The Mother’s Act-revisited

Mothers Act Fuels Multibillion Dollar Industry

by Evelyn Pringle

Motherhood has fallen prey to the psycho-pharmaceutical complex. If new legislation known as the Mother’s Act becomes law, the drugging of infants through pregnant and nursing mothers will no doubt increase.

Congress has rightfully refused to pass this bill for eight years. The official title is currently the “Melanie Blocker Stokes Mom’s Opportunity to Access Health, Education, Research, and Support for Postpartum Depression Act of 2009.”

The legislation was introduced in the House during the 110th Congress on January 4, 2007, by Illinois Democrat Bobby Rush and later reintroduced into both bodies of the new Congress in January 2009, after the bill died in the Senate last year.

Democratic Senator Robert Menendez from New Jersey, home to a large number of drug companies, and Richard Durbin (D-IL) are the main sponsors of the bill in the Senate.

In a March 30, 2009 speech on the House floor, Congressman Rush identified the target of this piece of legislation when he claimed that, “60 to 80 percent of new mothers experience symptoms of postpartum depression while the more serious condition, postpartum psychosis, affects up to 20 percent of women who have recently given birth.”

After the House voted to pass the legislation on that day, the Congressman stated: “H. R. 20 will finally put significant money and attention into research, screening, treatment and education for mothers suffering from this disease.”

However, he only mentions screening and treatment for postpartum depression. The true goal of the promoters of this Act is to transform women of child bearing age into life-long consumers of psychiatric treatment by screening women for a whole list of “mood” and “anxiety” disorders and not simply postpartum depression.

Enough cannot be said about the ability of anyone with a white coat and a medical title to convince vulnerable pregnant women and new mothers that the thoughts and feelings they experience on any given day might be abnormal.

The constant watching and barrage of questions such as are you depressed, are you anxious, are you moody, are you fearful of motherhood, are you sleeping well, are there changes in your eating habits, will predictably have the net effect of convincing many women that normal thoughts and emotions are a sign of mental disorders.

In the March 13, 2008 NewsWithViews article, “Branding Pregnancy as a Mental Illness,” Byron Richards writes:

“The Mothers Act has the net affect of reclassifying the natural process of pregnancy and birth as a mental disorder that requires the use of unproven and extremely dangerous psychotropic medications (which can also easily harm the child). The bill was obviously written by the Big Pharma lobby and its passage into law would be considered laughable except that it is actually happening.”

While mania, psychosis, agitation, hostility, anxiety, confusion, depression and suicidality are often cited as “symptoms” of mental illness, many of the same exact “symptoms” are listed as side effects on the warning labels for antidepressants, antipsychotics and anticonvulsants.

All of these drugs are now being prescribed to treat the “mood” and “anxiety” disorders that women will be screened for if the Act becomes law. In the case of pregnant women, no psychiatric drug has been FDA approved as safe for use.

The newly recruited customers will be stigmatized for life with labels of the most serious forms of mental illness simply because they are unlucky enough to become pregnant in the United States, where serious disorders lead to major profits from the prescribing of multiple classes of psychotropic drugs.

On September 1, 2008, Medical News Today ran a headline for a study that stated: “Americans Show Little Tolerance For Mental Illness Despite Growing Belief In Genetic Cause.” The study by University of Pennsylvania sociology professor Jason Schnittker showed that while more Americans believe that mental illness has genetic causes, the country is no more tolerant of the mentally ill than it was 10 years ago.

The study explored tolerance in terms of: unwillingness to live next door to a mentally ill person, having a group home for the mentally ill in the neighborhood, spending an evening socializing with a mentally ill person, working closely with such a person on the job, making friends with someone with a mental illness or having a mentally ill person marry into the family.

Multi-billion dollar industry

In an article for AlterNet on June 18, 2008, Dr Bruce Levine, author of the book, “Surviving America’s Depression Epidemic,” explains how the psycho-pharmaceutical cartel works. “Mental health treatment in the United States is now a multibillion-dollar industry,” he reports, “and all the rules of industrial complexes apply.”

“Not only does Big Pharma have influential psychiatrists… in their pocket, virtually every mental health institution from which doctors, the press, and the general public receive their mental health information is financially interconnected with Big Pharma.”

“The American Psychiatric Association, psychiatry’s professional organization, is hugely dependent on drug company grants, and this is also true for the National Alliance for the Mentally Ill and other so-called consumer organizations.”

“Harvard and other prestigious university psychiatry departments take millions of dollars from drug companies, and the National Institute of Mental Health funds researchers who are financially connected with drug companies.”

More Democrats than Republicans are supporting the Mother’s Act. The increased campaign funding to Democrats may well explain this turn of events. For the last eight election cycles the pharmaceutical industry has contributed far more to Republicans than Democrats. In the 2006 cycle the percentage was 28% to Democrats and 70% to Republicans, according to the Center for Responsive Politics, a nonprofit group that tracks political funding.

But the Democrats were close to matching the Republicans for the 2008 cycle with $5,099,942 to Democrats compared to $5,680,871 to Republicans, which is probably why the Democrats would allow such an obvious drug marketing scheme to be implemented.

“The Mothers Act, while appearing like an Act of benevolence, is a dangerous and unnecessary measure that will result in the further over-prescription of drugs that are already grotesquely over-prescribed,” says Kate Gillespie, one of the lead attorneys handling SSRI birth defect lawsuits and Paxil suicide cases at the Los Angeles based Baum, Hedlund, Aristei & Goldman law firm.

“The Act is a slippery slope,” she warns, “toward the forced drugging of women of childbearing years with drugs of questionable efficacy and serious safety issues effecting mothers and their innocent children – drugs that can cause horrific side effects, including, suicidal behavior, violence and devastating birth defects.”

“Of course, mothers who truly cannot cope should be helped,” Ms Gillespie says, “but do we really need legislation requiring mothers to be screened and drugged?”

“Take out politics and Big Pharma and the push for this legislation just doesn’t make sense,” she states.

“For politicians, a much safer issue than pushing drugs for pregnant mothers is promoting the expansion of medical treatment for postpartum depression,” according to Dr Levine,

He says the Mother’s Act “omits relevant truths” about Melanie Blocker-Stokes, the woman the bill is named after, and the following information about her suicide should be made known:

“Blocker-Stokes… did in fact receive extensive psychiatric treatment. She was hospitalized three times in seven weeks, given four combinations of anti-psychotic, anti-anxiety, and antidepressant medications, and underwent electroconvulsive therapy (electroshock).

