More mis-information from FOMM: Will Michigan outlaw your midwife?

The Friends of MI Midwives recently posted a lovely piece of fear mongering on their blog entitled, "Will Michigan Outlaw Your Midwife?"  in their response to Senate Bill 1208

Safer Midwifery for Michigan would like to address each point of their position and address the misconceptions: 

SB 1208 will outlaw all non-nurse midwives = FALSE
SB 1208 requires RN training to be eligible for midwifery licensure, but does not require AMCB training as an advance practice nurse and certified nurse midwife for entry into practice. The state is allowed to permit a license to a midwife with an RN license and additional training in midwifery. Please read this carefully, this does not limit licensure exclusively to certified nurse midwives. 

Eliminate access to out-of-hospital birth in most of our state = FALSE
FOMM is saying that since few CNMs practice OOH, this will limit the availability of OOH midwifery practices. The first fault in this reasoning is assuming that this bill limits licensure exclusively to nurse-midwives. This is false. Please see our first point.
    

Elminate the designation of Certified Nurse Midwife and create a new category of licensed midwife = TRUE
This bill aims to license all midwives practicing in the state of Michigan in an attempt to standardize practice guidelines.  Some may have to boost their coursework or skills, but the opportunity is present for all midwives to earn a license.  A few of our blog readers have commented that this has the potential to restrict hospital based CNM practice. This is not the intent of this bill, and I am confident the language will be revised.  
    

New York State licensed midwives under a board of midwifery in 1992. The credential permitted to practice under this law was the AMCB trained CM. And in the past 20 years, some CPMs have become licensed as CMs in New York.  This is another potential revision.
   

Legislate many new restrictions on which births can take place at home = FALSE
Safer Midwifery for Michigan advocates for the safe practice of midwifery. It is in the state’s interest to minimize risk of injury or death during homebirth, especially if state is authorizing license for these professionals, as well as state-funded Medicaid payments to these professionals.  Note – this bill does not criminalize home birth. It restricts who can use the term “midwife” or “licensed midwife” in providing home birth services and outlines a safe practice guidelines for licensed midwifery practice.
   

Eliminate free-standing , independent birth centers by requiring them to work under hospital supervision = FALSE 

Let's look at the SB1208 language regarding birth center licensure:

(B) PRESENT PROOF SATISFACTORY TO THE DEPARTMENT THAT THE

FACILITY HAS A CONTRACTUAL RELATIONSHIP WITH AN OBSTETRICIAN-

GYNECOLOGIST WHO IS LICENSED AS A PHYSICIAN UNDER ARTICLE 15, A

GROUP OF PHYSICIANS LICENSED UNDER ARTICLE 15, OR A HOSPITAL

LICENSED UNDER ARTICLE 17, THAT AGREES TO PROVIDE CONSULTING

SERVICES DURING DELIVERIES.

Providing proof of a relationship with a OB/GYN is not hospital supervision - it is a way for providing accountable, quality assurance to the clients of the birth center.  The Midwives Model of Care includes:

"Identifying and referring women who require obstetrical attention."

This provision is included in SB 1208 to assure that licensed birth centers provide care that is consistent with their own widely-publicized Midwives Model of Care statement.

To everyone supporting HB 5070 - please be informed consumers, and do your research. Don't believe everything you're told by your midwife, or by those purporting to be "friends" of midwives. Do your homework. Read the bills yourself. Take responsibility for your legislation. You are capable of making an informed, autonomous choice, and knowing the facts. Midwives are experts at supporting your individualized, informed decisions. Don't let them tell you what to do.

What We're Seeking: Defined Scope of Practice

I've written before about the number of midwife apprentices who seem to be speaking out about the dangerous practices they have witnessed in home birth.  What concerns me more are those who are too afraid to tell the truth for fear of being ostracized by their own community.  This speaks volumes about the tumultuous dynamic that exists within midwifery.  

Instead of really working to improve practices and keep mothers an babies as safe as possible, a strong undercurrent is working to adhere to misguided practices with purposefully vague guidelines.  What does it mean to "define scope of practice"? It means defining exactly what kinds of births are simply too risky to be taken on outside a hospital, and defining when/how a midwife should recognize that the situation at hand requires the expertise of an obstetrician.  Defined scope of practice helps a midwife assess precisely what is "low-risk" and what is not.  It helps her determine when to take action (ach-em, transfer of care) to ensure the safest circumstances.  Defined scope of practice sets boundaries, not restrictive boundaries, boundaries with a purpose.  Having a defined scope of practice leaves no question marks for the midwife and works to protect the mothers and babies she serves. 

We recently received the following email from a former apprentice regarding informed consent and lacking scope of practice guidelines.  Her words perfectly illustrate the dire need for defining a scope of practice for out of hospital midwives.

"Regarding informed consent...Do I think midwives are incapable of providing evidence-based information?  No.  They are perfectly capable.  But there is no incentive or requirement for them to do so.  Nor are there any professional practice guidelines or professional practice bulletins for CPMs or other out-of-hospital midwives to work from.

