As an advocate for US midwifery and women’s health, I recently had the opportunity to be temporarily lifted out of the trenches of our national battle for access to midwifery care.  As an Observer member of the Midwives Alliance of North America (MANA) delegation to the International Confederation of Midwives (ICM) Council I was given the opportunity to attend the 4-day meeting of the ICM Council at which historic decisions were made for the future of midwifery across the globe.  As a Congress [conference] Delegate, sent by my partners in Private Practice to network and learn about charting requirements and global issues as we continue to design and develop software for midwives, I was able to gain a perspective on the work that we do in the trenches.  Trenches that become so deep at times that we can no longer see the field or a “vision” of what it would look or feel like to no longer be digging.

The importance of a cohesive vision for any movement can sometimes be overlooked when we are shoveling “dirt” that seems to be piling back into our trench faster than we can move it out.  For a country like the US with a mainstream maternity model that is antagonistic to midwifery, the vision becomes very narrow and more of a battle strategy as we fight for the survival of our profession and the integrity of normal birth.

As a midwife who has been entrenched for more than 15 years in the consuming work of battling over birth in the US, the vision articulated by ICM sounded at first to me like so many organizational visions…too broad and ambitious to be realistic.

“ICM envisions a world where every childbearing woman has access to a midwife’s care for herself and her newborn.”  ICM Vision Statement

As those of us involved in organizational work know, what follows a vision is generally a mission, or purpose for organizing:

ICM’s Mission-To strengthen member associations and to advance the profession of midwifery globally by promoting autonomous midwives as the most appropriate caregivers for childbearing women and in keeping birth normal, in order to enhance the reproductive health of women, and the health of their newborn and their families.

Sounds great, but how does a vision and mission like that translate into anything but a cheering squad while we keep up our digging? Especially when you consider that the steps each member association or country would need to take to reach this common goal would be unique and wrought with different challenges. When the digging of the trench nearby inadvertanly throws more dirt into our own, it can lead to internal turf battles and stuggles over principles and purpose. In the United States where this has happened among midwives too many times to count, how can we come together on the steps to take and why should we spend the time trying?

We should come together because mothers and babies are dying at an alarming rate in most of the world. As an American midwife who cares for a predominately healthy, white, middle-class population in a community with access to multi-levels of maternity care, attending a global midwifery conference in a country with maternal mortality rates that are 14 times that of the US was sobering. [1] The paradox of the overuse of medical interventions being a driving force for midwifery in the US with the lack of access to vital, life saving interventions for most of the world’s mothers driving the promotion of midwifery globally is as significant as it is startling.

The Big Picture

In 2008, ICM reflected on its mission and then took steps to address maternal mortality as a primary issue.  By strengthening midwifery in developing countries that face severe issues of mortality and morbidity for mothers and babies, the ICM hopes to move closer to its vision of a midwife for every mother. One symbolic and tangible step was to plan for it’s first ever conference in Africa, specifically sub-Saharan Africa which bears a huge percent of the global burden of maternal and newborn death.

Rebecca Ullman is a certified nurse midwife from Oregon state. She retired from 23 years in a hospital based private practice and traveled to Niger to work with midwives.  Sitting with her at dinner in a café in Durban, South Africa, I was educated on the reality of the high stillbirth rate as an everyday occurrence for midwives, women and families in the developing world.

“While there is always joy in delivering babies, in Niger, that joy is mixed with the sadness and grief that is all too prevalent when childbirth becomes dangerous for mothers and babies because of poor health conditions and poverty.  During my three weeks in Niger, I delivered more stillborn babies than live ones.  We can only imagine the toll that puts on health workers, women, their families, the community and the nation.”

During a presentation about charting and clinical assessment using the WHO partograph, I learned that a typical provider/patient ratio on a labor unit is 3 to 25 in Ghana. Constancia Atachie, Prinicipal Nursing Officer with the Ghana Ministry of Health described conditions in a typical hospital where she worked and conducted research.

“You are literally running from bed to bed, sometimes carrying a new baby under your arm as you race to the operating theatre with another woman. Babies keep coming and you never stop until your shift ends and you do it all again the next day.”

Access to midwifery care is a big issue for us in the US, but access to any care at all is the bigger issue for most of Africa and the developing world.  As we dig in our trenches dedicated to development of the midwifery profession in the US, we need to understand that not only could our efforts be contributing to a more cohesive vision for global midwifery, but also our resources could be shared in ways that we can’t even imagine unless we are listening to the voices of midwives from across borders and oceans.