But despite her psychiatric treatment — or because of it — Melanie Blocker-Stokes jumped to her death from the twelfth floor of a Chicago hotel.”

“There is no evidence that antidepressant use by depressed mothers lowers their likelihood of suicide,” Dr Levine says, “and there is a great deal of evidence that antidepressant use can make some people manic, agitated, and violent.”

Money-making promoters behind the Act

Katherine Stone runs an internet website called “Postpartum Progress” and posts a daily blog. She also serves on the board of Postpartum Support International as the public relations outreach chairwoman. Her Bio says she “is a nationally-recognized, award-winning advocate for women with perinatal mood and anxiety disorders.”

“In 2001,” Katherine reports on her website, that “she suffered postpartum obsessive compulsive disorder after the birth of her first child. The feeling of isolation and shame she suffered inspired her to create Postpartum Progress, which has become the most widely-read blog in the United States on postpartum depression, postpartum OCD, antepartum depression, postpartum PTSD and postpartum psychosis.”

On another page titled, “The Art of Psychiatric Medication,” Katherine tells women to hang in there if a medication does not work because for her diagnosis of OCD, she states:

“I’ve taken many medications, including Effexor, Celexa, Seroquel, Risperdal, Wellbutrin, Luvox, Cymbalta, etc. Throughout all of them, I was on the road to recovery. Some just worked better than others at treating my symptoms.”

She ends the commentary by telling women: “You will find the right medication for you, and you will get better.

The prescribing of seven drugs, including two antipsychotics and five antidepressants, to treat OCD is a typical example of the profit-driven drugging that women snagged by the Mother’s Act will face, but it’s a far cry from the description Katherine wrote about regarding the comparatively minor treatment she received, when she stated in the June 7, 2004 issue of Newsweek, “in my case, that meant taking an antidepressant and going for weekly therapy sessions.”

Aside from all the serious health risks now known to be associated with these drugs, most women could not afford the 7-drug “cure” that Katherine ingested. According to DrugStore.com in December 2008, from first to last, at a middle dose for a 30-day supply, the drugs would cost: Effexor $197.86, Celexa $279.92, Seroquel $388.38, Risperdal $652.07, Wellbutrin XI $202.08, Luvox CR $135.99, and Cymbalta $366.62. The cost of “etc” is impossible to calculate without knowing how many more drugs she took.

In a March 11, 2009 Postpartum Progress blog, Katherine plugs herself for speaking jobs, along with a study that concluded “the Internet is a viable and feasible tool to screen for PPD.”

“I’ll be adding this study to the speech I give on how women with perinatal mood and anxiety disorders use the Internet,” she reports, and then adds:

“If you’re interested in having me speak at your event, let me know!”

On March 10, 2009, Katherine’s headline read: “It’s Petition Signing Time! Get Out Your Virtual Pen & Support Women with PPD”, and reported “that Susan Stone over at Perinatal Pro is alerting everyone to the new petition created by the Depression and Bipolar Support Alliance to support the Melanie Blocker Stokes MOTHERS Act. She states that last year’s petition generated more than 24,000 signatures. The petition has been reintroduced this year to try and get this legislation passed once again.”

The blog carried a live link to a page where “you can scroll down, enter your zip code and generate letters of support in a matter of seconds for the Melanie Blocker Stokes MOTHERS Act that will be sent to your local Congresspeople and Senators.”

Katherine further told readers: “I know you’re thinking ‘but I already did that last year.’ Well that was then and this is now. Do it again.”

The 2007 Annual Report for the Depression and Bipolar Support Alliance shows this Big Pharma front group received between $150,000 and $499,000 from AstraZeneca, Pfizer, and Wyeth. Abbott Labs, Cyberonics, Eli Lilly, Forest Labs, GlaxoSmithKline, Organon, and Otsuka American Pharmaceuticals each gave between $10,000 and $149,999.

The 2006 Annual Report shows that AstraZeneca gave the groupmore than $500,000. Abbott Labs, Bristol-Myers Squibb and Wyeth gave between $150,000 and $499,000, and Forest Labs, Glaxo, Janssen, Pfizer, and Shire Pharmaceuticals each gave between $10,000 and $149,000. The Depression and Bipolar Support Alliance in Baltimore also received $5,000 from Eli Lilly in the first quarter of 2008, according to Lilly’s grant report.

In the section of the 2007 Annual report “at a Glance: How We Met Our Mission,” among the things accomplished by the group, it states:

“Promoted Melanie Blocker-Stokes Postpartum Depression Research & Care Act at invitation of Rep. Bobby Rush (D-Ill.)

“Promoted MOTHER’s Act at invitation of Sen. Dick Durbin (D-Ill.)”

After writing letters to Congress through the link established by the industry funded Alliance, those visiting Postpartum Progress will hopefully click on the link to Amazon and buy the book “Perinatal and Postpartum Mood Disorders: Perspectives and Treatment Guide for the Health Care Practitioner” by none other than the Perinatal Pro “expert,” Susan (Dowd) Stone, and Alexis Menkin, at a special price of $43.20, for a savings of $10.80.

Katherine also provides a link to the PerinatalPro website, where women can find treatment for all the “mood” and “anxiety” disorders diagnosed with internet screenings atBlue Skye Consulting,” where Susan is listed as the Managing Director and Owner.

She also served as president of Postpartum Support International from 2006 – 2008, as vice-president and Conference Chair in 2005 – 2006, and will chair the group’s President’s Advisory Council through 2010. This group brags of being the leading proponent of the Mother’s Act. On March 2, 2009, Susan’s PerinatalPro Blog announced: “The Melanie Blocker Stokes MOTHERS Act moves forward!” and stated:

“Thank you to Congressman Bobby L. Rush, U.S. Senator Robert Menendez and Senator Richard Durbin for your unceasing efforts on behalf of America’s mothers!”

She should have thanked these members of Congress for boosting her career status and yearly income from her treatment center, speaking fees and book sales.

On PerinatalPro, Susan posts a running list of supporters for the Mother’s Act. On March 27, 2009, the list included many drug company funded groups. For instance, the American Psychiatric Association is listed as a supporter. In 2006, the pharmaceutical industry provided close to 30% of the Association’s $62.5 million in financing, according to the July 12, 2008 New York Times.

In the first quarter of 2007, Eli Lilly gave the Association grants worth more than $412,000, according to Lilly’s grant report. The group also received $623,190 from Lilly in the first quarter of 2008.