• The Royal College of Midwives writes practice guidelines and cites evidence for these practices.

• The ACNM publishes position statements and disseminates research through a peer-reviewed journal.

• Canadian midwives have guidelines for out-hospital-birth and informed consent. And even outline steps to take when mothers refuse a standard of care.

• AWHONN advocates for safer labor and delivery protocols and publishes its own guidelines for FHT monitoring in labor.

"But I have seen nothing even close to this coming from the professional organization(s) that represent CPMs and home birth midwives. 

"Most of the informed consent given by individual midwives are highly skewed toward the midwife's own personal biases and opinions.  They don't have specific professional guidelines to assist them.

"What is (and was) so frustrating to me is no one in OOH midwifery seems to be asking: 'What is the best/safest course of care in certain situations?'

"My first choice would be that midwives would put their heads together, scrutinize the research and evidence, make an HONEST assessment of what types of cases are being attended at home births (high-risk), and come up with (safe!) guidelines supportive of the midwifery model of care.  I don't see this happening."  

So I have to interject here an example in Michigan, of midwives "putting their heads together" for midwives, and regulating midwives with House Bill 5070.  Come on ladies, she said "honest assessment of what would be safe guidelines"!  You're not fooling anyone who really is looking for safer practices in midwifery.  You're just asking the state to hand you a license for your unsafe practices, without really considering what criteria would actually make things safer in home birth.  There are no practice guidelines, in this bill or anywhere else, that have anything to do with evidence-based research for a CPM or out-of-hospital midwives.  Just lots of magical intuition and trust in birth coming from NARM, plus the perks of writing prescriptions for pain control and a board of all midwives to keep your practices hidden.     

"I think the profession (NACPM) should write their own specific guidelines.  And I know I'm asking for moving mountains when I say this.  I think forcing CPMs to act like professionals will either force them to better themselves and their practices - or cause them to become completely fractured. But I think either option is preferable to what exists right now."

For more on this topic:

Home Birth Story: Why women shouldn't have to be their own midwives (coming soon)

Navelgazing Midwife: Succinct Reasons CPMs/DEMs Need to Get Their Act Together

Navelgazing Midwife: CPMs Don't Read This

The Marriage Between Legislation & Choice

Sometimes they say opposites attract.  Conversations about preserving our freedom as citizens don't exactly favor legislative action.  That being said, there are times when legislation and balanced regulation have worked to improve living standards and protect the people.  And so I ask, when do we consider legislation to be necessary to protect the people, or greater world?  When it comes to the food we eat, or the clean water we drink?  Traffic Laws?  Child Care?  Treatment of Animals?  Drugs?  How do we regulate, but still preserve freedom of choice?

I believe Senate Bill 1208 does exactly that, preserves choice and improves safety.  It defines "licensed midwife" to mean one of three things: 

1) A CNM (certified nurse midwife): a bachelors degree in nursing, graduate school in midwifery, and passing ACNM's exam to earn a license

2) A CM (certified midwife): a bachelors degree in something other than nursing, graduate school in midwifery, and passing ACNM's exam to earn a license

3) A new alternative to licensing is proposed: RN (2 years of nursing school), 50 births with a licensed midwife as an apprentice, and passing a state approved exam

Number three is where the controversy lies.  Our state currently has some midwives who have a CPM (certified professional midwife) credential.  They are fighting to be licensed in HB 5070.  The question is whether or not a CPM's preparation and "education" is sufficient to warrant a state issued license.  Senator Whitmer, among others do believe that more consistent education and training are needed to adequately assist women safely in their homes, birth centers, or hospitals.  In short, the CPM credential doesn't set the bar high enough when it comes to training or practice standards, and the way this credential is obtained varies widely among those who have earned it.    

Senate Bill 1208 proposes a different alternative for licensing, that being choice number 3 above.  It doesn't require graduate school, but it does establish a minimum standard of education and training that is acceptable to earn a state issued license.  

Those who are fighting for "choice" are fighting to be able to birth with anyone, qualified or not, unassisted even if that is their choice.  This bill does not take that right away.  What it does do, is stipulate that if someone is calling herself and advertising a "midwife" she must be educated according to standards, state-licensed, and insured.  It defines "midwife" as meaning something for consumers.  It does NOT say it is illegal to have your baby at home with our without a licensed midwife.  

Setting the minimum standard was an attempt to ensure that all midwives have had adequate coursework in pharmacology, physiology, clinical & emergency training.  It was aimed at helping midwives better understand the complicated ways our body systems function together.  It was meant to help them understand the way drugs interact, should be kept, and how they should be administered.  Some have even pointed out that an RN, plus 50 births without specificity toward where and what those birth setting should be, is NOT enough.  Still others feel the RN requirement is too much.  The most important aspect in all of this is the need to establish standards for education so that our midwives are prepared to be the best they can be and serve women safely.  This much needed debate has begun and  that is progress.  The goal, defining a bill that actually improves safety, preserves choice, and establishes standards for education and practices regardless of setting.  

