassroots network" in the subject line. We will definitely consider using them! LEARN ABOUT CfM! Check out our website Check out our blog Like us on Facebook GET INVOLVED! Are you interested in volunteering with some dynamic women in a supportive environment? Help CfM promote the Midwives Model of Care! We have many ways to get more involved. Get in touch with us! DONATE! CfM couldn't do it without your support. Make your contribution here!

Breech Resources

I got the following information from a birth email list I belong to and thought these resources were interesting/valuable:

Great photos of a breech home birth (mother kneeling) with Australian Midwife
Lisa Barrett

New organization for the UK promoting education in Breech Birth for Midwives and
Obstetricians and Informed Consent for mothers. Stories invited.

PowerPoint by Shawn Walker RM as well.

--
Molly
CfM Blogger

International Women's Day

"If ever the world sees a time when women shall come together purely and simply for the benefit of humanity it will be a power such as the world has never known." --Matthew Arnold

"I long to speak out the intense inspiration that comes to me from the lives of strong women." –Ruth Benedict

Tomorrow is the 100th anniversary of the first International Women's Day. For more information about celebrating check out the International Women's Day website. Or, visit the Imagine a Woman website to read this blog post or to check out this handout about 50 things to do to celebrate International Women's Day, Women's History Month, yourself, and the women who inspire you.

To bring it back to birth, you might also enjoy watching these helpful midwifery/birth videos from strong women on the Midwifery Today youtube channel.

“I believe that these circles of women around us weave invisible nets of love that carry us when we're weak and sing with us when we're strong.” --SARK, Succulent Wild Woman

"Loving, knowing, and respecting our bodies is a powerful and invincible act of rebellion in this society." --Inga Muscio

In honor of International Women's Day---and every day---let us celebrate our bodies, honor our mothers, and trust in the nets of love woven around us by a multitude of remarkable, powerful, everyday women.

--
Molly
CfM Blogger
(photo from my blessingway in January 2011, 38 weeks pregnant with my baby girl!)

Legislative Alert from AABC

Passing along a legislative alert from the American Association of Birth Centers:

Women and Children Lose in Budget Cuts: We need your help!

It always is a shock to me that Women and Children's Programs are at the top of Federal and State budget cuts. Republicans in the U.S. House of Representatives have passed large cuts in health services to women, infants, and children (H.R.1):

Hundreds of millions from WIC (Women, Infants, and Children):
WIC provides Federal grants to States for supplemental food, health care referrals, and nutrition education for low-income pregnant, breastfeeding, and non-breastfeeding postpartum women, and to infants and children up to age five who are found to be at nutritional risk.

Hundreds of millions from Maternal and Child Health Block Grants:
This Block Grant referred to as Title V is a public health program that reaches across economic lines to improve the health of all mothers and children, train providers and support services for children with special healthcare needs, offers newborn screening and genetic services, lead poisoning and injury prevention, and health and safety promotion in child care settings.

More than a billion from Community Health Centers:
Community Health Centers are key partners for many Birth Centers. They exist to fill the void in underserved communities and vulnerable populations by assuring access to comprehensive, culturally competent, quality primary care services.

This federal quandary is shared by many states: Demand for health services is growing and states are cutting Medicaid budgets for the poor and disabled. Medicaid accounts for approximately 25 percent of state spending when federal matching dollars are included according to the National Association of State Budget Officers.

PLEASE DO NOT SIT BACK AND DO NOTHING. WOMAN AND CHILDREN NEED OUR HELP NOW. This is not a Republican, Democrat, or Independent position. This is the moral and ethical action to take now.
ACTION STEPS
1. Call your U.S. Senators -( U.S. Capitol Switchboard: 202-224-3121).
Ask to speak to your Senator's health legislative aide.
2. Call your State Governor, Senators and Representatives
3. Tell them you are NOT in support of cuts to women and children's health! The deficit can be reduced by cutting waste in other areas.
4. Please let Karen Fennell (AABC's lobbyist) know of your contacts with legislators.
Tell her who you talked with and any comments or additional information requested. Call Karen at 301-830-3910; Send email to fennell.karen.s@gmail.com

Suggested Talking Points

WIC Program: This is one of the most efficient programs to improve child nutrition. The program gives expectant mothers with very small children important education on how to eat healthy during their pregnancy and how to feed their children healthy meals. And it provides them with coupons to incentivize them to purchase the best foods for their children. Research shows that without this intervention the nutritional intake of these children would be higher in fats, salts and sugars, according to a recent U.S. Food and Nutrition Services study. Instead if spending $1,400 a month in extra medical care for an obese child, for just $41 per month this program shifts these mothers and children into healthy eating patterns, says the Centers for Disease Control and Prevention. Clearly, the WIC approach is a useful and relatively cheap way to stem the rising tide of childhood obesity and a healthy pregnancy.