In her PerinatalPro blogs, Susan has nothing but praise for Katherine’s website and directs visitors back to Postpartum Progress with a live link. On March 16, 2009, Katherine posted a “Quick Survey on Postpartum Anxiety,” and wrote:

“The fabulous Karen Kleiman has asked me to ask you to participate in a short, five-question online survey on anxiety. She says ANYONE can answer it, regardless of the age of their baby(s) and regardless of diagnosis or lack thereof. ANY mother should answer the questions. It’s super quick — I know because I took it myself.”

Kleiman must be fabulous because she has three books for sale on Postpartum Progress with links to purchase them on Amazon. In fact, there are a total of fourteen books for sale on Katherine’s site from which she most likely gets a kick-back with every sale.

Kleiman’s survey is an excellent example of the methods used to con women into suspecting they are mentally ill via the “expert” blogs. The preface states: “The questions on this survey can be answered by a new mother of an infant or an empty-nester with good recall of the early days with her baby. Please answer as honestly as you can.”

The question, capital letters and all, reads: “When you were carrying your baby down a flight of stairs, did you EVER, at ANY time, have ANY thought, image or concern that you could accidentally drop your baby?” The survey further tells women:

If you answered YES to the first question, please describe the type of worry you had: Scary thoughts about dropping the baby,Scary images about dropping the baby, Both thoughts and images, Other.

How much distress did this cause you? A Great deal of distress, Some distress but I quickly got over it, Some distress that seemed to linger, Not much stress

Did this thought or image occur once or did it recur? Only once, It recurred frequently, It recurred persistently, It occurred off and on, Did you ever tell anyone about the fear of dropping the baby? (Please describe why you chose to tell someone or why you chose not to)

As a mother with good recall, the “honest” answer is yes, with two babies born 4 years apart, every single night as I stumbled out of bed half asleep for a nightly feeding, my normal fear instinct kicked in and warned me to be careful not to trip and fall down the stairs or drop the baby.

Women who take the survey are told nothing about what the results mean; but clearly the seed is planted that something is wrong if you “EVER, at ANY time, have ANY thought, image or concern that you could accidentally drop your baby”.

Katherine’s website also provides links to the “Top Women’s PPMD Treatment Programs & Specialists.” The first link on the list takes women to the “Emory Women’s Mental Health Program” that primarily focuses on “the evaluation and treatment of emotional disorders during pregnancy and the postpartum period,” according to Emory University’s website. Lilly’s 2008 first quarter grant report shows Emory’s Department of Psychiatry received $25,000.

The “experts” at Emory include some top pharmaceutical industry shills. For example, a link to “Articles” brings up roughly 90 studies and papers that include the co-author Dr Charles Nemeroff. Nemeroff is on an ever-growing list of academic researchers in the field of psychiatry under investigation by the US Senate Finance Committee for not disclosing millions of dollars of income from the makers of psychotropic drugs.

Emory’s investigation found he was paid more than $960,000 by Paxil maker, GlaxoSmithKline, from 2000 through 2006, but listed less than $35,000 on his Emory disclosure forms. All totaled, Nemeroff had earnings of $2.8 million from speaking and consulting arrangements with drug companies between 2000 and 2007, but only disclosed a fraction of that amount, according to the Senate Finance Committee reports.

On July 23, 2008, Medscape Psychiatry & Mental Health posted an article by Nemeroff titled: “Weighing Risk and Benefit for Treatment of Depression in Pregnancy and Post Partum”. On March 17, 2009, the Medscape website stated: “This article is temporarily unavailable.”

Maybe that’s because the “top expert,” Dr Nemeroff, recently stepped down as chairman of Emory’s psychiatry department.

************* epringle05@yahoo.com

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Physician and Midwife Groups Forge Unprecedented Alliance in Idaho

FOR IMMEDIATE RELEASE: Wednesday, April 1, 2009

Idaho Pushes Midwife Movement to the Tipping Point
Physician and Midwife Groups Forge Unprecedented Alliance as Idaho Becomes the
26th State to Pass Legislation Legalizing Certified Professional Midwives

BOISE, ID (April 1, 2009)—Governor C.L. “Butch” Otter signed into law today a bill to license and regulate Certified Professional Midwives, making Idaho the 26th state to legally authorize them to provide out-of-hospital maternity care.

In a notable reversal of longstanding anti-midwife policies, medical groups worked together with legislators, midwives, and advocates to reach consensus on a law that provides for independent practice, mutual collaboration, and the rights
of parents to choose where and how their babies are born.

“This is a great day for midwives and home birth advocates all across the country,” said Kyndal May of Idahoans for Midwives. “We truly have reached the tipping point, breaking through the medical lobby’s longstanding opposition and
developing a legislative consensus model that other states are looking to follow.”

Certified Nurse-Midwives (CNMs), who practice primarily in hospital settings, are legally authorized in all 50 states, while Certified Professional Midwives (CPMs), who specialize in out-of-hospital birth, until today were legally authorized to practice in just half the states. Representatives from The Big Push for Midwives Campaign noted that Idaho typifies recent legislative trends across the country, as a growing number of states come closer to passing CPM legislation.

“We’re seeing unprecedented advances this legislative season,” said Katie Prown, Campaign Manager of The Big Push for Midwives. “For the first time, physician groups are coming to the table and negotiating in good faith, and bills that
had long been stalled in previously antagonistic committees are suddenly starting to move.” States that have recently seen significant legislative advances include South Dakota, Indiana, Illinois, Iowa, North Carolina, and Alabama. Idaho joins Missouri and Maine as among the most recent states to legally authorize CPMs to provide maternity care.

“It’s clear that organized medicine has finally realized that, between current economic trends and the drive for healthcare reform, the demand for access to CPMs and out-of-hospital maternity care is only going to grow,” said Susan
M. Jenkins, Legal Counsel for the Big Push. “It simply makes good sense to pass laws that provide for regulatory oversight, transparency, and accountability, all of which are necessary to ensure safe practice.”

Thousands of people from across the nation watched the Senate floor vote on live video from the Idaho statehouse last week, cheering on their fellow midwife advocates on Facebook, Twitter, and email groups. “It’s very exciting to be part of
a growing national movement,” said Michelle Bartlett, CPM, Legislative Liaison for the Idaho Midwifery Council. “I’m humbled to hear from so many advocates in other states who are looking to us as a model for how to work with every
stakeholder to craft CPM legislation that addresses the needs and concerns of all of us who care about the health and safety of mothers and babies.”