Ultimately, women want and deserve choices when it comes to where and how to give birth.  The goal is to make all of those options as safe and consistent as they can be.  Senate Bill 1208 does not take away anyone's choice to have a home birth or a birth center birth.  It works to make sure that "midwives" attending home births are educated to a baseline standard, and are competent to be delivering babies.  We're not talking about baking cookies here, we're talking about life's most complicated event, and that must be attended by people who have met appropriate standards.  No matter how natural  your view of birth may be, we can all agree that birth is not to be taken lightly, that it is precious, and at times dangerous.  Not just anyone should be allowed to call herself a midwife, nor should just anyplace be allowed to call itself a birth center.  

This bill represents a healthy marriage between legislation and the rights of women to choose where they give birth...plus the added bonus of ensuring that your midwife is well educated and trained to be taking on the inherent responsibilities of attending that birth.  Recognizing there is a shortage of qualified midwives to serve in this capacity should tell us all we have a long way to go if we are to demonstrate excellence in midwifery on a consistent basis.  Michigan mothers deserve better and the time for change has come.    

Here are some other links for exploring CPM training and practices: 

Navelgazing Midwife: Succinct Reasons CPMs/DEMs Need to get Their Act Together

(Links below coming soon) 

Home Birth Story: Why women deserve not to be their own midwife 

Tell Me About This Credential: The CPM or the Certified Professional Midwife

Big Bill Debate: HB 5070 & SB 1208

Much conversation has circled our state and community in the recent week since Senator Whitmer announced Senate Bill 1208.  A reader asked for a side by side comparison of the two bills.  This chart represents to the best of my knowledge and interpretation what these two bills have to offer.

The bottom line is that something has to be done to make sure Michigan's midwives are educated, licensed, consistently as safe as the can be, and accountable.  The question then is what should that legislation look like?  Just like good writing, authors of bills go through many revisions.  We have two bills that stand on opposite ends of the spectrum, two that will undergo many debates and revisions before a vote can be taken.  Perhaps by discussing the specifics we can find common ground for advocacy that can help our Senators and State Representatives address these issues with specific recommendations from the people they serve.     

View Comparison Chart: House Bill 5070 & Senate Bill 1208

Here's more food for thought...if you're feeling conflicted about NARM's credential not being enough (House Bill 5070), but feeling like a RN requirement is not a good fit either (Senate Bill 1208), check out Florida's regulations, where licensed midwives have standards in line with International and National guidelines.  

Florida Department of Health: Licensed Midwives Statues and Rules

Midwives Association of Florida

I'd love feedback on this post, no matter where your perceived allegiance lies because in that conversation is where we will find something that works.  Please be specific.  If you feel your "choice" is threatened, specify how and why.  If you feel there are issues with requiring insurance, specify what those concerns are.  If you feel something is missing or misrepresented, please indicate so in the comments so we can discuss it.  Please don't make an accusation toward either bill without backing up your statement with specifics from that respective bill, or we won't get anywhere here.   Thank you for participating in a conversation aimed at preserving choice and improving safety, one that can leave propaganda at the door.  

The Big Push Back

MANA has been hard at work with their "Big Push for Midwives" campaign, aimed at licensing CPMs in every state.  So far they've been successful in 27 states, but not in Michigan.  State Representative Ed McBroom supports licensing for (CPMs) home birth midwives with his House Bill 5070, but what he fails to address in his bill are all the important elements that go along with licensing that would actually help make home birth a safer option than it is at present.  

For example, Representative McBroom forgot to include a sound educational standards for the preparation and training of midwives.  He also missed defining "midwives" as licensed individuals and not anyone who decides to call herself one, defining a scope of practice as being only for low-risk pregnancies, detailing transfer of care protocols, encouraging collaboration with OBs, establishing a balanced board to conduct oversight of the practice, and requiring midwives to report all outcomes.  Not only did he leave these important elements to improving safety out of his bill, he went further to cite NARM as the source who would determine educational standards and hold midwives accountable.  This bill seemed more like a favor to the lay midwives that delivered his four children than one that was meant to really protect women and babies.  

Should home birth midwives be licensed?  Yes.  A licensed midwife should be the only "midwife" allowed to practice by law.  The caveat is that handing incompetent people a license does not improve safety.  Licensing is only one piece of the puzzle.  All of the other pieces have to fall into place if the end result is genuinely aimed at improving safety.  As it turns out, the "Big Push for Midwives" is more complicated than MANA would have us understand.  It's not actually just about licensing midwives. 

Michigan families deserve more...and now they have the chance to support a bill that would actually preserve choice and simultaneously improve safety for women choosing out of hospital birth in our state.  Senator Whitmer introduced Senate Bill 1208 July 18th, 2012 at our state's capitol. 

