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.”

ACOG State Legislative Update–Who’s afraid of a few “lay” midwives?

The ACOG recently published their yearly state legislative update. The main topic was those troublesome ‘lay’ midwives and home birth. While the document is full of the typically misinformed information and erroneous assumptions about midwives, it has the flavor of someone who is afraid–very afraid. Let me quote from the document and set the record straight.

The report first mentions that home birth bills are on the rise in states across the country, fueled by state midwifery guilds and MANA (Midwives of North America) and its credentialing organisation, NARM (North American Registry of Midwives). It complains that because of Republican majorities in states and the crafting of a model bill by The American Legislative Exchange Council (ALEC) that many of these bills are not only being introduced, but passed. They are afraid of the trend of conservative lawmakers who lump home schooling and home birthing together.

Interesting…I home schooled my children back in the day when we were considered pioneers and many states still considered us lawbreakers. The question of the day was “what kind of quality education could they possibly get?” and “what will you do about socialization?”. Funny, no one asks those questions much anymore. Home schooling has been around long enough now for people to see the fruit, and the educational outcomes from many public schools and accompanying issues with negative peer pressure has made many a doubter look longingly over to the other side of the home school fence. Perhaps home birthing will enjoy the same awakening if enough people buck the system to embrace birth as a normal event?

To quote again from the document: “The ‘lay midwives’ internal philosophy on state regulation and licensure appears to have shifted. In the past, their position on licensure reflected the dominance of midwives who did not want to be regulated, opposed state licensure, and defended within their individual guilds the right to stay unlicensed and practice underground. While there are midwives who still do not want to be regulated and who do not support the current licensure campaign, for the most part you don’t see them speaking publicly against licensure in the legislature or elsewhere. Even the nurse-midwives no longer can be counted on to speak publicly against home birth or lesser trained midwives.”

Excuse me while I take a moment to laugh out loud at this one. Even the nurse-midwives have turned coat and can’t be counted on to speak out against home birth? Maybe a good portion of them are simply tired of following obstetrical authoritarian’s non-evidenced based protocols and have had enough of a glimpse over the fence at the outcomes of their home birthing sister midwives to just decide not to say anything at all. Some of them have home birth practices of their own. I recently attended a Christian midwifery conference and there were midwives in attendance of every persuasion–‘lay’ midwives, CPMs, CNMs, whatever you call yourself. No one wore a name tag with their credentials, just our names. You know what sifted to the top? Not a title—wisdom (experience+knowledge), knowledge, skill. No matter what your title, you learned a few new things from someone who had put something solid into practice and knew that it worked. CNMs learned from CPMs and vice versa. It was quite refreshing.

Next point in the ACOG document says: “The term direct entry is used to refer to midwives who enter the profession of midwifery directly without earning a nursing degree. Both certified professional midwives (CPMs) and certified midwives (CMs) are considered direct-entry midwives, although their level of education and training varies markedly. CPMs are largely self-taught and their training is typically through aprenticeship. CPM was the title chosen by MANA and NARM in the mid-1990s for their credentialed direct entry midwives. By comparison, CMs must undergo three years of university-affliated training, and while there is no nursing prerequisite, these direct-entry midwives must complete the same science requirements and sit for the same certification exam as a nurse-midwife. ….More states are adopting the CPM credential as a requirement for midwifery licensure, and not the CM credential which both ACOG and ACNM recognize. Of the roughly 21 states that license midwives to attend home births, all use the CPM credential. By their lack of training and because they do not work collaboratively with hospital-based obstetric providers, CPMs are the least qualified midwives to attend a home birth.”

So much is wrong in that one paragraph, I hardly know where to start. True that all midwives who enter the field without first becoming a nurse are called direct entry. It is odd that both the ACOG and ACNM recognize and approve of this route, as long as you can pass the certification exam and will work collaboratively with a hospital-based obstetric provider (can you say CONTROL?). But if you get an equal didactic education somewhere other than their own hallowed halls and your clinical experience occurs in a home birth setting, then you are seen as decidedly inferior. Anyone who calls the process to become a CPM a ‘lack of training’ has not actually seen the hoops you must jump through, nor understood the knowledge required to pass both the clinical and written exams. In this situation, I think ‘lack of training’ can be interpreted “we can’t control them!”. And the last time I looked, CPMs and CNMs were using many of the same textbooks to obtain their education. Much has been said about the apprenticeship model recommended to receive the clinical training necessary for certification as a CPM. Because a physician must go through an internship before he/she is allowed to practice independently, I fail to see much difference. Both models offer the opportunity for hands-on experience under the supervision of a person with infinitely more experience and knowledge. It is an ideal way to learn how to apply your book knowledge into practical terms. They call it internship, we call it apprenticeship. A rose is a rose is a rose.