Idaho is a priority of The Big Push for Midwives Campaign, a nationally coordinated campaign to advocate for regulation and licensure of Certified Professional Midwives (CPMs) in all 50 states, the District of Columbia and Puerto Rico, and to push back against the attempts of the American Medical Association Scope of Practice Partnership to deny American families access to legal midwifery care. Through its work with state-level advocates, the Big Push is helping to forge a new model of U.S. maternity care built on expanding access to out-of-hospital maternity care and CPMs, who provide affordable, quality, community-based care that is proven to reduce costly and preventable interventions as well as the rate of low-birth weight and premature births.

Birth by surgery: The skyrocketing cesarean rate

Medical boon or lawsuit shield? Benefits, risks debated

Story By Mary Beth Pfeiffer

Two weeks before Kristi Ashley gave birth to a son in 2007, an ultrasound exam estimated the baby at a hefty 12 pounds, 10 ounces — too big, her doctor believed, for a safe vaginal delivery. After the child weighed in at 9 pounds, 4 ounces in the delivery room, Ashley came to believe that the planned cesarean section she had, with its attendant pain, long recovery and what she called “emotional damage,” may have been a rush to judgment.

“It’s very hard to go up against your physician, especially at the 12th hour,” said Ashley, 38, of Hopewell Junction. “I think doctors are very quick these days to get scared. They would rather opt for the surgical solution.”

Determined to avoid another surgical birth and aided by a supportive doctor, hospital and birthing coach, Ashley last month did something that has become increasingly rare for post-cesarean women today: She gave birth vaginally, to another son.

In an era of soaring malpractice premiums, technology that sometimes sets off false alarms, physicians pressed for time and mothers-to-be conflicted by fear, cesarean-section birth is soaring to its highest http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_12.pdf“>levels ever.

From 1999 to 2007, the proportion of New York babies born by cesarean section skyrocketed 42 percent. In 1999, just under 1 in 4 babies was born surgically. By 2007, the figure was 1 in 3 — or 34 percent of births — and there is nothing to suggest that the relentless uptick, evident locally as well, is showing any sign of slowing.

In Ulster and Dutchess counties, with cesarean rates in the top sixth of counties statewide, surgical birth rates increased from 1999 to 2007 by 64 percent and 36 percent respectively. Orange ranks in the middle of counties statewide but also saw its section rate rise by 36 percent in that time.

At Vassar Brothers Medical Center in Poughkeepsie, 1,072 babies were delivered via cesarean section in 2008 — two of every five births, for a rate of 40 percent. In Ulster County, Kingston Hospital had a cesarean rate of 40 percent in 2007, the latest figure available, while Benedictine Hospital’s was 35 percent, nearly double what it was in 1999.

Even Northern Dutchess Hospital in Rhinebeck, with a reputation for progressive natural-birthing practices, saw its surgical birth rate soar by 52 percent since 1999 — to 29 percent of all births in 2008.

The World Health Organization calls for a maximum cesarean section rate of http://www.unicef.org/sowc/“>15 percent in any nation in the world. Anything above that “seems to result in more harm than good,” according to a 2006 research summary in the British medical journal Lancet.

Factors hotly debated

Physicians, midwives, childbirth experts and researchers point to a confluence of factors behind the growing rate of cesarean section — factors that are hotly debated both in medical literature and hospital corridors. Some say that more mothers are older, obese, more prone to multiple births and, in particular at Kingston and Vassar Brothers hospitals, less healthy, increasing risks of surgical measures. Others contend that overused interventions to induce and augment labor, manage pain and monitor for fetal distress have driven cesarean rates to unnecessary heights.

All agree that fewer women are opting for once-popular vaginal birth after cesarean, or VBAC, as Ashley did. But some believe doctors emphasize its risk – that the scarred uterus could tear – while minimizing the drawbacks of surgery. VBACs have declined precipitously at five local maternity hospitals; at Northern Dutchess, 17 percent of women who had a previous cesarean gave birth vaginally in 2008, compared to 41 percent in 1999. In 2007, just 3 percent of post-cesarean women birthed vaginally at Kingston Hospital, where the procedure is officially banned. The figure was 33 percent in 1999.

Amid the debate, there is widespread agreement that medical factors are only a part of the story. Cesareans have become so common and accepted that first-time mothers – frightened by societal depictions of overwrought laboring women — sometimes request them simply to avoid labor; doctors, hospitals and insurance companies acquiesce. Moreover, obstetricians, who pay $84,500 a year for malpractice insurance in Ulster and Dutchess and $137,600 in Orange, may see cesareans as a way to avoid lawsuits over injuries to infants from vaginal birth — as well to manage precious time. Obstetricians must attend 54 births just to cover annual malpractice premiums in Westchester County, a medical society study showed; cesareans are undoubtedly quicker and more convenient.

“I see colleagues around me who seem to operate out of fear,” said Dr. Ira Jaffe, a Rhinebeck obstetrician who estimated his cesarean rate at less than 20 percent. “They always have in the back of their mind, ‘How is it going to look in court?’ It’s the defensive medicine.”

“It’s not in the best interest of women and babies to do this many C-sections,” he said.

And the more common cesareans become, the more accepted they are as an alternative way to have a baby. “When you talk to co-workers and friends, so many people have had C-sections,” said Kimberly Revak, 37, of Fishkill, who has had two cesareans, the last with twins in February. “We’re kind of losing that experience” of vaginal birth.

As in Ashley’s case, an ultrasound overestimated the size of Revak’s first baby, putting her at 12 pounds while she delivered at under 9. “It’s easier to go along than to choose the other way and have a problem,” she said.

Telling both sides

For a community of activists who say the cesarean section rate is out of control, the question is whether women like Revak are getting both sides of the story – on one hand that cesarean sections no doubt save lives in high-risk circumstances and are generally safe, but that they contribute in other cases to prematurity, cause respiratory problems in babies and increase maternal bleeding and infection.

“Women are getting cheated by not being encouraged to believe both in their ability to birth and that birth can be a positive experience,” said Christie Craigie-Carter, Hudson Valley coordinator of the International Cesarean Awareness Network, or ICAN, who echoes other mothers who believe they’ve had needless or questionable cesareans at the expense of a core maternal experience: vaginal birth.

Assemblywoman Amy Paulin, a Democrat from Scarsdale in Westchester County, said she is “very alarmed” by the rising cesarean rate.

A Paulin http://www.amypaulin.com/press_rel_detl.asp?id=50“>bill, signed into law last year, requires the state to educate women on birthing procedures, such as the induction of labor and use of pain-numbing techniques like epidurals, that increase risk of cesarean section. Paulin, a three-time mother who had two midwife-attended babies at home, believes that cesareans are often performed for reasons of convenience, fear and liability. “We have a huge problem,” she said.