This bill establishes appropriate, reasonable standards for education and a defined scope of practice for midwives.  It will raise the professional bar for all midwives in Michigan, while preserving a woman’s choice to give birth outside the hospital.  In essence, it will ensure that women choosing out of hospital birth are in fact low risk, and that they are attended by educated, licensed, insured, and accountable midwives.  Here’s what this bill does for you: Senate Bill 1208 Highlights 

Michigan says, "No thank you MANA," we need something more. We deserve regulations that improve safety and allow us the freedom to have an educated, licensed, insured, accountable midwife attend our out of hospital births.  Indeed, this is the Big Push Back.

Thank you, Senator Whitmer, for representing the voice of many women and babies in our state and for working toward safer practices and improved standards for midwives. 

Learn More

www.michiganmidwifebill.blogspot.com

Hey Michigan, we need your voices!  Check out our website to learn how you can help and why this bill matters.  You'll find links to the bill, highlights, details about who to contact, what you can do to help, and more!  Now is the time for safer options in birth for Michigan moms and babies.  Help us make a difference.  

Lansing State Journal: Michigan Midwife Bill calls for new rules for those who deliver outside hospitals

Actions Speak: Senate Bill 1208

Senate Bill 1208 Introduced! 

July 18th, 2012  

Lansing, Michigan

A moment of joy for us on the Capitol steps, after Senator Whitmer introduced Senate Bill 1208 today. Fifteen months after Magnus's death, someone is finally taking action to make out of hospital birth safer for Michigan mothers and babies.  Thank you Senator for preserving choice, improving standards, and protecting the citizens you serve.  Further more, thanks to every friend, stranger, and family member who has heard our story, shared it, and is working toward doing something good.  Your voices count and are being heard! Our gratitude is beyond words.  

Learn More

We've created an entire web page dedicated to supporting Senate Bill 1208.  
Please visit us at www.michiganmidwifebill.blogspot.com   
In order for this bill to move forward, we will need your support and your voices.  
Magnus thanks you and Michigan mothers and babies need you!  

Ask an OB: "Birth isn't a disease, it's a normal bodily function"

"Ask an OB" is a weekly series with Dr. Maude "Molly" Gurein, MC, FACOG.  If you have a question you'd like to ask her, please share it with us here. 

Can you address the NCB claim that, "Birth isn't a disease process, and therefore doesn't need medical intervention"?   ~ Michigan mom

This is an interesting statement because it contains an assumption that I don't believe to be correct.  The assumption is that we decide to medically intervene base on whether or not something is a "disease process".  This is actually not true - we decide to intervene if we believe we can reduce pain, suffering, death, or disability.  

Tripping in the forest and breaking your leg isn't a "disease process" - it's a side effect of living life.  Lack of sanitary sewers is not a disease process, but it kills a lot of people.  Getting cancer because you are old and your immune system is weak is also a natural process.  Is obesity a disease process?  How about smoking?  We use "medical intervention" in all these conditions because we believe we can reduce pain, suffering, disability, or death.

Pregnancy related morbidity and mortality were staggering before the modern era, and continue to be a source of concern today. 

"In 1915, the maternal mortality rate was 607.9 deaths per 100,000 live births for the birth registration area.  In 2003, the maternal mortality rate was 12.1 deaths per 100,000 live births in the United States.  Despite the tremendous overall improvement, maternal mortality continues to be a significant public health issue and commands an enormous amount of attention."  [CDC, Maternal Mortality and Related Concepts, 2007]

Based on the facts, I believe pregnancy qualifies as a condition that can cause pain, suffering, disability, or death, and therefore qualifies as a condition that benefits from "medical intervention".  Check out these graphs to see if "medical intervention" has been a good thing for maternal mortality in the US since 1915 or for a perinatal mortality in the state of MI since 1970:

Going back to the 1950's, after antibiotics and general anesthesia, but before risk-based prenatal  care and intervention, fetal monitoring, and timely cesareans,  and you will find a maternal mortality rate 7 times higher than today & a perinatal mortality rate 8 times higher than today.  Yes, your cesarean rate is also 8 times higher.  You pick...

So Many Questions

I'd like someone to explain to me why midwives are seemingly infallible?  Why are they not capable of making mistakes, of acting negligently, of doing harm?  Are they not human?  Are they somehow immortal?  No matter how much you love your midwife as a friend or "sister", no matter how "empowering" your home birth might have been, is it too much to consider that midwives are human and make mistakes?  Is it too much to understand that in the nature of their job those mistakes can be so great that they cost lives and permanent damage?  And further, if those mistakes are repeated, does a community not deserve to know there is a problem?  

Why are midwives not capable of malpractice? (Meaning they deviate from a standard of care that otherwise prudent people of the same profession adhere, putting women and babies at risk of death or injury.)  The inherent problem here is that too often there is no consistently defined, standard of care I suppose.  

Why is it that when a family suggests mistakes were made and actions are taken to hold midwives accountable, that that family is made out to be the enemy?  Why is accountability not expected of the "profession" of midwives?  Why is every death or injury not worthy of at least an investigation?  Why is every death and injury not reported to anyone?  Why are these situations ignored, dismissed as irrational, or worse imagined never to have happened?  Why are these situations not acknowledged, addressed, and carefully analyzed to improve practice?  

