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

The Bottom Line (from physician members of the workgroup):
They’ll give us medications if we agree to restrict access to homebirth for women they believe should not birth at home (ie. no twins, breeches, or VBAC).  You can read about the history on how we came to have the statutory authority to attend these births with informed consent in two previous posts:

Making Lemonade- a recipe to support HB 2163

Evidenced Based…it’s now the law

Our Reaction:
Virginia Midwives will never sacrifice the rights of women to have access to care in the setting and with the provider of their choice.  We will continue to work to educate the Board of Medicine about the issues related to their in-decision on medications and strive to develop a comprehensive model for obtaining medications that addresses as many of the concerns that we can without creating new obstacles or barriers to practice.

Deren and I were appointed to this workgroup to represent the interests of the CPMs. At 3:30am on the day of the meeting, one of our clients woke up in labor. I drew the short straw and went to Richmond for the meeting while Deren and our new assistant midwife, Debbie, stayed here in Charlottesville to be midwives. Even though I had to make the presentation alone, it was nice to be able to anchor myself in the resolve to continue this frustrating work of building relationships with medicine…we do it for women and babies and we won’t stop pushing until midwives have all of the resources they need to provide optimal care for families who birth out of hospital in Virginia.

Next Steps:
The next workgroup meeting date has not been set.  It will be sometime before June, most likely in late April or early May.  Stay tuned for more information.  You can join the Friends of CMA yahoogroup  to stay involved in advocacy efforts with the Commonwealth Midwives Alliance.

About The Author:
Brynne Potter is a Certified Professional Midwife (CPM) who has worked in the field of midwifery since 1991. She is a member of the North American Registry of Midwives (NARM) Board of Directors and a partner at Mountain View Midwives, a midwifery practice in Charlottesville, VA. Brynne is also a co-founder of Private Practice, practice management software for midwives.

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?

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.

Click on the rainbow to watch a short slideshow from my trip

Though you might not know it from my  previous post about squeezing lemons in our Capital this week, I have actually just returned from the jungles of Belize feeling somewhat transformed and completely inspired by my Professional Training in the Arvigo Techniques for Maya Abdominal Massage (MAM).  It wasn’t just the breathtaking views from Rosita Arvigo’s mountain top home where the class was held.  It wasn’t only jungle walks to said mountaintop from the camp along the Macal River where I slept at night to the sound of Howler monkeys in the trees overhead.  And finally, it wasn’t just the fact that I spent 7 entire days without making a single meal for myself or others.  What actually facilitated this feeling of deep satisfaction and well-being were the healing techniques themselves. 
Based on the teachings of Don Elijio Panti, a Mayan Bush Medicine legend in his country, and developed by his apprentice, Dr. Rosita Arvigo, the techniques apply anatomy, physiology, herbology, and naprapathy (the study of the ligaments, joints and muscles) with Ancient Maya healing techniques to address common female and male complaints.
I think it was the holistic blend of traditional and modern perspectives that helped me to connect so deeply to this work. Don Elijio and the mayan shaman who trained him did not need to understand why certain points in the body coorespond to specific illnesses and symptoms.  They believed it worked because they were connected to a lineage of healers that can probably be traced back for hundreds of years of first hand knowledge of rainforest plants and their medicinal properties, massage techniques, and healing through a deep connection to the elements of both the natural and spiritual world. The only other healing technique with this kind of lineage is Chinese or Tibetan Medicine and ironically this work has many parallels in it’s underlying concepts and techniques.
I am so excited to be able to begin to offer this work to my midwifery clients (past, present, and future) who will potentially benefit from the 40% reduction in labor time reported from the midwives who are using these techniques.  I learned methods for getting labors started and keeping them going and most importantly, improving well being in pregnancy for a healthier birth.  
For non-pregnant or peri and post menopausal women, and for men there are health benefits from this work as well.  Fertility support, endocrine, lymphatic, and chi balancing, and low back pain relief are universal results of the massage techniques. I experienced this first hand as my classmates and I performed the techniques on each other throughout the week.  Within two days of having mere novice MAM practitioners work on my low back and abdomen, I experienced relief from symptoms that I have had since a fall onto my sacrum when I was 18.  Some of the other benefits I had are too graphic to share in a blog post, but suffice to say…I am a convert!
Check out our website for more information on massage services through our practice.

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?

On Christmas Eve, Pushed author Jennifer Block opined in the LA Times that homebirth and Certified Professional Midwives must be key elements of Obama’s healthcare reform strategy.  Read the article or more cool stuff on Jennifer’s blog, PushedBirth.

She highlights some pretty startling facts: Not only is childbirth the most common reason for a hospital stay — more than 4 million American women give birth each year — it costs the country far more than any other health condition. Six of the 15 most frequent hospital procedures billed to private insurers and Medicaid are maternity-related. The nation’s maternity bill totaled $86 billion in 2006, nearly half of which was picked up by taxpayers. 

Anyone know the average cost of a birth in Charlottesville?