But while physicians acknowledge room for debate, many accept and even embrace rising cesarean rates, in particular for women having just one or two children, when cesareans are safest. Some noted that planned cesareans generally produced better outcomes than emergency procedures performed after problems arise.

“Is it wrong?” asked Dr. Carla Eng, an obstetrician who delivers babies at Vassar Brothers Medical Center. “It’s hard for me to answer that. The final outcome is to have a healthy baby and a healthy mom.”

“It’s not necessarily a bad trend,” said Dr. Cornelius Verhoest, an obstetrician for 25 years who practices in Fishkill and Poughkeepsie and specializes in urinary disorders. Verhoest, who recently married and is considering fatherhood, said he would encourage his wife to have a cesarean section. He and other obstetricians said the procedure helps avoid potential “pelvic floor disorders” such as urinary incontinence that sometimes follows vaginal childbirth.

“There’s more fevers, wound infections associated with C-section,” acknowledged Dr. John McAndrew, chairman of obstetrics and gynecology at Kingston Hospital, where the cesarean rate hit 43 percent in 2006. “However, it’s safer for the baby.”

Weighing surgical risks

Physicians and researchers concerned with rising cesarean rates take issue with that assertion, which they say fails to weigh the risk that a baby will be damaged or die in vaginal delivery – what drives many decisions to operate – against surgical risks to mother and child.

“In low-risk or no-risk mothers, studies have consistently shown higher morbidity (illness) in infants delivered by cesarean section,” said Dr. Lucky Jain, a pediatrics professor at Emory University School of Medicine in Atlanta who has studied respiratory problems in C-section http://www.ncbi.nlm.nih.gov/pubmed/16549212“>babies. “We have created a monster here without knowing what the long-term impact is.”

“There is no evidence that cesarean is safer for the baby,” said Dr. Jed Turk, newly appointed obstetrics and gynecology chairman at Vassar Brothers Medical Center and a proponent of lower cesarean rates. “It is not a good trend.”

To be sure, every obstetrician knows of or has experienced a vaginal birth gone bad; some said that they and other colleagues had been sued more than once. “If anything goes wrong, the first question you’re asked is, ‘Why wasn’t a C-section done?’ ” said Dr. Scott Hayworth, chairman of the New York district of the American College of Obstetricians and Gynecologists, who calls lawsuit fears “the leading cause” of rising cesareans.

In one case reported on VerdictSearch.com, a legal research service, a Suffolk County jury awarded $212 million in 2005 to a boy born in 1998 with brain damage after a delayed cesarean section (the award was later reduced to $10.6 million). In another, a Bronx jury awarded $64 million in 2002 to an 18-year-old woman who suffered cerebral palsy during her vaginal birth.

Locally, an Ulster County case was settled for $3 million in 2006 after a baby boy allegedly suffered brain damage during a vacuum extraction birth in 2001 at the former Mid-Hudson Family Health Institute in Kingston, which had been licensed to perform births.

“Physicians are less risk-tolerant,” said Dr. Michael Rosenberg, president of the 25,000-member Medical Society of the State of New York, echoing several local obstetricians who acknowledged the role of litigation fear. “When a physician is forced to make clinical decisions influenced by the threat of lawsuits, they are not rendering the best medical care to their patients.”

Vaginal birth undoubtedly has risks. One in 5,000 to 10,000 babies suffers permanent shoulder damage, and one in 1,000 suffers moderate to severe brain damage, according to a 2006 http://cat.inist.fr/?aModele=afficheN=18208466“>article in the professional journal Seminars in Perinatology. These injuries, as well as 6,000 stillbirths, could be avoided nationwide if the nation’s 3 million annual vaginal births were performed surgically at term — but that would mean additional costs and maternal and infant complications.

While researchers do not suggest universal cesarean section, momentum currently favors surgical birth – with troubling implications. At least two of New York’s 146 maternity hospitals have rates above 50 percent, and 23 are in the 40s; the state’s rising rates worry health officials.

“C-section is major surgery, which involves a longer recovery time for the mother and can have other significant consequences,” said Barbara McTague, family health director for the state Health Department.

The cost of cesareans in a cash-starved health-care system is just one consequence. A cesarean birth cost the state Medicaid program $7,200 on average for hospital care in 2007 – 49 percent more than a vaginal delivery. The state’s cesarean price tag was $189 million.

Earlier deliveries

Of greater concern may be the effect of cesareans on babies that are increasingly being delivered early. Thirty-six percent of elective cesareans were performed before 38 weeks, according to a http://content.nejm.org/cgi/content/short/360/2/111“>study published in January in the New England Journal of Medicine, producing infants who had high rates of breathing problems, prolonged hospitalization and sepsis, a severe bacterial infection.

As significant, the study found that 10.2 percent of all cesarean-born babies were admitted to neonatal intensive care units, and 4.4 percent suffered from respiratory distress syndrome caused by fluids that are normally wrung from infant lungs during labor and vaginal delivery. Twenty-thousand babies delivered near-term by cesarean section suffer respiratory distress each year, according to a 2006 http://www.ncbi.nlm.nih.gov/pubmed/16549212“>article in Seminars in Perinatology, while death rates of C-section babies before 28 days were nearly triple those of vaginal deliveries, according to a 2006 http://www.ncbi.nlm.nih.gov/pubmed/16948717“>study by researchers at the U.S. Centers for Disease Control in Birth: Issues in Perinatal Care.

Studies have also found 20 percent higher incidence in both childhood-onset http://www.ncbi.nlm.nih.gov/pubmed/18292986“>diabetes and http://www.ncbi.nlm.nih.gov/pubmed/18352976“>asthma among cesarean babies, who have one-third to three-quarters the level of healthy http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1774211“>bacteria in their intestines as vaginally born babies.

“When a baby comes out the normal way, they swallow vaginal mucus en route and get a nice dose of healthy bacteria to jump start their digestion,” said Dr. Joseph Malak, a Poughkeepsie pediatrician who called “surreal” the number of cesarean babies he sees on hospital rounds. “This doesn’t happen when babies come out through an abdominal incision.”

Malak believes that the rising cesarean rate may be linked to “a dramatic increase” in recent years in infants with colic, acid reflux, eczema and milk allergies – effects that, some say, obstetricians do not consider when weighing vaginal versus cesarean birth.

“You hand the baby to the pediatrician and you release the mother from your care,” said Dr. Carol Sakala, who has a doctorate degree in public health and is program director for the research and advocacy group Childbirth Connection, based in New York City. “There’s very little thought to the ongoing consequences.”