How is it that Michigan has no regulations for midwives to date?  How is it that there is no defined scope of practice or mandated reporting of outcomes?  Why can anyone call herself a midwife regardless of educational training?  Why do midwives not have to be certified in neonatal resuscitation?  Why can midwives traffic prescription drugs illegally and that's somehow okay?  Please tell me how midwives who are arrested repeatedly or out on bail on one state can come to MI and set up a birth center, no questions asked?  

Why do midwives not have to bother with carrying insurance?  Are they infallible, on par with God himself who can make no mistake? Why don't we expect more of our midwives? Why are midwives exempt from any and all accountability?  

I don't presume to have the answers to these questions because many of them are puzzling to me.  I will say this...that midwives and the women who value their care need to think deeply about these questions.  If midwifery is to be a responsible, professional, sustainable option for women, midwives must hold themselves to a higher standard. Having "choices" in the birth of our babies does NOT mean subjecting ourselves to unaccountable, randomly educated, and apparently criminal midwives.  

Why can't we expect midwives to be educated, licensed, insured, ethical, and held accountable when they have made mistakes?  What's wrong with higher standards?  Why is it rendered "anti-midwife" sentiment to expect professional standards and conduct?  Can't I have my midwife, my choice, and some standards too?

Establishing standards does not equal elimination of choice, it simply asks that those choices be as safe as they possibly can be.  

"Where is my midwife?"

Dear Kirsti Kreutzer, Sylvia Santaballa, Maria Radonicich, and Anna Van Wagoner,

I recently learned about your "Where's my midwife?" campaign.  I'd like to know where my educated, licensed, insured, ethical, transparent, accountable midwife might be? You know, the one who practices within a defined scope of practice, who risks out carefully according to clearly defined protocols…that one who works collaboratively with the hospital and doctors and appreciates that sometimes women and babies need help.  Where is my midwife who is insured?  Where is my midwife who reports her outcomes and makes them known publicly?  Where is my midwife who appreciates the value in balanced information and real informed consent over warped ideology?    

And furthermore, where is my midwife who will get me to the nearest hospital should I need help instead of driving me nearly an hour to a hospital in another state so she won't get in trouble?  Where is my midwife who recognizes breech babies are high risk and is humble enough to admit she doesn't have the skills necessary to attend such a birth?  Where is my midwife who won't use prescription drugs illegally, or techniques she's not trained in using, but will get me to the people who can safely do so should I need it?  Where is my midwife who understands scientific evidence enough to use antibiotics instead of garlic to treat Group B Strep?   

Where is my midwife who is accountable to women and babies first and foremost?  Where is my midwife who can see the errors and mistakes in her own practice, and that of her greater "profession", acknowledge them, and work to change them?  Where is my midwife who acknowledges the dead babies that didn't have to die and doesn't pretend they didn't exist?  Where is my midwife that knows many of these deaths were preventable and were the result of negligent care?  Where is my midwife who sees the alarming discrepancies within the practice of midwifery and shares my concern?  

You see ladies, it isn't about increasing the number of midwives out there, it's about improving the quality of care, educational training, standards, ethical practices, and outcomes within midwifery first.  Supporting all midwives as one lump group is completely disregarding the enormity of the issues they face within their own practice, many of which are extremely dangerous and rather unaccountable.  You're asking for a double standard here.  I wish that Natural Childbirth Advocates would realize that if they can't first fix what's at "home", you can't very easily point a finger elsewhere, nor can you spread their mission safely.  When I read your call to action statement, I read it differently perhaps that you intended:  (note italics are where I substituted the words "home birth" for hospital") 

"Are you tired of witnessing women being violated during birth and feeling  to stop the train wreck happening before your eyes? Do you wonder how there can possibly be such a giant gap between what medical research recommends and the standard procedures in home birth? ... Are you ready to stop being a bystander and work for change?

Let’s stop talking about how bad things are and do something. Let’s come together, gather our allies, learn from the people who have improved maternity care in their communities and lay the groundwork for a full-scale birth revolution! Join the national grassroots movement to change maternity care.

"Where’s My Midwife?" invites you to spend a weekend at the Farm in Tennessee, plotting and scheming, coming up with activities that can be carried out in any community at any time for little to no money. These activities will raise public awareness about our broken midwifery model of care, and draw attention to the methods that are producing better results for mothers and babies. We need to put public pressure on the people, organizations and businesses in positions of power and hold them accountable for improving outcomes."

Hosting retreats on "The Farm" and sending women out there to promote midwifery without addressing the issues within the profession itself is grossly irresponsible.  If you want to promote midwifery, it ought to be a sound, consistently reliable, transparent, professional service you're promoting, not something dysfunctional that means a million different things.  

When will this be about honest self-reflection and improving maternity care on all fronts, finally moving past blind ideology, and acknowledging that many midwives are part of the problem in this "train wreck" called maternity care?  Enough finger pointing and diverting blame elsewhere.  Time to clean up your own house before criticizing hospitals.    