Maternal and Child Health Block Program: The program has been cut by 30%. This program is the safety-net care for women and children. The block grant pays for child immunizations and prenatal care for tens of thousands women and children. It is obvious that without access to immunizations more dollars will have to be spent to care for kids sick with easily preventable illnesses. Reducing access to prenatal care is both life-threatening and costly. A preemie baby's health costs are 10 times higher than a full-term, healthy-weight child, according to the March of Dimes. It makes no sense to cut a program that has a proven track record of delivering health to babies and driving down America's health care costs.

Community Health Centers: Funding for community health centers will be cut in half. Senator Orrin Hatch (R-UT), who was a cosponsor of the legislation responding to President George W. Bush's call to expand funding for these centers in 2008, says that "since 2001, additional funding has allowed health centers in more than 750 communities nationwide to provide care to about four million new patients. These centers provide affordable and quality care to at-risk Americans who otherwise might have to might have to do without." As state by the Center for American Progress, "No health care costs will be avoided by cutting this $1 billion out of the budget because the absence of care doesn't stop you from getting sick. It simply means you get sicker and you turn up at the emergency room or hospitals when your illness has progressed to the point that you care needs are exorbitantly expensive.

State Medicaid Cuts: Most States have budget proposals to cut funding for Medicaid. Talk to staff about what you know best - health and costs implications of a lack of prenatal and newborn care. A useful resource is the article Ten Myths About Medicaid published by The Kaiser Commission on Medicaid and the Uninsured.
--

Jill Alliman, CNM, MSN

Chair, Legislative Committee

American Association of Birth Centers

Snow Baby

Guest article by Katie Tonarely

When Kara Kay started feeling crampy contractions on a Tuesday, she didn’t call a hospital or obstetrician. She didn’t have one. Instead, around 11 a.m. on Tuesday, February 1, Kara called her husband, Mike Benedict, and her Certified Professional Midwife, Deborah Smithey. Then, she sat back, enjoying the early feelings that she knew would eventually bring her her baby. While she waited comfortably inside, the worst blizzard in 100 years raged outside, and Deborah and Mike worked to make their way to Kara.

Choosing a Midwife
A hospital birth was never an option for Kara. “I’ve never been really comfortable with a hospital,” she says. “I never imagined I would have a birth in a hospital.” Mike agrees. After typical hospital experiences with his first two children, he was ready for a change. “It allows the father to be much more involved,” he says of his home birth experience.

A Certified Professional Midwife provides more in-depth care, Deborah says. Prenatal visits usually last an hour or more, and whatever is on the mom’s mind is up for discussion. Of course the CPM also checks how the mother is doing physically: blood pressure, pulse, fetal heart rate and growth. Midwives also focus on a lot on nutrition and overall health during pregnancy.

For Kara and Mike, the safety of home birth was a big factor for them, too. “I feel it’s safer overall, because there aren’t any doctors to force you to take unnecessary drugs or inventions that tend to cause more problems that solve them,” Mike says. Deborah cites a 2009 study that confirms these claims. The study, “Outcomes of Planned Home Births with Certified Professional Midwives: Large Prospective Study in North America” by Kenneth C Johnson and Betty-Anne Daviss, found that birth at home is safer, has better outcomes and fewer interventions.

Getting There
Mike knew the storm was coming and was planning to come home from work early anyway, but when he got the call from Kara, he left so he could get home to be with his wife. Getting there, though, proved to be a challenge, as the snow fell and cars and trucks slid into ditches on either side of the highway. “It was just white; you couldn’t see anything,” he said. After his own car ended up in a ditch, someone picked him up, but that car ended up in a ditch, too. Not really sure what he should do next, Mike started walking and running the mile-and-a-half home. “When I saw the tow-trucks and 18-wheelers stuck in the snow, I started to panic. That’s when I started to get anxious.” The couple of mile journey too him over an hour. “By that time, I was pretty nervous. I was ready to get home,” he says.

