A soapbox of two midwives practicing in Central Virginia..

Suzie contemplating her potential...

When President Obama signed part two of the Health Care Reform Legislation [The Health Care and Education Reconciliation Act of 2010 ("Reconciliation Bill")] on March 30th, a provision of the FSLA (Fair Labor Standards Act) was amended to require employers to provide space for working moms who need to express breast milk.

A new paragraph (r) is added to Section 7 of the FLSA that requires employers to provide unpaid, reasonable break time for nursing mothers to express breast milk, as such employee has need to express the milk, for one year after the child’s birth and a place to express the milk “other than a bathroom, that is shielded from view and free from intrusion.” An employer with less than 50 employees will not be required to implement this provision if doing so would cause the employer an “undue hardship.”

This provision is effective immediately.

A great step for healthy babies.

How many of you have pumped milk or nursed your baby in a bathroom?

Mountain View Midwives has moved.  We are no longer nestled in the womb of Brynne’s basement and have emerged into a real, live commercial space.  Our new home at 1111 Rose Hill Drive, Suite #1 has lots of sunshine and some extra space for gathering.  Join our facebook fan page to get news of our planned Open House (May 1!), Yoga Classes, Postpartum Moms Group, Home Birth Meetup, and more.

Not in the opinion of the Commonwealth of Virginia.
As a follow up to last year’s passage of legislation that would require evidence-based informed consent for all women seeking home birth Evidence Based-It’s Now the Law, the Virginia Regulatory Townhall posted the first of two public comment opportunities.
Please read the following open letter to Midwifery Advocates and take a moment to post a comment to the Commonwealth of Virginia regarding your thoughts on informed choice in maternity care.

Dear Midwifery Advocates, Researchers, and Educators -

I am writing on behalf of the Certified Professional Midwives licensed in Virginia to ask for your support involving establishment of regulatory precedent for evidenced-based informed consent for women seeking maternity care.  As some of you may already know, last year the VA General Assembly passed a bill that required CPMs to provided evidenced-based informed disclosure to all women seeking home birth. You can read the history of how this happened here:  http://midwifemonologues.com/making-lemonade-a-recipe-to-support-hb-2163/

Risk factors that were listed in the law included vbac, twins, and breech presentation but also allowed for “other high risk pregnancies”.  The law does not state that these conditions would prohibit CPMs from attending a woman at home, just that the CPM will be required to provide clear, evidence-based informed consent before doing so.

The process that follows a statutory mandate for regulatory change in Virginia is open to the public and participation is simple.  The notice of intended regulatory action (NOIRA) has recently been posted to the Virginia Townhall Website.  The summary and details of the guidelines for this regulatory change are listed in a pdf (here) and there is now a 30 day public comment period.  Comments can be submitted by any member of the public, both in Virginia and outside of the state.

[Read more →]

Leave it to those coffee loving, fault line dwelling northwesterners to come up with a brilliant new twist on lowering incentives for unneccessary c-sections.

Beginning this month, the state of Washington will pay hospitals the same amount for an uncomplicated C-section as for a complicated vaginal birth when it reimburses them through Medicaid. Almost half of all births in Washington are paid by Medicaid, so this measure will have a significant effect on the economics of birth in the state.

Take away the incentives for too many c-sections By Carolyn McConnell

This is a great example of ways we can reform healthcare be envisioning a system that rewards lower interventions, lower costs, and better outcomes. Check out the MAMA Campaign (Midwives and Mothers in Action) to find out how to get involved in ensuring that midwifery care is on track to be a part of the health care reform train.

This summer, scores of midwives and advocates are working relentlessly to lobby federal lawmakers as they draft language for the Health Care Reform bill. The Obama administration has promised Americans a new law by fall of this year and Congress is working all summer on multiple versions of an omnibus bill that will bring sweeping changes to our health care system…maybe.

Though a reading of tea leaves is probably still the best way to predict what will actually pass into law, Certified Professional Midwives are aiming to be part of the brew.  By getting CPMs listed as eligible Medicaid providers in each and every version of the Health Reform bill, the new MAMA Campaign (a coalition of organizations representing midwives and consumers) is forging a path that will bring multiple benefits to women seeking midwifery care from CPMs all across the country.

Please join the MAMA Campaign and pledge your support to this historic opportunity for midwifery in the US.  Read more about the benefits of federal recognition of the CPM and the organizations that have come together to endorse this important work.

