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.

Crunching numbers

I was finally able to get some figures to try and determine what the cesarean section rate is running with my local hospital.  It’s difficult to get an exact number because of the way they have their figures broken down.  You have to get the actual birth rate from one site for a calendar year and the hospital gives you its cesarean rate for a calendar year, but between the two it looks like we are running around a 50% cesarean rate here.  A surgical nurse told me recently he t hought it might even be higher because he saw so many of them.

Either way….that is criminal.  HALF of the women in this area are not allowed to birth their babies vaginally?  High intervention rates, high induction rates, high epidural rates, and across the board denial of VBACs have resulted in this soaring rate.

My childbirth classes are geared to those intending to have a hospital birth.  I try to teach them how to avoid an unnecessary cesarean birth, coping techniques for a natural birth and the many advantages of natural birth.  If I can save a few women from the trauma, recovery from major surgery and psychological scarring of surgical birth, it’s worth my time.  Some of them learn too late the consequences of their choices in birth.

I recently tried to help an expectant mom achieve a vaginal birth after a cesarean birth for her first child.  I’ve never seen a mom want something so much and work so hard to attain it.  She was a warrior and as long as she and the baby were both fine, I continued to fight with her for her goal.  But ruptured membranes for too many hours, a posterior baby that wouldn’t turn anterior, a large baby and a marginal pelvis combined with a dysfunctional labor were more odds against us than we could fight.  She ended up in a transfer with her uterus still intact and baby still in good shape.  But she had another cesarean.  It was hard emotionally on us both.  I knew she had done everything she could possibly do and I knew I had also, but it just wasn’t going to happen.  I know that the cesarean was necessary and I’m glad that eventually she will know it was the only way to safely deliver her child.

When she and her family arrived at the hospital they were treated as criminals for having attempted a VBAC.  Every person they encountered was rude and misinformed about the statistics concerning VBAC safety (a nurse told them there was a 99% rupture rate!).  The OB on call lied to her and said her uterus was ruptured and that’s what you get when you use an illegal midwife.  When she was finally able to get her actual surgical records, she discovered there was no rupture at all.  This same OB told another VBAC homebirth transfer several years previous to this that he had done a vertical incision just so she would never try something that stupid again.  Again, she was smart enough to request her actual surgical records and discovered only the external incision was vertical, the actual uterine incision was transverse.  This same hospital was doing VBACs themselves until just a year and a half ago, when pressure was put on them by other hospitals in the region, and insurance companies. It had nothing to do with good science or the vast body of medical studies that have shown us there is only a 0.05% chance of rupture, meaning there is a 99.05% chance of NOT rupturing!  It had everything to do with community standards, which are frequently not based on medical evidence.

Is it any wonder some women want to run away?

Not all physicians support AMA stand on home birth

Not all physicians agree with the AMA’s position, however. Dr. Andrew Kotaska, noted Canadian researcher and Clinical Director of Obstetrics and Gynecology at Stanton Territorial Hospital, issued the following response:

I would invite ACOG to join the rest of us in the 21st century.
Modern ethics does not equivocate: maternal autonomy takes precedence over medical recommendations based on beneficience, whether such recommendations are founded on sound scienctific evidence or the pre-historic musings of dinosaurs. In the modern age, the locus of control has, appropriately, shifted to the patient/client in all areas of medicine, it seems, except obstetrics. We do not force patients to have life-saving operations, to receive blood transfusions, or to undergo chemotherapy against their will, even to avoid potential risks a hundred fold higher than any associated with home birth. In obstetrics, however, we routinely coerce women into intervention against their will by not “offering” VBAC, vaginal breech birth, or homebirth. Informed choice is the gold standard in decision making, and it trumps even the largest, cleanest, RCT.

Science supports homebirth as a reasonably safe option. Even if it didn’t, it still would be a woman’s choice. ACOG and the AMA are, by nature, conservative organizations; and they are entitled to their opinion about the safety of birth at home. As scientific evidence supporting its safety mounts, however, (to which BC’s prospective data is a compelling addition) they will be forced to accede or get left behind. The concerning part of this proposed AMA resolution is the “model legislation.”

If ACOG and the AMA are passive-aggressively trying to coerce women into having hospital births by trying to legally prevent the option of homebirth, then their actions are a frontal assault on women’s autonomy and patient-centered care. Hopefully the public and lawmakers realize the primacy of informed choice enough to justify Deborah Simone’s words: “We don’t need to be angry or even react to these overtly hostile actions from the medical community. We just need to keep doing what we do best; the proof is always in the pudding.”

It is sad to see the obstetrical community still trying to earn itself a wooden club as well as the wooden spoon; if the resolution passes, it is sad to see the politico-medical community helping them.