First Steps on a Path to a Vision

At ICM, Debbie Pulley, CPM, shares information at the MANA Booth with midwives from Sierra Leone.

It was with these images in my mind that I looked to the steps toward the vision being presented by the leadership of ICM at this Congress.  ICM is stepping up to lend its voice in a powerful way to the World Health Organization (WHO) and the United Nations Population Fund (UNFPA) in their efforts to promote midwifery care as a means to reduce maternal mortality.  The voice is coming in the form of a set of Global Standards, Competencies, and Tools that were developed and designed to guide the leaders of the world in the development, implementation, and promotion of midwifery in their countries.

ICM sees these core documents as “pillars” of its global effort to provide high quality, evidence-based health services for women, newborns, and childbearing families. These “pillars” were developed over the last 3 years by expert Task Forces and were adopted by the Council of Delegates in Durban last month. They include:

• Updated Essential Competencies for Basic Midwifery Practice
• Global Standards for Midwifery Education and Companion Guidelines
• Global Standards for Midwifery Regulation
• and a new tool for strengthening Midwifery Associations, the Member Association Capacity Assessment Tool (MACAT).

US Delegates to ICM Council in Durban. Holly Powell-Kennedy, ACNM President, Melissa Avery, ACNM Past President, Diane Holzer, MANA Past President and Geradine Simkins, MANA President.

In the months to come, US midwives will be having important conversations about the impact of these standards on our models of midwifery and our current and future efforts to move forward as part of this new vision.  There is much to digest and reflect upon, but some immediate highlights of challenges and triumphs from the documents include the separation of nursing from midwifery, autonomous regulation, and access to training and education that allows for a scope of practice that honors the central role between mother and midwife and the primary care relationship.

Though some of the standards might cause a struggle for many US midwives to support, if we can understand the context for the inclusion it may become easier to keep a shared vision for the future.  Since we are not in a position to imagine a system that could allow for autonomous regulation or access to adequate midwifery education for direct entry midwives in all 50 states, it makes it hard for us to embrace documents that set these kinds of standards for our profession. When we read that the basic skills of a midwife should include things like HIV treatment, pharmacologic augmentation of labor, and pharmacologic pain relief in labor, we can’t help but wonder how this would relate to midwives who provide care in out-of-hospital settings in the US. As we review these documents together we must keep in mind two important things:

1. In most of the developing world, midwives do not have a higher-level provider to refer to in their community.  Referrals and transfers of care take place over hours of travel, and often there is not time or resources to make the trip.  These standards will be invaluable tools for those countries that are in the process of establishing midwifery as a profession through internationally funded projects. Whatever the midwives are trained to do will be the extent of the care most women and babies in the world will receive.
2. These standards are a vision, not a mandate.  We have an opportunity to lend our voices to the ongoing development of guidance and companion documents for each of the standards.  The council was told by outgoing ICM President, Bridget Lynch, “These are living documents.  Take them into your communities.  Understand them, live with them, and bring back your thoughts to the next Congress (2014 in Prague!).”

Digging our trenches
Playing on the beach as a kid, my brother and I used to dig holes in the sand around our castles.  As we dug our trenches, we aimed our digging for each other.  We had to dig to the same depth and start our turn towards the same spot at the same time.  I still remember the funny thrill of getting closer and closer with our arms until we finally broke through and I felt his digging fingers wiggling at the tips of mine.  We would join hands inside our own trenches and thrill at the ocean waters now flowing back and forth between our projects.

Watching other countries touching fingertips as they merge their visions within their own systems created a bit of a longing for me and a new perspective about the unique challenges we face here in the US.  In the context of Canada, New Zealand, and even most developing countries, we really have an incomparable health system. In fact, in the context of these documents it might be fair to say that we have no health system.  We are unique in our array of 50 different regulatory bodies that create different definitions, designations, and limitation for all types of midwives.  Canada has a health system that provides for health care for all of is citizens. New Zealand has no malpractice insurance issues because health providers can’t be sued in that country.  We are a “high-resource” country with models of care that are more in line with “low-resource” countries in terms of a lack access to quality care for all of our citizens.

Looking to ourselves and visioning our future for US midwifery
Midwifery has been fighting for survival for more than 100 years in the US.  This has resulted in a significant lack of access to training in a model of care that we all agree needs to be preserved and resurged as standard for all maternity providers to integrate and utilize.  We don’t have enough midwives to train the workforce needed. The result is that we have aspiring midwives spending years and countless dollars learning to be nurses before they can become midwives or leaving the country to gain training in out of hospital birth in foreign context and cultures.  How will we integrate those experiences for young midwives as they return from Haiti, Africa, and Indonesia?  How will we move forward with our vision to unify US midwives and grow our profession while still maintaining the integrity of our foremothers efforts to keep birth normal by keeping it simple?  How can we reconcile our converging priorities and unique challenges with the rest of the world?

