Category — Advocacy

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.

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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?

Start with two lemons: Two bills introduced by a freshman Delegate from Harrisonburg who “loves midwives” but lends his ear to obstetricians in his community who feel quite differently.

Throw out the rotten fruit: HB 2167- a bill intended to eliminate VBAC births at home but written in a way that singled out low-income women from accessing midwives for normal birth after cesarean birth.  Happily, the strong surge of consitituent phone calls, emails, and letters to the Delegates of the General Assembly put a prompt end to this bill in the Health, Welfare, and Institutions (HWI) committee.

Re-examine remaining fruit: HB 2163- a bill that requires the regulations of Certified Professional Midwives in Virginia to include discussing information about risks associated with VBAC, twins, breech, and “other high risk pregnancies” was upheld by the HWI committee on the same day.  The lesser of two evils, this bill is redundant and sets a higher standard for informed choice for midwives than any other profession.

Slice through the skin and squeeze the juice: “Higher standard of informed choice for the profession of midwifery”.  Isn’t this what we have been trying to say all along?  Informed Choice is the hallmark of midwifery care.  How can we oppose a bill that clarifies that for us?  The concern is that the Board of Medicine will get to oversee the development of standardized documents…what will they require us to say?

Add Sugar: How about making the bill better, stronger, and able to leap tall buildings?  Why not clarify that the information the CPM gives her client be “evidence-based“? If accepted, this phrase would be precedent setting in VA statute. Imagine if ALL informed choice were evidenced-based?  Imagine if the Board of Medicine reviewed all practitioners based on evidenced-based practice rather than community standard of care, which is often driven by defensive medicine and convienience. The bill then changes from redundant to strenthening of the Midwives Model of Care.

Add water, and maybe a few other fruits: While we’re at it, let’s try to fix another problem that the Board of Medicine is having with the practice of midwifery.  Our statue specifies that a woman cannot be required to seek the care of another health care professional during her care with a midwife.  This was included by wise individuals who knew that in other states that license midwives, a requirement for a woman to be evaluated by physician in order to have a home birth was an obstacle to practice as no physician would be willing to assume liablity for the outcome of his/her “approval”.  This phrase in the statute, however, prevented the Board of Medicine (BOM) from moving forward with its NOIRA request last February  (scroll to 2008 action alerts at this link) to set limits on the scope of practice for CPMs. This came up at last Friday’s Midwifery Advisory Board meeting.  The BOM has a lengthy process for determining that a change in statute is necessary, but an end result of a recommendation for removal of the phrase that blocked their NOIRA is not something that we want.  The midwives think a better solution is to use the bill that is before us to give a compromise to the Board.  How about if we clarify what we already do in situations that involve potential risks in  pregnancy and birth: offer options for consultation or referral to a physician as part of our informed choice?  This gets at the heart of the cultural divide between physicians and the midwifery community.  The opponents of home birth genuinely believe that midwives can’t possibly be giving women informed choice that includes risks and we are potentially even keeping them from seeing physicians in a timely manner by not offering or facilitating consultation or transfer of care.  Midwives say they get little or no support in some communities in Virginia (Charlottesville is not in that category, UVA is a FABULOUS model for good collaborative relationships) when they do try to consult.  Many OBs don’t want our clients and they refuse our calls for appointments. Something needs to change and while we don’t want to fix our problems through legislation, this bill is moving forward and there is an opportunity to offer a gesture towards a peace process by reiterating consultation and referral as part of informed choice.

Stir and serve: A draft amendment (which would technically be called a “substitute”) has been offered to Delegate Lohr.  Along with lobbyists from the Medical Society and VA ACOG, Delegate Lohr has agreed to amend his bill at the request of the Commonwealth Midwives Alliance.  The VABirthPAC Board of Directors has also reviewed and approved the new language.  Now, we offer it to the rest of the Commonwealth in the hopes that you will also agree that this is a worthy bill.  We have the opportunity to have an historic precedent….medicine and midwifery on the same side of a bill.  We hope that this gesture will move us forward to the necessary place of problem solving, rather than fighting at the Board of Medicine and in Virginia communities.

The proposed substitute language will be voted and (hopefully) adopted this Thursday by the Senate Health Licensing Subcommittee.

Please contact Delegate Lohr today to let him know that you support the substitute amendment for HB 2163 and to thank him for listening to midwives.
You can also contact the members of the Senate Health and Education Committee to let them know that they should support HB 2163, with the substitute.

Thanks for all you do for birth-

Brynne

UPDATE: HB 2163 passesd the Senate Health Licensing Subcommittee with a unanimous vote on Thursday, February 12.

Since your bill would essentially mandate surgery for the underprivileged women in your community, I highly encourage you to become educated about the risks of cesarean section, especially when a woman has more than one.  The maternal death rate is rising in our country.  The CDC has acknowledged that the death rates are actually under reported and that many of these deaths are attributed to the rising c-section rate and the associated complications for future pregnancies.

Dear Delegate Lohr:
 
Thank you for your prompt reply and your attention to this important issue of access to midwifery care. I appreciate your willingness both to hear and act upon some of the items we discussed this week. Thank you for your promise to pull HB 2163 from the docket.

I am looking forward to reviewing your amendments to HB 2167.  Without seeing the actual wording, I remain a bit unclear as to how this bill will affect CPM practice. As I discussed on Wednesday, the issue of VBAC (vaginal birth after cesarean) is an evolving area of medical and cultural understanding. Since the scientific and medical experts still disagree about the best route for a woman to take for all of her birth options, l contend that legislation seems premature.  The next several years would be expected to bring about emerging information that will help to inform the most evidenced based decision making for women and their providers.

When we understand that the rate of uterine rupture (the primary concern among some obstetricians for VBAC deliveries) is 27 out of 10,000, we know that 400 women will need a repeat c-section to prevent 1 uterine rupture during labor. Since uterine rupture itself has varied degrees of severity and since midwives do not induce or augment labor and because they provide constant, hands-on care and one-on-one monitoring to identify the slightest variation in heart tones well before they become a problem and take appropriate measures to stabilize or transport, many researchers, mothers and Virginia DMAS have all made the evidenced-based decision that Home VBAC (or HBAC) is a reasonable choice for families to consider. Every study has shown that when providers follow these guidelines, the risks associated with VBAC are reduced to the very same level as for other extremely rare events, all of which CPMs are trained to identify and assess well before they become emergencies. Link to Research on Uterine Rupture

I make the comparison between VBAC at home and repeat c-section because the option of VBAC in hospital is not available to many women in the Commonwealth.  Many hospitals and providers in Virginia have “No VBAC” policies, which leaves women no other choice but to stay out of the hospital for their normal birth.  Since your bill would essentially mandate surgery for the underprivileged women in your community, I highly encourage you to become educated about the risks of cesarean section, especially when a woman has more than one.  The maternal death rate is rising in our country.  The CDC has acknowledged that the death rates are actually under reported and that many of these deaths are attributed to the rising c-section rate and the associated complications for future pregnancies. When you factor in the reality that many of your constituents plan very large families, the physical and financial burdens of 5-10 future surgeries is staggering.  [Read more →]