The midwife’s journey took even longer. She and her husband left Stockton at about 1 p.m. Normally, her drive to Carthage takes about an hour. They drove a four-wheel-drive truck to maneuver through the 13 inches of snow, with more falling by the minute. In the back seat of the truck, she had her midwifery supplies packed. “The roads became more and more treacherous as we went,” she says. “At one point, we couldn’t see the road at all.” To break through the snow drifts, they had to drive fast, but were also sure to go slow enough, so as not to lose control.

When they finally made it to the highway, they expected to it be clear. Normally, highway 71 is a four-lane highway, but only one lane was moving. “Semi-trucks and pick-ups were stranded on both sides of the road, and some were even stopped in the road,” Deborah says. “I have never seen anything like it.”

Deborah and her husband made it to Kara at 4:30 p.m. The one-hour journey took three hours.

Labor Land
Pregnant with her first, Kara expected a longer labor. Though the world outside was urgent with worries of weather and time, Kara sat comfortably in her home, not worried at all. “I just didn’t realize how bad the weather was,” she says. “I wasn’t concerned.”

As labor progressed through the afternoon and night, Kara used what she had learned in her Bradley Method class. She worked on breathing slowly and had visualizations and mantras ready to help her get through the tough times. “I’m just in labor land; I’m just passing through, “she repeated.

When it was finally time to push the next morning, February 2, Kara worked hard. She says, though, that she never felt the head descend. She counted on Mike and Deborah’s encouraging words. “I didn’t feel like I was getting anywhere,” she says.

Once the baby’s head came out, the midwife helped deliver the baby’s stuck shoulders. Called shoulder dystocia, this complication can be rather painful, yet Kara didn’t know it was happening until later. She continued to rely on her midwife’s encouragement. “Deborah reached up; it wasn’t invasive at all,” Mike says. “At that point, I was really glad that Deborah braved the storm.”

Snow Baby
Mike caught his daughter, Kaliyah Winter, at 7:49 a.m.. She weighed 9 pounds, 12 ounces. “I don’t think this experience will ever leave my mind,” he says.

For her post-partum care, Kara stayed put and was able to enjoy time with Kaliyah. “The midwife came to us,” Mike says. “I didn’t have to lug my baby out in the cold and snow.”

After she realized the snow’s devastation, Kara couldn’t help but be grateful for the midwifery model of care. “This just shows the dedication, loyalty and passion of midwives,” she says. “I’m totally thankful to Deborah and her husband.”


When there’s a natural disaster, Deborah asserts that midwives are best to handle birth. She asserts that it would be ideal for every Missouri county to have a Certified Professional Midwife ready to handle births in an emergency. “Common sense tells us that it would be far safer for a midwife to travel to a birthing mother then have a mother risk delivering along the side of the road in horrible conditions,” she says. In addition, CPMs are trained to handle common complications, such as cord entanglement, shoulder dystocia and post-partum hemorrhage.

For Mike and Kara, the intensity of the storm outside was nothing to compare to the positive feelings associated with bringing a new baby peacefully into the world. “It’s just a miracle, and I’m thankful everything turned out,” Kara says.

--
In addition to being a wife and mother to two boys with another due in May, Katie Tonarely spends her time writing for several publications, including Springfield, Missouri's "News-Leader" and "Moms Like Me." She also does web content writing for Demand Media Studios.

For more about homebirth and midwifery in Missouri see:
http://www.friendsofmomidwives.org

"Birth Witnesses" Guest Post

I very much enjoy maintaining the Citizens for Midwifery Facebook page. I share relevant quotes there almost every day and really appreciate the dynamic, vibrant responses I get from the various "likers" present on the page. Recently, I shared this quote:

“Please, choose your birth attendant and place of birth carefully. Search hard for the attendant that you connect well with. You and your baby deserve to be treated with utmost respect and dignity. There are attendants who believe in the sacredness and sanctity of birth. You may, however, need to act as a detective to find them.” –Janice Marsh-Prelesnik (The Roots of Natural Mothering)

This quote resonated with me because of the final line—I am very familiar with that feeling of needing to be a “detective” in order to unearth the kind of care needed/desired/deserved by my family. The quote then prompted some great comments about the value of inviting women (other than formal birth attendants) to witness our birth experiences—sisters, friends, nieces. A commenter named Bonnie shared her ideas that one of the very best ways for young women to learn what birth is really like is to be invited to witness a real birth. And, that this may be one of our most transformative keys to making true and lasting changes in our current birth culture. I was fascinated with her ideas and invited her to write a guest blog post about them. She graciously agreed and her wonderful article on the subject is now available to read here.