An incredibly bold and insightful article from a US Obstetrician.  If there are physicians like this within the bureaucracy, then there is hope for our future.  Please pass this along and send this woman some huzzahs! The following wins the Midwife Monologues award for “Best Quote of the Year”:

Industrial obstetrics strips the locus of power definitively away from women. The history of childbirth in America reflects a persistent trend of increased control by physicians and increased medicalization. Childbirth moves, first, out of the home, and now out of the vagina. Stipulate that antibiotics and blood banks are good and necessary things, and that emergencies may, in fact, develop: still, the majority of births will be normal. Or they would be, without interference. The species that cannot birth its young becomes extinct. But fear has pushed nearly all American childbirth into the hospital, a campaign which continues even now that that battle looks to have been won. (American College of Obstetricians and Gynecologists, 2008)

Still, despite the implied promise of safety if all the rules are followed—ID bracelets, intravenous lines, electronic fetal monitoring—labor may follow an unpredictable path. The definition of “normal” becomes ever narrower, and toleration of deviance ever lower. The final stage of this philosophy takes the process of birth away from the woman entirely and turns it into a surgical procedure performed by the doctor. Childbirth becomes a manufactured experience, shorn of any real risk or real power, one in which the woman is so far alienated from the capabilities of her body that she is only a package on an operating table for a professional to open.

Plante LA. Mommy, What Did You Do in the Industrial Revolution? Meditations on the Rising Cesarean Rate. The International Journal of Feminist Approaches to Bioethics. Spring 2009;2(1):140-147. DOI: 10.2979/FAB.2009.2.1.140

More highlights:

The cesarean rate in the US has been rising for decades, and in 2006 hit an all-time high of 31% (Hamilton, 2007.) This record is likely to stand for only a brief time, that is, until figures are released for 2007. Can it really be that one-third of women are unable to birth without high-level technological support? And is there an endpoint in sight? “In the next decade or so the industrial revolution in obstetrics could make Cesarean delivery consistently safer than the birth process that evolution gave us.” (Gawande, 2006,8) Against such an argument, who could hope to stand?

Gawande makes a case for the standardization of obstetrics. “You seek reliability. You begin to wonder whether forty-two thousand obstetricians … could really master all these techniques … obstetricians decided that they needed a simpler, more predictable way to intervene when a laboring mother ran into trouble. They found it in the Cesarean section.” (7) He suggests that techniques for effecting vaginal delivery—maneuvers to reduce a shoulder dystocia, deliver a breech baby, assist delivery with forceps—are so subject to variations in skill that they cannot be standardized for reliably good outcomes, while the cesarean operation is commonplace and consistent. It is, if you will, the least common denominator: every obstetrician knows how to perform one. While this is a fascinating perspective on the changing of obstetrical practice, for those of us who actually work on a busy obstetrical unit industrialized childbirth conjures up images of the factory floor.

The drive toward fewer delivery options appears at first glance to be supported by upper-middle-class women, who have the least number of social and economic obstacles to autonomy. In fact, cynical staff at hospitals delivering large numbers of well-insured upper-middle-class women often refer to their institutions as baby factories: these are the places in which cesarean rates are highest. It is, after all, a paradox: women with higher incomes, higher levels of education, and commercial insurance have higher rates of cesarean delivery. If cesarean is a response to any perceived risk, why would women at statistically lower risk of a poor outcome have higher cesarean delivery rates? New Jersey has the highest cesarean rate among states, (Denk 2006) but no lower levels of maternal or perinatal mortality. (MacDorman 2007, CDC 1999) What it does have, however, is the highest median household income. (Census Bureau 2007)

And then she goes on to support the choice for homebirth!

Let us enumerate what a full spectrum of childbirth choices entails. Women can give birth at home unaided; at home with family or with trained assistance; in a birth center, either freestanding or hospital-based; in the hospital delivery room with trained assistance; or in the operating room where they are acted upon. But of all these choices, extending across the entire range of reliance upon the medical profession (from none to total), exercising the options at the end of the spectrum where the physician has the least sway will get women the least support. The American College of Obstetricians and Gynecologists calumniates not only women who want a home birth but anyone who advocates leaving that option open. (American College of Obstetricians and Gynecologists, 2008.) Once in the hospital, women who might like to exercise their right to self-determination by choosing vaginal birth after cesarean, or vaginal breech delivery, will have a hard time of it. (Leeman and Plante, 2006) Is it not the opposite of autonomy to support only those choices which increase the woman’s reliance upon the physician?