I do support collaborative care, including excellent midwives, and I want to know where is my midwife who practices ethically, has sound educational training behind her, is licensed, insured, and accountable?  This is certainly not just any midwife in America, and most often not home birth midwives.  In fact she's rather elusive and I'm not entirely sure she exists.  I hope for the sake of improving all maternity care that she does, that I just haven't met her yet.

Sincerely,

Safer Midwifery for Michigan

Ask an OB: Why do docs induce when women are overdue?

"Ask an OB" is a weekly series with Dr. Maude "Molly" Guerin, MC, FACOG.  If you have a question you'd like to ask her, please share it with us here.

Why do doctors get nervous and want to induce women when they are overdue?  Doesn’t Mother Nature know when the best time is? ~ Lansing mom

Most of the time she does. My three boys were 14, 12, and 10 days overdue – I had no nonstress tests, no ultrasounds, no discussion of induction, even though my blood pressure was high – and everyone lived!  My how times have changed in the last 30 years. The problem is that stillbirth does become more common as pregnancy advances, dramatically after 42 weeks – it’s 17 times higher after 42 weeks than it is at your due date. That being said, the chances are good that your baby will be fine even at 42 weeks – look at these numbers:

Completed Weeks	Stillbirth/10,000 births
37	2.4
38	3.6
39	4.0
40	2.6
41	9.4
>42	34.7

Obstetrics&Gynecology, VOL. 103, NO. 1, JANUARY 2004

So in today’s world we like to get people delivered before 42 weeks. Usually once you pass your due date we are checking the amniotic fluid by doing a quick ultrasound once a week – this helps us know the placenta is still working well. Also doing a nonstress test by putting you on the monitor for 20 minutes twice a week helps us know the baby is doing well. These tests are not perfect, and our data on them is always being updated, but currently they are the standard of care and recommended by the American College of Obstetrics and Gynecology.

Here is a meta-analysis of studies on the management of post-dates pregnancy by the highly respected Cochrane Group:

The Cochrane Pregnancy and Childbirth Group trials register was searched.

Selection criteria

Randomised and quasi-randomised trials of interventions involving the intention to induce labour at a specified gestational age.

Main results

Twenty-six trials of variable quality were included. There were four trials of routine early pregnancy ultrasound, two of nipple stimulation, nineteen of routine versus selective induction of labour and one of antenatal fetal monitoring. Routine early pregnancy ultrasound reduced the incidence of post-term pregnancy (odds ratio 0.68, 95% confidence interval 0.57 to 0.82). Breast and nipple stimulation at term did not affect the incidence of post-term pregnancy (odds ratio 0.52, 95% confidence interval 0.28 to 0.96). Routine induction of labour reduced perinatal mortality (odds ratio 0.20, 95% confidence interval 0.06 to 0.70). This benefit is due to the effect of induction of labour after 41 weeks. Routine induction of labour had no effect on caesarean section.

In other words, induction of labor after 41 weeks reduced the chances of the baby dying by 80%. And since we never know if your baby is going to be one of the 9966 out of 10,000 who is fine, or be one of the 34 that is not – we want to get you delivered.

Ask an OB: Group B Strep, What the Research Says

Today's post is a special edition of Ask an OB, which is typically a weekly series.  Dr. Maude "Molly" Guerin, MC, FACOG, had some insightful thoughts to share  on the Group B Strep conversation. 

Is screening all women for Group B Strep just another example of doctors looking for problems that are not really there? I want to keep things as simple as possible for my birth and this seems optional to me. - On the fence mom 

Again, this is an excellent example of making an informed choice. Get the data from a reliable source, and decide for yourself what you want to do.

Here are the FACTS:

            • 20% of women carry Group B Strep as a normal part of their healthy vaginal   

              bacteria. It doesn’t hurt them and it is supposed to be there.

            • 1 to 2 out of every 100 babies born vaginally to women who carry Group B Strep 

              will develop sepsis, a severe infection from GBS, usually meningitis or pneumonia.

            • 20 - 50% of babies that get septic from GBS will die

            • Starting in the mid-1990s research showed that getting IV antibiotics during labor 

              reduced the risk of sepsis from 1 – 2 per 100 babies to 1 in 1000 babies. (Morbidity  

              and Mortality Weekly Report www.cdc.gov/mmwr. Recommendations and Reports,
              November 19, 2010 / Vol. 59 / No. RR-10)

Graph: Incidence of Early and Late Onset Group B Strep Disease


Research into using antiseptic vaginal douche (chlorhexidine) rather than IV antibiotics was initially promising because it appeared to reduce babies being born with GBS on their skin. Unfortunately the chance for sepsis did NOT go down with this intervention (Vaginal chlorhexidine during labour to prevent early-onset neonatal group B streptococcal infection Brenda C Stade^1,*, Vibhuti S Shah², Arne Ohlsson² Editorial Group: Cochrane Pregnancy and Childbirth Group Published Online: 23 APR 2008).