While cesarean delivery is safer than ever for the mother, it is not risk-free. According to a 2008 http://www.ajog.org/article/S0002-9378(08)00268-8/abstract”>report in the American Journal of Obstetrics and Gynecology, 2.2 women died for every 100,000 cesarean births – 10 times higher than for vaginal births. “Cesarean delivery is associated with an increased risk of postpartum maternal death,” concluded a 2006 http://journals.lww.com/greenjournal/Abstract/2006/09000/Postpartum_Maternal_Mortality_and_Cesarean.12.aspx“>report in the same journal.

In New York, the rate of maternal mortality rose 70 percent from 1997 to 2007, when 40 women died as a consequence of pregnancy. Researchers say the rise, seen nationally as well, may be related in part to better reporting as well as to rising rates of obesity; one http://www.childbirthconnection.org/pdf.asp?PDFDownload=LTMII_report“>survey found that a quarter of pregnant women were obese. While no link has been proven between rising maternal deaths and rising cesarean rates, a state-sponsored study in 2004 identified three of the major causes of maternal death as embolism, hemorrhage and infection – all of which occur at higher rates in cesarean section.

Growing complications

Indeed, serious obstetrical complications increased by 27 percent from 1998-99 to 2004-05, according to a 2008 report in http://www.ncbi.nlm.nih.gov/pubmed/19155897“>Obstetrics and Gynecology. These included renal failure, pulmonary blood clots, shock, blood transfusion and ventilation — upticks that parallel rising cesarean rates.

“It looks like there’s an association,” said the study’s author, Dr. Susan Meikle, an obstetrician and medical officer at the National Institutes of Child Health and Human Development. She and others argue that indicators like maternal mortality and illness should be dropping if, indeed, more cesareans are a good thing. “Where’s the benefit from the increase?” she asked.

In its 2006 review of optimal cesarean rates, the British medical journal Lancet, for one, showed “no reductions” in mother or child illness or death in populations with cesarean rates above 15 percent.

“There is an awful lot of lying to women about cesarean,” said Dr. Marsden Wagner, former director of women’s and children’s health for the World Health Organization and author of several books on childbirth. “All of those thousands of women who are getting unnecessary cesareans in New York state are at double or more risk of dying and the babies are at risk of dying.”

The argument over cesarean’s benefits is perhaps most pointed when it comes to vaginal birth after cesarean; many doctors fear that the scarred uterus will tear, resulting in hemorrhage and loss of oxygen to the infant.

“There’s a real risk,” said Dr. Maureen Terranova, obstetrics chief at Northern Dutchess Hospital. “They have to be willing to accept that 1 percent risk of uterine rupture.”

“When it occurs, it can be catastrophic,” said Kingston Hospital’s McAndrew, who has seen uteruses so thin in surgery that the baby is visible. “That’s the thing that makes us reluctant to tread in that water.”

Melissa Ptacek, 47, of Garrison in Putnam County, said it took her years to recover from a uterine rupture from which her daughter – now a normal 11-year-old – had to be resuscitated. “I wouldn’t want anyone to go through what I had to go through,” she said.

In a study published in the http://content.nejm.org/cgi/content/abstract/351/25/2581“>New England Journal of Medicine in 2004, 124 women suffered uterine rupture among 17,898 who attempted vaginal birth after cesarean — a rate of 0.7 percent. Seven babies suffered brain damage, including two who died. A 2000 research http://www.google.com/search?hl=en&q=%22Evaluation+of+Cesarean+Delivery%22&b”>summary by the American College of Obstetricians and Gynecologists put the risk of rupture in vaginal birth at 0.2 to 1.5 percent for most women with one prior cesarean. In an advisory that subsequently sent cesarean rates climbing, the organization recommended that post-cesarean vaginal births only be attempted in hospitals “with physicians immediately available to provide emergency care.”

Proponents of vaginal birth after cesarean say the risks of rupture must be balanced against the downsides of surgical birth. “The conversation about VBAC doesn’t touch on dozens of other concerning outcomes that favor vaginal birth,” said Sakala of Childbirth Connection, noting that cesareans make breastfeeding difficult, lead to adhesions and cause significant pain for up to six months. More than 7,000 repeat cesareans would be needed to save the life of one baby from a ruptured uterus, she said, citing a 2004 British Medical Journal http://www.bmj.com/cgi/content/abstract/bmj.38160.634352.55v1“>study.

Other proponents argue that not all ruptures are catastrophic and some have actually been caused by labor-enhancing medications, called http://content.nejm.org/cgi/content/abstract/345/1/3“>prostaglandins, whose dangers for post-cesarean women are now recognized.

http://www.poughkeepsiejournal.com/article/20090329/NEWS01/903290311/1006

Childbirth Without Choice

by Pamela Paul

Posted February 20, 2009 | 03:20 PM (EST)

It would seem perfectly natural that a woman could give birth naturally if she wants to. Guess what? She can’t.

An increasing number of hospitals in this country are refusing to offer women the option of delivering the way nature intended, if she had a cesarean section the first time around (and guess what — chances are she has because the 31% of all births are now C-sections — up 50% in 10 years).

I wrote an article in this week’s issue of Time magazine called “The Trouble With Repeat Cesareans”on the subject of women’s diminishing patient’s rights. I won’t repeat the story here, since you can link to it here, but will give some of the back story for those who want more:

This was a story I’ve been wanting to write for a long time. The short version is, doctors and hospitals are no longer allowing many women to have a vaginal birth after cesarean (or VBAC, pronounced “vee-back”) because the “medicolegal” costs are too high. Or, as one ob-gyn put it when I asked why she and other doctors no longer allow VBACs, “”It’s a numbers thing. It is financially unsustainable for doctors, hospitals and insurers to engage in a practice when the cost of doing business way exceeds the payback. You don’t get sued for doing a C-section; you get sued for not doing a C-section.”

Now, I think most of us realize that many hospitals are for-profit institutions and that doctors need to make money too, increasingly hard in this era of managed care. It is nonetheless tough to hear a physician talk about medical care in such bare-bones financial terms. So, um, we can’t get the most appropriate care because it costs too much? What’s especially galling is that VBACs are actually a much less expensive “procedure” (if childbirth can be termed that way) than cesarean sections, which are major abdominal surgery and require days more in the hospital. The costs the doctor is referring to are the malpractice insurance costs passed on to doctors. And those costs aren’t even reasonable, but are largely in response to a few high-profile cases of VBACs gone awry dating back 10 years, many of which involved a labor-induction drug called Cytotec, which is no longer used during vaginal births after cesarean.