Click on the picture to support apprentice trained midwives

A recently revised Position Statement from the American College of Nurse Midwives (ACNM) seeks to limit recognition of midwifery providers to those who have received their training through government accredited programs. The North American Registry of Midwives (NARM) oversees the credentialing of midwives who have received their training through time honored and evidenced based systems that emphasize clinical competency over all other criteria (Certified Professional Midwives-CPMs).

NARM has posted an online petition in an effort to organize our voices and convince the ACNM to reconsider its position on apprentice trained midwives.  This letter seeks to unite US Midwifery under the common goal of providing women with access to the provider and setting of their choice for birth.

There are many great opportunities mounting to move midwifery forward on both the state and national level.  We must stand together as a community of midwives if we are going to have a real voice for change in maternity care. Whether you are a CPM, CNM, a midwifery consumer, advocate, or none of the above, please go to : http://www.thepetitionsite.com/1/support-evidenced-based-midwifery-education to read more details about this issue and sign the petition to make your voice heard.

Learn the outcome of the petition. Sign up to receive an email update.

Please take a moment to comment on this article about the struggle to practice evidenced based care in the medical community. Believing in Treatments That Don’t Work
Here is my favorite quote:

Treatment based on ideology is alluring. Surgeries to repair the knee should work. A syrup to reduce cough should help. Calming the straining heart should save lives. But the uncomfortable truth is that many expensive, invasive interventions are of little or no benefit and cause potentially uncomfortable, costly, and dangerous side effects and complications.

Does anyone else see some of the missing examples?  How about bed rest for preterm labor, induction for post dates or macrosomia, or universal gestational diabetes screening as a start?

On March 30 Governer Kaine signed HB 2163, giving final approval to a bill that will set an historic precedent for setting standards for informed choice in maternity care.  Effective July 1, 2009, regulations for Certified Professional Midwives will require that midwives disclose to their clients “evidenced based information” about the risks associated with vbac, breech, and twin deliveries occuring at home or birth centers. Get your reading glasses on everyone, you’re gonna be getting even more stuff to read from your midwife!

Midwives and home birth consumers originally opposed the bill introduced by Delegate Matt Lohr (R), Harrisonburg, because it showed a lack of understanding that the hallmark of midwifery care is already education and informed choice.  Another injustice was that it’s wording implies that only the risks associated with home birth (and not hospital birth) need to be addressed by the Commonwealth as priority issues. Many advocates wondered why women in medical practices aren’t being told of the risks associated, now and for future pregnancies,  with elective repeat cesearean section.  In fact, they aren’t even being given the opportunity to choose between relative risks. (see article on VBAC Bans)

When the midwives asked Delegate Lohr to add the qualifier “evidence based” to the language of the bill, we found ourselves more able to accept the redundant legislation in the hopes that it will not only provide some measure of education and reassurance about the Midwives Model of Care to the medical community but it will also create a legislative model for a standard for informed choice for all other health professionals.

Another great result of this unexpected drama at the General Assembly…a renewal of energy for the midwifery grassroots network in Virginia.  It was pretty amazing to see how quickly we can muster our forces to fight back against any efforts to restrict access to midwifery care in Virginia.  We renewed our connections through the VA Birth PAC listserv and also saw the new technologies of blogs, facebook, and even twitter giving us the much needed connections to all of the people who care about birth.  Perhaps most important, we showed the legislators and the medical community that our community remains a powerful force and that respectful communication and open dialogue will bring the most success in the ongoing struggle to understand how to integrate midwifery care into the existing healthcare system.

Way to go everyone!

Mother's protesting VBAC bans in Santa Barbara, CA

It was enough of a pleasant surprise when Consumer Reports analyzed maternity care in the US and gave the midwives model top ranking,”Maternity Care: High-tech vs high-touch“.  But when the stodgy and mainsteam biased Time Magazine comes out with a story this week in the Health and Science section titled “The Trouble with Repeat Cesareans“, you know the truth can no longer be suppressed by obstetric communities that refuse to practice evidence-based care.
There are many communities in Virginia where hospital or provider “VBAC Bans” are greatly impacting women’s choices for natural birth.  How can we have come to a place where we are mandating major abdominal surgery for mothers when the evidence shows that it is harmful? And more importantly, how do we get out of it?