So, let’s start with 1000 healthy pregnant ladies who deliver vaginally and are not screened for GBS. Statistically, 200 of them will carry GBS. Then 4 of those 200 babies will get septic. Then 1 or 2 of those babies will die. Alternatively you could be screened, and if positive for GBS get a heparin lock placed for an every 4 hour dose of antibiotic while in labor. Know the facts from a reliable source and make your choice.

The Freedom to be fully Informed

Being Independence day, I felt the need to address the notion of freedom.  Many out of hospital birth advocates feel that regulation will infringe upon their choices in birth, somehow limiting their freedom.  They feel they have the inherent right to make decisions for themselves.  While I don't disagree with making educated choices or the right to do so, I do think the inconsistent and unregulated information being disseminated to expectant mothers about all the great things out of hospital birth has to offer, without honest discussion of risks involved, is more accurately taking advantage of women in order to promote an ideal.   

What about the right to be fully informed?  What about the freedom to make choices without being fed half truths and ideology?  What about standards to ensure true informed consent happens so that all women can make an educated choice?  Giving consent or making a choice based on manipulated information, isn't making a choice at all.  I have to point out further that mothers are making the best decisions they can with the information they do have, and trusting their caregivers to offer ethical, accurate information.  This is not a matter of "not doing their research", it's a matter of purposefully only giving information to support certain claims and practices.  The misleading practices and information I'm referencing are being presented as being the whole story, when in fact they are not. 

A blog reader and anonymous ex-apprentice midwife recently asked us to share her thoughts about a recent Group B Strep post.  Her thoughts were insightful and frightfully accurate.  I couldn't help but identify with the kind of "informed consent" she illustrates in her writing, the kind that some would call sly manipulation.  It's the same "informed consent" women are getting about ultrasounds, gestational diabetes testing, and numerous high risk scenarios (including breech deliveries)...half truths, underestimated risk, and misrepresentation from too many out of hospital midwives.  Read for yourself and see what you think...informed consent or manipulation...

"Midwives will carefully and painstakingly explain that GBS is a type of bacteria that is present in 30% of all pregnant women and that it causes no harm to the pregnant women. Then they explain that sometimes newborns contract GBS during birth, and some of these babies get sick, and then a small amount of these babies die from GBS infection.

Midwives will review the CDC recommendations with their clients – that IV antibiotics are administered to all women in labor who tested positive for GBS during their pregnancy. They might then add their own commentary about how most of the antibiotics administered are completely unnecessary because most of the babies born to GBS positive mothers will not become sick from GBS.

Midwives will tell their clients that until 2002, the CDC offered women a choice – they could opt for prophylactic IV antibiotics OR IV antibiotics only when additional risk factors were present. The risk for developing septic GBS infection in newborns increases with low-birth weight babies, babies born at or before 37 weeks of gestation, or during labors when ROM has exceeded 18 hours. Midwives will leave out that the reason the CDC switched to the IV antibiotic prophylaxis recommendation only is because is more effective at preventing newborn sepsis than the risk-factor based strategy.

These two options will be presented equally – sometimes along with this: “If you know that you will refuse antibiotics in labor regardless of your GBS status, ask yourself whether you want the GBS screening at all. Regardless of a woman’s GBS status, we will transfer care if risk factors develop or signs of infection become apparent during labor.”

Midwives will present alternatives: argh, the garlic suppositories, courses of oral antibiotics during pregnancy (with MD collaboration), probiotics, Hibicleans douching during labor, or stating that they’ll seek out antibiotics per the 2002 (outdated) recommendations if any of those risk factors occur during labor.

Midwives will provide this informed consent and ask parents to make a decision. Some parents will opt to be tested for GBS, others will refuse. A consent form documenting the parents’ decision will be signed. For the mothers who test GBS positive, they will be given another choice, would you like to go to the hospital for IV antibiotics or would you like to consider IV antibiotics only if other risk factors are present. These mothers are in their third trimester of pregnancy, are attached to their midwife and idea of home birth, and leery of what seems to be excessive intervention in hospital practices. They will think opting for IV antibiotics during labor if risk factors are present is a reasonable option.

Some midwives will offer the Hibiclens douching during labor. And for the parents that choose this treatment (which does have some limited evidence to support it – and is not without its own set of risks), it will be used in a pretty half-assed manner – and the schedule of douching (every 4 hours) will go by the wayside once labor becomes active.

Some women will go into labor at 37 +1, or have PROM at 37 +1 – (GBS colonization increases the risk of PROM) and there will be no discussion of how there are now increased risk factors. The woman will be treated like any other woman in labor. She will be allowed to wait until labor starts. There will be no discussion of her baby’s estimated birth weight or gestational age. There will be no discussion of increased GBS infection in babies born early. There will be no discussion of having to transfer at 18 hours post ROM for IV antibiotic treatment, as discussed (take note, but not explicitly consented to) during prenatal care.