Meanwhile, according to the International Cesarean Awareness Network (ICAN), out of 2,849 hospitals with labor and delivery wards nationwide, 28% have total outright bans on VBAC and an additional 21% have de facto bans in that they say they’ll do it but none of the doctors on staff will do it. That’s half of American hospitals, but the numbers are probably much worse. Many of the rest will allow what’s often termed “Cinderella VBACs” (a term coined by Henci Goer ) — “yes, you can have a VBAC as long as you have it Monday – Friday, between 8 am and 5pm and you aren’t over 40 weeks and we don’t think your baby is too big”.

Moreover, even if the hospital allows VBACs, it doesn’t mean that all the doctors there are willing or eager to perform them. Take my own case. After I had a cesarean with my first child, I made a point to find a new practice that was VBAC-friendly. (I would have stayed with my first doctor, but my insurance switched, a whole other story). The practice I eventually signed up was very encouraging, telling me that VBACS had a 60-80% success rate and that their particular practiced boasted a 75% success rate. All good. Right?

Except, when I hit the 6 month point, my doctor said to me casually, “OK, let’s schedule your C-section now.”

“Excuse me?”

“Oh,” he said, “You know, you only have a 13% chance of success with your VBAC.” He went on to explain that since I had reached the “pushing” phase of my first labor, my chances of a successful VBAC were dismally low and therefore it made no sense to attempt one.

Furious at the bait-and-switch (doctors love, love, love C-sections — in and out in an hour! No messy labor! No pesky doulas or family members hanging around!), I asked him to produce the study that said so. It turns out that the study, which dated back to 1999, was contradicted by several later studies, all of which showed a significantly higher rate of success — between 40-60%. One study showed no difference in success rates at all, no matter where the first labor ran into trouble.

The doctor on call when I ended up giving birth on Thanksgiving weekend, was, needless to say, very much put out by my inconveniencing him. His revenge? He refused to talk to me while I was in labor, and didn’t answer his pager when I was ready to push. So that’s an example of a hospital that allows VBAC and supposedly pro-VBAC doctors for you. The truth is, doctors who are truly VBAC-friendly are few and far between. The good news is, I gave birth, via VBAC, to a perfectly healthy little boy and had a much quicker, easier recovery than I did with my C-section (which was hell, but another story).

I’ll end with this story, much more dramatic than mine: After giving birth to her first child via cesarean, Alexandra Orchard, a CPA in Colorado Springs, was told her second baby measured too large to be delivered vaginally. “My doctor said, ‘You’re not only risking her life, you’re going to break her collarbone when you push her out,'” Orchard recalls. Through tears, she scheduled a second cesarean. “I was in so much pain after each surgery that I don’t even remember when I met my children.” With her third child, Orchard was determined to get a VBAC, but her doctor refused. Orchard researched the risks and with the help of a midwife, labored for 30 hours and gave birth at home to a daughter, now almost two years old. Orchard is apprenticing to become a midwife because, she says, “I don’t want my daughter to have to fight like I did.”

Physicians group out of step as Health Care Organizations supporting CPMs increases

WASHINGTON, D.C. (February 17, 2009)—Two major health care organizations have joined the growing number of groups calling on policy makers to increase access to Certified Professional Midwives (CPMs) and out-of-hospital maternity care. Acknowledging the large body of evidence supporting the safety of home delivery with CPMs, who are specifically trained to care for mothers and babies in out-of-hospital settings, nursing and perinatal health care organizations criticized the American Medical Association (AMA) and the American College of Obstetricians and Gynecologists (ACOG) resolutions calling for bans on CPMs and home birth. The groups also joined Consumer Reports magazine in highlighting the need for a major overhaul of the U.S. maternity care system. “I am very proud to be an American, but I am embarrassed that our country, founded on the ideals of individual liberty and freedom, can also support ‘authoritative’ initiatives such as these by the ACOG and AMA, initiatives that are founded on neither science nor an understanding of the physiologic and psychosocial needs of mothers and babies,” said Nancy K. Lowe in an editorial published in the Journal of Obstetric, Gynecologic, & Neonatal Nursing, the official journal of the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN). “What is most risky about home birth in the United States is that for most women who desire it there is a scarcity of qualified providers of home birth services.” Consumer Reports magazine cited the desire for economic gain as one of the driving forces limiting access to CPMs and Certified Nurse-Midwives (CNMs), who are licensed in all 50 states and practice primarily in hospital settings, but who remain subject to anti-competitive regulations promoted by the AMA and ACOG. CPMs are legally authorized to provide out-of-hospital care in just half the states, while advocates working to reform the law in the remaining states face stiff resistance from physician groups seeking to establish a monopoly on the maternity care market in the U.S. “Midwives provide a safe and cost-effective alternative to the current model, where the market is dominated by high-cost, high-tech specialists producing less-than-optimal outcomes,” said Katie Prown of The Big Push for Midwives Campaign. “Babies delivered by midwives are far less likely to be pre-term or low birth-weight, which are two of the leading causes of neonatal mortality and of the enormous costs associated with long-term care. Midwives and out-of-hospital birth are an integral component of responsible health care reform, and the AMA and ACOG know this. That’s why they’re fighting so desperately to protect their turf, even if it means denying women maternity-care options in the process.” The National Perinatal Association (NPA) added to the growing list of organizations calling on the AMA and ACOG to end their vendetta against midwives and home birth and instead follow the World Health Organization’s (WHO) call to “‘work in a spirit of recognition and respect for each other’s authority, responsibility, ability and unique contribution.’” The Big Push for Midwives is a nationally coordinated campaign to advocate for regulation and licensure of Certified Professional Midwives (CPMs) in all 50 states, the District of Columbia and Puerto Rico, and to push back against the attempts of the American Medical Association Scope of Practice Partnership to deny American families access to legal midwifery care. Through its work with state-level advocates, the Big Push is helping to build a new model of U.S. maternity care built on expanding access to out-of-hospital maternity care and CPMs, who provide affordable, quality, community-based care that is proven to reduce costly and preventable interventions as well as the rate of low birth-weight and premature births. Media inquiries: Steff Hedenkamp (816) 506-4630, steff@thebigpushformidwives.org.

Flawed logic

GINA L. PENISTEN • SIOUX FALLS • FEBRUARY 2, 2009

For years, like other state legislators, Rep. Bill Thompson’s position on midwife licensure rested on theoretical armchair logic. The armchair logic proceeds like this: Licensing midwives would encourage home births. Home births result in “train wrecks” that don’t happen in hospital labors. This will lead to a worsening of South Dakota’s already terrible infant mortality rate.