If we want to be part of the global vision, the first step is in understanding it.  When we can appropriately place ourselves in the global context, we not only gain tools to understanding our unique obstacles and challenges, but we also discover opportunities for strengthening our purpose and our profession. Taking time to read through the ICM core documents should be a priority for all practicing midwives and midwifery advocates in the US.  Alongside these documents, the newly released UNFPA report, The State of the World’s Midwifery, Delivering Health, Saving Lives gives the much-needed global context to understanding the ICM vision.

Complete Lunar Eclipse

Witnessing the full lunar eclipse over the Indian Ocean was a symbolic moment for many of us. A reminder to be humble, to remember that there are greater forces at work, and that we all share one magestic world. The Road to Durban was a worthwhile trip but it will be the journey home that will prove to be most important step towards uniting midwives around the world.

1. Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, Makela SM, Lopez AD, Lozano R, Murray CJL. Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5. The Lancet. 2010 Apr 12; 375:1609–23.

Sunrise over the Indian Ocean. Durban, South Africa. June 14 2011

I recently had the opportunity to travel to South Africa as part of a delegation for the Midwives Alliance of North America as an Observer to the International Confederation of Midwives (ICM) Triennial Council meeting. I had the unique privilege of listening and learning about the organizational processes that unfold as midwifery leaders from over 50 member countries meet and work together to move midwifery forward on the global level. The Council business meeting preceded the Congress, which was an historic conference of over 3000 midwives from as far as Afghanistan and as near as Zimbabwe.  As the first ever ICM Congress held in Africa, and with over 1000 midwives from South Africa alone in attendance, the milestones, themes, message, and vision were focused on the greatest threats to our global society: maternal and infant mortality and the contributing factors that lead to it.

Part 1: Is Freedom a Theory of Relativity?

The start of my journey to Africa included a layover in the heart of the empire that gave birth to the former colonies of my homeland and my destination. The irony of the unintentional connection to have a visit in London at the start of a journey towards new understanding about the connections between women in all cultures was highlighted by our stumbling upon a global phenomenon in support of women happening in Trafalgar Square. While the Sluts Rally [1], an international series of protests spawned from the negligent comments of a Canadian police officer regarding the relationship of proper dress code and sexual assault, may seem like a frivolous feminist effort, there is significant connection when we understand that cultural colonization continues it’s global creep.

Sluts Rally, Trafalgar Square, London, UK June 11, 2011

How can a rally in Trafalgar Square that seems on the surface to be demanding the right of women to wear their underwear in public without harassment mean something to women in South Africa who live in a country that leads the world in rape crimes?

Rape Statistics: South Africa, US, and UK

• It is estimated that a woman born in South Africa has a greater chance of being raped than learning how to read. [2] One in three of the 4,000 women questioned by the Community of Information, Empowerment and Transparency said they had been raped in the past year.[3]
• More than 25% of a sample of 1,738 South African men from the KwaZulu-Natal (Durban) and Eastern Cape Provinces admitted when anonymously questioned to raping someone; of those, nearly half said they had raped more than one person, according to a non-peer reviewed policy brief issued by the Medical Research Council (MRC). [4]
• According to United States Department of Justice document Criminal Victimization in the United States, there were overall 191,670 victims of rape or sexual assault reported in 2005. 1 of 6 U.S. women has experienced an attempted or completed rape. From 2000-2005, 59% of rapes were not reported to law enforcement.[5][6]
• According to a news report on BBC One presented in 12 November 2007, there were 85,000 women raped in the UK in the previous year, equating to about 230 cases every day. According to that report one of every 200 women in the UK was raped in 2006. The report also showed that only 800 persons were convicted in rape crimes that same year.[7]

It is indeed sobering to realize that many of our common bonds with the women of South Africa are in the shared threats of sexual assault, exploitation, and access to quality maternity care. It would seem that the ties that bind are less of an issue of resource and more of an issue of society.  A lack of priority for the issues that face women in the world crosses country and culture.