After the baby is born, there will be no increased duration of time for monitoring the baby for signs and symptoms of infection. There will be no extended immediate postpartum presence (which in a home birth practice would be staying at the home for 6-12 hours after the birth). There will be no additional visits to the family’s home during the first hours and days postpartum – only the standard home visit at 24-48 hours postpartum. Some midwives provide information regarding early signs of respiratory distress (nasal flaring, grunting, increased respiratory rate, difficulty feeding), and assign the task of assessing the baby to the postpartum parents, but most do not.

The midwives will hedge their bets that *this* case of a GBS positive mother will not result in a baby with a life-threatening infection – because statistics are on their side. It’s not that midwives believe they are putting their patients at increased risk. They themselves don’t really believe the risk is real.

And this brings up one of the major problems with “professional” midwifery: that they are not acting like a group of professionals. A professional organization should provide standard of care guidelines and evidence-based practice guidelines based on scientific evidence. Midwives should not be left to their own devices to scour the medical research and understand what is and isn’t an increased risk. And some of these complications are so rare, that midwives will rarely encounter them in their small practices. But the profession *will* encounter these complications – and any adverse outcome encountered by one midwife will reflect on the entire profession, and, not to minimize this point, cause harm to the people they serve: women and babies. THAT is why there are practice standards. Or should be.

In a nutshell: home birth midwives don’t risk out GBS + mothers because they have no professional practice standards.  Well, I take that back, they do have practice standards, see above."

This is the kind of "informed consent" that women have been taught to believe is "educating women about birth, empowering women, and giving women "choice".  What many women aren't realizing is that they are not choosing among safe options, they're being  manipulated into a false sense of security by people that are practicing by their own rules.  Too many midwives are taking a gamble with the lives of the women and babies they serve, some knowingly doing so, and others because they don't understand the severity of risks involved.  

No matter how you look at it, functioning without consistent standards of care and without adequately informing women is unacceptable, and is infringing upon our right to have quality care, honest and accurate information, and a birth that is as safe as it can possibly be regardless of location.        

Ask an OB: How Often Does Pitocin + Epidural = Cesarean?

Ask an OB is a weekly series with Dr. Maude "Molly" Guerin, MC, FACOG.  If you have questions for her, please share them with us here.

I'd like to know how often Pitocin and epidural, when given together results in a cesarean...ballpark estimate. ~ Safer Midwifery Blog Reader

This question is really two questions: does induction of labor increase cesarean section AND does epidural use increase cesarean section?

Epidural use does NOT increase cesarean section. This is an established and well-tested fact. In the early days of epidural use when the medications used were very strong labor was often prolonged, and OBGYNs misinterpreted this to mean that labor was obstructed and a c section was necessary. As the medications have changed, and the doses have gotten lower over the past 10 years, the effect on labor course has disappeared. We sometimes have to wait longer for women to feel like pushing, but we have learned to be patient. Here is one example of many, many studies that have shown this:

OBJECTIVE: More than 50% of pregnant women in the United States are using epidural analgesia for labor pain. However, whether epidural analgesia prolongs labor and increases the risk of cesarean delivery remains controversial.

STUDY DESIGN: We examined this question in a community-based, tertiary military medical center where the rate of continuous epidural analgesia in labor increased from 1% to 84% in a 1-year period while other conditions remained unchanged-a natural experiment. We systematically selected 507 and 581 singleton, nulliparous, term pregnancies with spontaneous onset of labor and vertex presentation from the respective times before and after the times that epidural analgesia was available on request during labor. We compared duration of labor, rate of cesarean delivery, instrumental delivery, and oxytocin use between these two groups.

RESULTS: Despite a rapid and dramatic increase in epidural analgesia during labor (from 1% to 84% in 1 year), rates of cesarean delivery overall and for dystocia remained the same (for overall cesarean delivery: adjusted relative risk, 0.8; 95% confidence interval, 0.6-1.2; for dystocia: adjusted relative risk, 1.0; 95% confidence interval, 0.7-1.6). Overall instrumental delivery did not increase (adjusted relative risk, 1.0; 95% confidence interval, 0.8-1.4), nor did the duration of the first stage and the active phase of labor (multivariate analysis; P >.1). However, the second stage of labor was significantly longer by about 25 minutes (P <.001).

CONCLUSION: Epidural analgesia during labor does not increase the risk of cesarean delivery, nor does it necessarily increase oxytocin use or instrumental delivery caused by dystocia. The duration of the active phase of labor appears unchanged, but the second stage of labor is likely prolonged. 

(Am J Obstet Gynecol 2001;185:128-34).

The influence of induction of labor on the cesarean section rate is harder to answer because there are lots of variables involved. Over the years it has become clear that if your cervix is ready (dilated, soft, thin, at the front of the vagina, with the head down well), and if this is not your first delivery, induction of labor probably doesn’t increase your c-section rate. If your cervix isn’t ready and if it is your first delivery, your rate is very likely increased, as much as doubled.

This is why we try hard not to induce first-time moms unless they or their baby are in trouble and pregnancy needs to end. Reasons to induce include high blood pressure, reaching 41 weeks, baby dangerously small, diabetes, among others.

So to decrease your c-section risk – be patient and wait for spontaneous labor, unless there are complications that warrant induction.