Andrew Kotaska

Physician group seeks to outlaw home birth!

Father Knows Best Meets Big Brother Is Watching

Is Jail for Moms Next?

WASHINGTON, D.C. (June 16, 2008)—Just in time for Father’s Day, at its annual meeting last weekend, the American Medical Association (AMA) adopted a resolution to introduce legislation outlawing home birth, and potentially making criminals of the mothers who choose home birth with the help of Certified Professional Midwives (CPMs) for their families.

“It’s unclear what penalties the AMA will seek to impose on women who choose to give birth at home, either for religious, cultural or financial reasons—or just because they didn’t make it to the hospital in time,” said Susan Jenkins, Legal Counsel for The Big Push for Midwives 2008 campaign. “What we do know, however, is that any state that enacts such a law will immediately find itself in court, since a law dictating where a woman must give birth would be a clear violation of fundamental rights to privacy and other freedoms currently protected by the U.S. Constitution.”

Until the AMA proposed ‘Resolution 205 on Home Deliveries,’ no state had considered legislation forcing women to deliver their babies in the hospital or limiting the choice of birth setting. Instead, states have regulated the types of midwives that may legally provide care. Currently, 22 states already license and regulate CPMs, who specialize in out-of-hospital maternity care and have received extensive training to qualify as experts in the types of risk assessment and preventive care necessary for safe and high-quality care for women who choose give birth at home. Certified Nurse Midwives (CNMs), who are trained primarily as hospital-based providers, are licensed in all 50 states and the District of Columbia.

The resolution did not offer any science-based information for the AMA’s anti-midwife or anti-home birth position.

Maternity care is a multi-billion dollar industry in the United States,” said Steff Hedenkamp, Communications Coordinator for The Big Push for Midwives. “So it’s no surprise to see the AMA join the American College of Obstetricians and Gynecologists in its ongoing fight to corner the market and ensure that the only midwives able to practice legally are hospital-based midwives forced to practice under physician control. I will say, though, that I’m shocked to learn that the AMA is taking this turf battle to the next level by setting the stage for outlawing home birth itself—a direct attack on those families who choose home birth, who could be subject to criminal prosecution if the AMA has its way.”

The Big Push for Midwives (http://www.TheBigPushforMidwives.org) is a nationally coordinated campaign organized 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 to deny American families access to safe and legal midwifery care.

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.

Pennsylvania reverses rulings against midwife Diane Goslin!

It’s about time we had some good news on the legal front.  Why are we allowing the financial and philosophical ‘competition’ to control this vital right of women to birth where and with whomever they desire?  Story follows:

In a stinging blow to both the Pennsylvania Medical Board and the Pennsylvania Medical Society, Pennsylvania Commonwealth Court reversed all three rulings the PA Board of Medicine had issued against Diane Goslin:

– the Cease and Desist Order;

– the $10,000 fine for the unlicensed practice of medicine; and

– the $1,000 fine for the unlicensed practice of midwifery.

Pennsylvania midwife Diane Goslin may now legally attend births.

PA Commonwealth Court Justice Friedman opined that “practicing midwifery cannot be construed to be the same as practicing medicine…”  Therefore, the court reversed the egregious and erroneous PA Board of Medicine ruling.

Additionally, the Court found that the PA Medical “Board deprived [Diane Goslin] of due process” rights as required by Pennsylvania law.

The Court further pointed out that the 1985 PA Nurse-Midwifery Act, “…authorizes the Board to impose penalties only upon persons who practice as a nurse-midwife without a nurse-midwife license.”  Goslin practices as a Certified Professional Midwife.


PA Commonwealth Ruling

News Releases

Harrisburg News

Philadelphia News

York Daily Record

Save HomeBirth web site

The Trust Birth Conference

I’m going. This conference is sponsored by Ancient Art Midwifery Institute and Carla Hartley. She says it will be her last one and it is worth putting everything else aside to attend. Some of the biggest names in the birth community will be there. Dr. Sarah Buckley, Dr. Michel Odent, Dr. John Stevenson, Jan Tritten, Heather Cushman-Dowdee (Hathor, the cow-goddess), Rixa Freeze, Henci Goer, Mindy Goorchenko, Gail Hart, Ricki Lake, Gloria Lemay, Sheri Menelli, Shonda Parker, Karen Strange, Sheila Stubbs, Debby Takikawa, and many others. Everyone is talking about it…be one of the ones who gets to attend this life-changing event.

Click here for just one of the YouTube clips.  Friday sessions here.   Saturday morning here.  Saturday afternoon sessions here.  Sunday sessions here.