International Confederation of Midwives Walk to Durban
This sense of international despair for our future was transformed in a rally of hope as thousands of midwives from all over the world arrived in South Africa and joined together in a Walk to Durban in an effort to highlight the focus of the World Health Organization (WHO) and the United Nations Population Fund (UNFPA) on midwives as the key to delivering health and saving lives of women and babies everywhere. We may be the key, but the lock can only be turned with significant support for access to midwifery education, autonomous midwifery regulation, and strong professional associations that will serve to bring back the ancient art of providing safe and effective maternity care with each woman at the center of the system that serves her.

Today is Independence Day in the United States.  A day to celebrate the hard earned freedoms that we generally take for granted.  For those of us who live in the safety nets of protected environments, let’s take a moment to envision our nets spreading to women all over the world.  Envision a world where all childbearing women are safe from rape, HIV, postpartum hemorrhage, fistulas, sepsis, and death.  Every woman can stand together for this most inalienable human right.

Up Next:

ICM, An Organization With a Vision

____________

Resources:

[1] http://wearechangetoronto.org/2011/04/10/solidarity-slut-walk-london-ontario/

[2] http://news.bbc.co.uk/2/hi/africa/1909220.stm

[3] http://news.bbc.co.uk/2/hi/africa/258446.stm

[4] Jewkes, Rachel; Yandisa Sikweyiya1, Robert Morrell, Kristin Dunkle (2009) UNDERSTANDING MEN’S HEALTH AND USE OF VIOLENCE: INTERFACE OF RAPE AND HIV IN SOUTH AFRICA. South African Medical Research Council.

[5] http://www.rainn.org/statistics/

[6] Tjaden P, Thoennes N. Extent, nature, and consequences of intimate partner violence: findings from the National Violence Against Women Survey. Washington (DC): Department of Justice (US); 2000. Publication No.: NCJ 181867.

[7] http://www.bbc.co.uk/blogs/thereporters/markeaston/2008/07/rape_a_complex_crime.html

In a recent Washington Post article, [Midwife Karen Carr, convicted in Alexandria baby’s death, is under investigation in Md. May 13th] Carr commented, “institutionalization has taken the heart out of health care”. While this may be partly true, we also need to acknowledge that those same institutions provide a critical safety net for mothers and babies who both desire and deserve a satisfying birth experience and good outcomes outside of hospitals.

In that same article, Dr. George Macones (ACOG), made the erroneous statement, that: “The newborn death rate is two to three times higher for planned home births than for those that take place in hospitals”.  Actually, neonatal death is rare in home birth and no more frequent than low risk hospital birth. [1,2,3]

Macones is likely citing a statistic published in his organization’s revised position statement on home birth [4], which utilized a single meta-analysis published by Wax, et al.[5]  As described in a recent Medscape article by five prominent home birth researchers [6], 4 of the 7 studies that were included in the meta-analysis to calculate the neonatal death rate were included inappropriately. These studies did not exclude for planned and unplanned home births and/or did not exclude for congenital birth defects.

Why is ACOG willing to promote unsound evidence as justification for its position of aversion to home birth? Possibly due to sensationalized stories of home births gone wrong or their individual member’s experiences with birth, they cannot believe the large body of evidence from the US, Canada, and Europe that show planned home birth to be safe for mothers and babies.  In a recent conversation I participated in with Dr. Macones and others on NPR’s Kojo Nnamdi show, Dr. Macones said, “it shouldn’t come as a surprise to anyone [that there would be an increased risk to newborns in home birth]“. [7]

Actually, it would be a great surprise to myself, US midwives, international midwives, and even the OB organizations of European Union countries like the UK, all of which are striving to make midwifery and home birth available to more women because of the significant cost savings and excellent outcomes for mothers and babies associated with this model of care. [8,9,10,11]

All maternity care providers, midwives and physicians alike, adhere to the fundamental ethical principles of beneficence, to do good, and non-malfeasance, or do no harm. We all make decisions based on the best evidence available to provide women information about risks and benefits of all options for their care. Though many midwifery advocates would argue that there is a significant body of evidence to show the safety of home birth, US physicians continue to argue that the evidence is outside of the country and therefore irrelevant.  Rather than continue the finger pointing over why things are different for US women, let’s take the next step from the productive conversation that was led by Kojo Nnamde in May. Let’s start talking about what we agree on and start coming up with solutions to identified problems.