Obviously, this year Thompson has stepped away from the armchair logic position and did some real-world research. As every legislator who has looked carefully at the certified professional midwife credential and actual outcomes in case-controlled studies of midwife-attended home births, Thompson now is a proud cosponsor of the bill. He obviously realized that the armchair logic suggesting women with midwife-attended home births have increased incidents of “train wreck emergencies” is not at all supported by evidence. In fact, if the retired teacher defined “train wrecks” as child-birth emergencies requiring cesarean sections, the midwife-attended home-birth group gets an “A” (96.3 percent vaginal delivery rate). The hospital group gets a “D” (68 percent vaginal delivery).

Neither group can claim an advantage in terms of immediate mortality because instances of actual deaths are equally remote whether you started in the “A” or “D” group.

Now, if only every legislator would step away from the armchair and vote based on facts, perhaps South Dakota will be the next instead of the last state to license certified professional midwives.

http://www.argusleader.com/article/20090202/VOICES09/902020313/1052/OPINION01

Home-birth advocates press pro-midwife campaign

By DAVID CRARY

NEW YORK (AP) — With health care costs high on the national agenda, advocates of home births are challenging the medical and political establishments to give midwives a larger role in maternity care and to ease the state laws that limit their out-of-hospital practice.

Pending bills to further this goal have significant backing in several states, which home-birth supporters want to add to the 25 states that already have taken such steps.

Nationally, a group called the Big Push for Midwives marked President Barack Obama’s inauguration with an e-mail campaign urging him to ensure that midwives who specialize in home births are included in deliberations on federal health care reform.

“We’re at a tipping point now,” said Katherine Prown, the Big Push campaign manager. “Home births are still only a small part of the total, but it’s poised for growth.”

The campaign seeks to emphasize that in this time of economic crisis, home births can be a safe, satisfying and moneysaving option for many women. But it runs into adamant opposition from the American Medical Association and the American College of Obstetricians and Gynecologists.

“Childbirth decisions should not be dictated or influenced by what’s fashionable, trendy, or the latest cause celebre,” the obstetricians’ policy statement says. “Despite the rosy picture painted by home birth advocates, a seemingly normal labor and delivery can quickly become life-threatening for both the mother and baby.”

According to the latest federal data, there were only about 25,000 home births nationally in 2006 — most of them assisted by midwives — out of nearly 4.3 million total births.

Midwife-attended home births increased by 27 percent between 1996 and 2006. Home-birth advocates believe the numbers will rise as more states amend their laws to accommodate the practice, which they contend is at least as safe as hospital births for healthy women with low-risk pregnancies.

One of the strengths of the state-by-state campaign is its diversity, Prown said.

“We’re one of the few movements that’s succeeded in bringing together pro-life and pro-choice activists, liberal feminists and Christian conservatives,” she said. “In every state we manage to recruit Republican and Democratic co-sponsors who normally would never be on the same bill together.”

The states are now evenly split on legal recognition of certified professional midwives (CPMs) — those who lack nursing degrees and who account for most midwife-assisted home births.

Half the states have procedures allowing CPMs to practice legally — including five which have taken such steps since 2005. The other 25 states lack such procedures and CPMs are subject to prosecution for practicing medicine without a license.

Depending on legislative decisions, the balance could shift this year. Among the battlegrounds:

_In North Carolina, a House study committee recommended in December that the legislature develop licensing standards for CPMs. The committee said the current system doesn’t meet the needs of women who chose non-hospital births because of the “extremely limited supply” of obstetricians and nurse-midwives offering to handle such births.

_In Idaho, advocates who failed previously to get a voluntary licensing bill through the legislature are back with a mandatory licensing bill. State Rep. Janice McGeachin, R-Idaho Falls, says the changes helped persuade the state boards of nursing and pharmacy to drop their opposition. The Idaho Medical Association, which fought the earlier version, has expressed respect for the changes in the bill and is deliberating on whether further changes might produce a version it could accept.

_In Illinois, advocates also are back with a new version of a licensing bill that failed in 2007. Rep. Julie Hamos, D-Evanston, says it toughens qualification standards for CPMs — changes that prompted the Illinois Nurses Association to drop its opposition. The Illinois State Medical Society remains opposed.

“There are many in the legislature who feel a need to have this option — they need to be educated,” said Dr. Shastri Swaminathan, the society’s president. “We’re in strong opposition to licensing midwives who don’t have the medical training to provide safe home births.”

Cost is a major element in the debate. A routine hospital birth often can cost $8,000 to $10,000, with higher bills for cesarean section deliveries that now account for 31 percent of U.S. births.

Midwives’ fees for home births are often less than a third of the hospital cost, in part because the mothers generally don’t receive epidural anesthesia or various other medical interventions at home.

For pregnant women, insurance coverage can be a decisive factor in their choice. Many insurers cover care by nurse-midwives in hospitals; coverage is less common for midwives who aren’t nurses or who assist with home births.

Many obstetricians acknowledge that the spiraling cost of maternity care and high rate of C-sections are problems.

“But the answer is not to have births at home,” said Dr. Erin Tracy, an obstetrician at Massachusetts General Hospital in Boston. “We obviously support women’s empowerment, but the No. 1 guiding principle has to be the health and safety of the mother and baby.”

The national physicians’ groups do support births assisted in hospitals and birthing centers by midwives who’ve completed nursing school or an equivalent postgraduate program.

The American College of Nurse-Midwives, which represents these midwives, says it differs from the AMA in considering home births a legitimate option for pregnant women. But the college says only nurse-midwives or others with comparable training should be allowed to assist.

“We don’t believe it’s safe without being integrated into the full health care system,” said Melissa Avery, the college’s president.

The education standards endorsed by the college would exclude many of the estimated 1,400 certified professional midwives, who often acquire training through apprenticeships.

Jane Peterson of Iola, Wis., is an example. She began a midwife apprenticeship in 1980 and has attended more than 1,330 births since then, many of them before she and her counterparts were legally authorized to practice under a 2005 state law.

Peterson, 56, said she strives to develop collaborative relations with local doctors so that transfers to hospitals go smoothly if risk factors develop. She believes such cooperation should be encouraged nationwide, so more women can feel comfortable about choosing home births.

“People will tell you that you changed their lives,” said Peterson, reflecting on the rewards of her job.

“It’s hard work — getting up on a cold winter night, going out one more time through the snow. What keeps you going is the recognition women feel — as though they are a different kind of mother when they’ve been able to give birth their way.”