Enjoy!

--

Molly

CfM Blogger

Happy Holidays!

As you gather with your family for the 2010 Holiday Season, we wish you love, joy, and memories to last a lifetime, and we thank you for your support of Citizens for Midwifery. As we greet 2011, we hope every day brings new wonders and a promise of a more peaceful world for birthing women, babies, and families around the world.

Warmest Wishes!

--
Molly
CfM Blogger

CfM e-newsletter & FREE membership!

Citizens for Midwifery is pleased to have launched our new e-newsletter! You can read the newsletter online here. A printable version is available here. You can also subscribe to the newsletter via Facebook by going to the CfM Facebook page and clicking on the tab that says Email Signup.

An especially important announcement from this first edition is that membership in Citizens for Midwifery is now FREE! Here are the details:

Anyone who signs up with CfM either on our signup page, on Facebook, or CfM’s “Grassroots News” yahoo group will now all be considered members of CfM and will receive the free CfM e-news. In this day and age of social networking the concept of CfM membership needed to evolve to include all the ways people communicate and participate in CfM’s activities. We hope you will be excited by this open membership structure and will encourage all your friends, clients, Facebook friends and associates to sign up for a free membership with CfM today.

Membership is now free, but CfM still needs your financial support. Please donate today! We are so grateful to all the individuals and midwifery practices who have been paid members with CfM over the years. Many of you have been faithful members for years. Your support has made all our work on behalf of consumers, midwifery, and the Midwives Model of Care possible. We hope you will continue to support CfM with an annual donation. If you are a midwife who has been giving “Gift Memberships” to your clients we hope you will continue to make a donation to CfM in honor of each of your clients and encourage your clients to sign up for free with CfM. Donations of any amount are greatly appreciated!

Your donations are fully tax deductible. Donate at our suggested giving levels, or in any amount you can. Donate today on the CfM website or by mail Thank you for your support.

Grassroots Network: Effective Health Care Program Update: New Draft Key Questions and a Draft Review Are Now Available for Comment

Dear Friends,

The federal Agency for Healthcare Research and Quality (AHRQ) is preparing a review document about “interventions” that are effective in reducing cesarean sections, and all of us have a chance to give input!

ARHQ has drafted 4 key questions for members of the public to answer on-line, plus you can also upload a document. Go to: < http://www.effectivehealthcare.ahrq.gov/index.cfm/research-available-for-comment/comment-key-questions/?pageaction=displayquestions&topicid=263&questionset=147 >.

Scroll down below the questions to read the draft review (not too long). This will help you to see where they are starting from. For example, the word “intervention” is really used to denote any action (or non-action) that is being studied for its effect on reducing cesarean rates, even if you don’t normally think of it as an intervention. Also, it is apparent that routine hospital practices (that we know can interfere with labor) aren’t really mentioned in the list of “interventions”…

NOTE: The deadline for comments is December 29!

Wonderful that AHRQ is looking seriously at the topic of how to reduce the cesarean section rate, and that they are inviting comments from the public! I would encourage you to be respectful and informative in your comments, so that they are helpful and useful for the purpose of this review.

Please feel free to pass this on to other relevant lists you may be on!

Sincerely,

Susan Hodges, “gatekeeper”
For CfM

Grassroots Network: Premature birth rate down

Hello Friends,

We hope you all enjoyed a wonderful Thanksgiving holiday!

This grassroots news message contains good news! According to March of Dimes analysis of 2008 birth data, the United States rate of premature births, or babies born before 37 weeks gestation, has declined for the second year in a row. This two-year decline comes after a 30-year increase in the rate of premature births. In 2006, the rate was 12.8% and in 2008, the rate fell to 12.3%.

Below is a link to a report from USA today that offers a more detailed description of the decline. We also include the link to the March of Dimes news source that not only notes the decline in premature births for 2008, but also includes an update on the state of births in 2010 as well as information on efforts to further decrease the number of babies born prematurely in the US. As you'll see in both articles, the decline is largely attributed to policy changes that prevent cesarean sections and labor inductions before 39 weeks gestation.

USA Today: http://www.usatoday.com/yourlife/parenting-family/babies/2010-11-18-premature18_ST_N.htm

March of Dimes: http://www.marchofdimes.com/nov17_2010.html

We hope you all continue to send us information that you wish to share with the group. We can be reached at info@cfmidwifery.org.

Sincerely,
Stephanie Hucker for Citizens for Midwifery