Women have the right to choose their provider and place of delivery. Home birth will continue to be a reasonable choice for many mothers and is on the rise in the United States. Midwifery care leads to fewer interventions for mothers.  Fewer interventions like cesarean section, when combined with good outcomes for babies will amount to significant cost savings for everyone. Systems of care that integrate midwifery and medical models will allow for increased choices for women and optimal outcomes. Legislation offering licensure and regulation of CPMs in all 50 states, including Maryland and the District of Columbia, will allow for improved mechanisms of accountability and remove obstacles to communication, collaboration, and integration between physicians, midwives, and the women we all serve.

Citations:

1. Johnson K, Daviss BA.  Outcomes of planned home birth with certified professional mid-wives: large prospective study in North America. BMJ 2005;330;1416.

2.Hutton EK, Reitsma AH, Kaufman K. Outcomes associated with planned home and planned hospital births in low-risk women attended by midwives in Ontario, Canada, 2003-2006: a retrospective cohort study. Birth. 2009;36:180-189.

3.  de Jonge A, van der Goes BY, Ravelli ACJ, et al. Perinatal mortality and morbidity in a nationwide cohort of 529,688 low-risk planned home and hospital births.BJOG. 2009;116:1177-1184.

4.American College of Obstetricians and Gynecologists issues opinion on home births. http://www.acog.org/from_home/publications/press_releases/nr01-20-11.cfm

5.Wax JR, Lucas FL, Lamont M, et al. Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis. Am J Obstet Gynecol 2010;203:243.e1-8.

6.Carl A Michal, PhD, Patricia A Janssen, PhD, Saraswathi Vedam, SciD, Eileen K Hutten, PhD, Ank de Jonge, Phd. Planned Home Birth vs. Hospital Birth: A Meta Analysis Gone Wrong. Medscape Ob Gyn 4/01/2011; http://www.medscape.com/viewarticle/739987

7. Midwifery in Our Region, 5/16/2011. Kojo Nnamdi http://thekojonnamdishow.org/shows/2011-05-16/midwifery-our-region

8.  American College of Nurse-Midwives. The American College of Nurse-Midwives expresses concerns with recent AJOG publication on home birth. Available at: http://www.medscape.com/viewarticle/725382 Accessed March 28, 2011.

9. Simkins G. Letter. RE: Maternal and newborn outcomes in planned home birth vs. planned hospital births: a meta-analysis. July 6, 2010. Available at: http://mana.org/pdfs/MANA-Response-AJOG-Article-7-6-2010.pdf Accessed March 28, 2011.

10. National Association of Certified Professional Midwives. Press release. July 6, 2010. Available at: http://www.nacpm.org/documents/070610-NACPM-Press-Release-Wax-etal.pdf Accessed March 28, 2011.

11. Royal College of Obstetricians and Gynaecologists Position on Home Birth. 1/04/2007. http://www.rcog.org.uk/womens-health/clinical-guidance/home-births

If this truly is a battle, then women and babies are the collateral damage. Mothers need to take charge of their own healthcare decisions by designing and managing their own collaborative care and the US government is now giving them to tools to do it.

Many healthcare consumers are creating collaborative care for themselves when they hire multiple providers, like doulas and obstetricians, to support different aspects of the same conditions. They take what they like from each provider and then try to leave the rest behind.  It amounts to a customized “standard of care”.  The US government is now supporting this movement with the adoption of Final Rules from the Dept of Health and Human Resources on Electronic Health Record (EHR) Incentives. Mandates for patient access to their own electronic medical records will put the flow of information directly into the hands of consumers who will then be able to share their health information with multiple providers during the course of their care. No longer will they need the permission of their primary provider (through a request form) to access their records.

The implications of this simple change in “who really owns the information” stand to create ripple effects in the status quo. Despite the clear challenges presented when collaborating providers don’t even know they are collaborating, there are significant benefits to a shift in power from provider to patient. Changes in maternity models will soon be driven by the economics of consumer demand rather than a profession that holds a lock on our current healthcare system through a monopoly on insurance reimbursement and standards of care. When providers stop fighting over the slices of pie, maybe women will stop being unnecessarily cut when they have their babies.

Why Can’t the Maternity Care Providers Work it Out?

Elton says:

Some observers, including Wax, further suggest that American women should draw only limited conclusions about the safety of home birth from studies conducted in other countries. The experience of home birth in the Netherlands, for instance, where 1 out of 4 mothers delivers at home, bears little resemblance to the process most American women endure.

…In the Netherlands, moreover, midwives are fully integrated into the health care system and obstetrics practices, making transfers to hospitals routine. In the U.S., where 1 out of 200 women gives birth at home, midwives can be and have been arrested for bringing their patients to hospitals in states that do not license CPMs.