“To bolster their case for licensure, midwives like to cite European countries’ experience with midwives and home birth. This may play well with an uninformed public, but the analogy is flawed. The conditions that make home birth relatively safe in some countries–the Netherlands for example–do not pertain to much of the US. The Netherlands is a geographically small, densely populated country where everyone lives within 20 minutes of a hospital.”

Very misleading statement! Yes, it is a small, densely populated country, but everyone does not live within 20 minutes of a hospital, as reported. The hospital situation in the Netherlands is not at all like the US. There is not a hospital in every town, and even in towns with hospitals, because of the dense population, the traffic alone sometimes prohibits speedy arrival at a hospital. Most are operated by the government or universities, not privately owned, so there really aren’t that many hospitals. Every city and village doesn’t have a hospital, yet the Netherlands enjoys a MUCH better infant mortality rate than the US. Most of their births occur in their homes and are attended by non-nurse midwives because they treat pregnancy and birth as a normal event, not a medical emergency. Usually only the high risk pregnancies are encouraged to birth in their hospitals with obstetricians. Hmmmm, OK so if home birth is safe in that country only because they live so close to a hospital and we’ve blown that theory out of the water, we’ll have to assume their statistics are better than ours for other reasons. Could it be that perhaps if you treat birth as a normal event and you don’t induce, augment, confine, over-monitor and otherwise harass a laboring woman, things just might work better? That would be a hard one for the ACOG to swallow.

“In their recent testimony to state legislators, midwives have been citing a 2005 study on the safety of home births by direct entry midwives in the US. (Johnson KC, Daviss B. Outcomes of planned home births with certified professional midwives: large prospective study in North America. BMJ 2005;330;1415) This study concluded, “certified professional midwives achieve good outcomes among low risk women without routine use of expensive hospital intervention.” ACOG continues to assert that studies comparing the safety and outcome of births in and out of the hospital are problematic, not scientifically rigorous, and unconvincing.”

In other words, they see the proof, but they just can’t wrap their minds around it. They believe what they want to believe.

“…in Missouri, ‘lay’ midwife bills get introduced year after year. These bills have been stopped–up to now–mainly by deft political maneuvering and hardball tactics employed by the State Medical Society, not by any persuasive testimony about comparative safety or quality of care.”

Quite an admission, wouldn’t you agree? They go on to discuss how nurse-midwives have previously been their front-line defense against these bills, but now they are a fickle ally. Maybe there is a growing respect between the two sets of professional women, in which the knowledge each possesses is no longer mistrusted.

“Physician back-up for midwives and out-of-hospital deliveries is a growing concern in some states. …In 1993, California licensed midwives to do home deliveries under physician supervision. But implementing regulations for the 1993 law were only recently finalized after years of wrangling over key issues including the physician supervision requirement in the authorizing legislation. Medical liability insurers in the state were refusing to cover physicians who back-up midwives and midwifery proponents in the legislature threatened to waive the requirement for physician supervision altogether.”

It was the ACOG who got the requirement for physician supervision thrown in at the last minute. With the liability insurers already refusing to cover physicians who backed up midwives, it created a situation impossible to abide by for CA midwives. Or was that the idea….?

It’s slightly amusing that this review refers to legislative handbook developed by MANA as being full of “lobbying advice, tactics and propaganda”. Is everyone aware that the ACOG is basically a lobbying organization for the advancement of obstetricians and gynecologists? Isn’t this a little like the pot calling the kettle black?

Lastly, the document mentions the problem of hospitals refusing to do VBAC (vaginal birth after cesarean) deliveries as being one of the reasons many women are seeking out other alternatives, including home birth with midwives. The most up-to-date studies all support VBAC attempts as being the safer approach to subsequent births in the majority of situations. Yet hospital after hospital have closed out this option, choosing to bow under the pressure of regional medical standards and insurers demands, rather than evidence-based studies. What are women to do who don’t wish to undergo major surgery to birth their babies again, especially when the number of primary unnecessary cesareans is so unreasonably high? They go to the only sane choice available–they turn to highly skilled, highly educated home birth midwives.

Honestly? They sound a little worried.