It is unacceptable for US obstetricians to point to the lack of timely access to hospital care for women choosing to labor at home when those same obstetricians refuse to adopt integrated collaborative systems like those utilized by countries that support out of hospital delivery and have better outcomes in maternity care as a whole.

Melissa Cheyney discusses one of the biggest obstacles to collaboration in her Huffington Post article, Why Home Births are Worth Considering.  She envisions the most important step in improving outcomes in maternity care:

Instead of a maternity system based on fear and misinformation, we need a system based on collaboration and mutual respect.

Cheyney highlights a lack of mutual respect and understanding between midwives and obstetricians as impacting collaboration and transfer of care:

…research has shown deep mistrust between doctors and some midwives. Many doctors have expressed the belief that only hospital births are safe, while midwives say they often feel marginalized and disrespected.

Such studies [e.g. Wax] only deepen this mistrust and have the potential to increase hostility during encounters when midwives and their clients have to seek hospital care for complications. The end result is a system that can be detrimental to women and their babies because of the impaired ability to communicate across a cultural divide.

Peace between providers due to a change in perspective from either side is an unlikely outcome.  As good negotiators know, the best way to mediate any dispute is to find compromises that result in a win for everyone.  Everyone “wins” in the birth battle when women have better outcomes.  It is the result we all want and we have great examples of birth models that work, and what makes for better outcomes is collaboration.

The question remaining is: how will obstetricians and midwives meet the challenge of a newly empowered patient who creates her own collaborative care?

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?

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.

More and more women are asking us about the benefits of ingesting their own placentas after their birth.  The practice is becoming more well known, CBS just did a story on it.  The benefits are considered worth the yuck factor; better milk supply, reduced postpartum depression and more balanced hormones in the weeks following birth. 
There are some intriguing recipes that you can try- the simplist is to just dehydrate it and put it in capsules.  Many of our clients bury their placenta and plant a tree or shrub to commemorate their baby’s birth. 

What did you do with your placenta?

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. 

Your constituent has raised some interesting and valid points.  Obstetricians are struggling in your community. However, fear of liability and lack of reimbursement for normal birth are untenable obstacles to optimal outcomes for mothers and babies.  Something must change and I believe we can all agree on that.  However, I must emphatically tell you that restricting reimbursement for midwives will not affect the problem at all.  As I indicated in our discussion, CPMs do not seek VBAC patients.  Rather, women who desire a VBAC seek out providers who will work with them in order to have a normal vaginal delivery.

Very few midwives are actually enrolled as Medicaid providers.  Our client fees are already low and many of us offer reduced fees to low-income women.  Our clients are choosing midwifery care and home birth because of our model of care and they will pay out of pocket, babysit our children, build us a shed, or trade chickens and eggs for the birth experience they want.  I do not know of a single Virginia CPM who would turn a woman away and force her to go to the hospital for a mandated c-section because her insurance will not reimburse for the birth.

Preventing CPMs from delivering VBAC babies would not end the practice of home VBACs, it would actually turn it from a very safe option to a dangerous one, with VBAC mothers having their babies alone at home with no monitoring whatsoever. This trend was the impetus for Delegate Hamilton’s efforts to pass licensure legislation for CPMs in the first place.  More and more Virginia women were choosing to birth unattended, rather than being forced to have their babies in hospitals.  Many of these women were and will continue to be women seeking VBAC.
 
Since providing a lesser quality of care to Medicaid clients than what would be available to them if they were insured or self-pay is against Federal guidelines, I sincerely ask that you pull this second bill as well and that we instead work together after the session to find a better solution to your OB’s concerns. We believe there are other more productive approaches that could be taken to increase access to hospital VBACs for women in the Harrisonburg area, and we’d like to engage in a dialogue with the stakeholder groups. I know that we ALL have the same goal in mind: optimal outcomes for mothers and babies.

Again, thank you so much for your time and consideration of these issues. As a reminder, as of January 19th I’ll be out of the country until February 1st.  In the interim, please contact Becky Bowers-Lanier, our lobbyist at 804-382-0991 or becky@macbur.com. If she needs the technical expertise of other CPMs, she will be able to access them quickly to provide you with answers to any of your questions.

Respectfully,

Brynne

p.s. As you may have noticed, I inserted links to a couple of very useful resources about C-section and VBAC.  You can also review the full text of numerous studies regarding VBAC and the risks of Cesarean delivery on the resources section of my practice website, many of which were published in ACOG’s Journal. I would strongly encourage you to ask your OB for the evidence on the position she is asking you to take regarding VBAC safety.