"Labor" Day - A Rally for Improving Birth

The upcoming weekend signifies to most Americans, a day of recognition for their hard work.  Labor Day for some marks the end of summer.  For Natural Childbirth Advocates, Labor Day seems like a good day to hold a rally at our State Capitol to proclaim to the world the desperate need to reduce cesareans and induction rates.  (No, not infant mortality rates or birth injuries.  You read it right, cesareans and inductions.)     

  

     "We need women, men and children to come stand in support of evidence-based   

      maternity care for everyone on September 3, 2012. The Rally will be held in locations 

      all over the country as the launch to Empowered Birth Awareness Week."

Hmmm.  Where to start on this one.  Whomever made the decision to use an existing national holiday to promote their natural childbirth agenda, may want to reconsider.  Some find it blatantly disrespectful and outright appalling.  I'm not sure if it was intended to be a cute play on words, ("labor" meaning your body preparing to give birth) but newsflash, that's not the definition of the word we recognize as "Labor Day".    

     "The Purpose – The National Rally for Change is to encourage and insist that all 

      maternal healthcare providers practice evidence-based care. On average it 

      takes 20 years for proven research to become practice. For the sake of mothers and

      babies everywhere, we can’t wait 20 years."

Really?  Evidence-based care for ALL maternal healthcare providers?  What about out of hospital midwives?  (Note that out of hospital birth saw a 29% increase over the last five years.)  Last time I checked there isn't much evidence supporting putting garlic in your vagina to prevent gestational diabetes.  Nor is there much evidence for taking on the delivery of a breech baby outside a hospital with next to no experience.   There isn't much research that supports a midwife or a Naturopath doing vacuum extractions outside the hospital either.  Research supporting a midwife using expired drugs that she doesn't know how to dose?  Nope.  I don't know what research has to say, but I'm pretty sure there's an ethical conflict with midwives who are caught practicing negligently, costing lives, and then just decide to change the name of their birth center, and continue to practice.  These are real stories and real people, not just wild accusations.  The things that are happening to babies in the care of renegade midwives is horrifying...yet some find cesarean and induction rates to be the center for concern.

      "The long-term effects of unnecessary inductions and cesareans are just starting to be 

      realized. This matters for all people.  This is not a protest, but a public outreach event 

      located where the vast majority of the population gives birth." 

I'd venture to say the "long term effects" of the death of a child has a far greater impact on any given family than having a cesarean.  The death of child impacts the parents, siblings, grandparents, aunts, uncles, friends in a ripple effect that never fully dissipates.  The "long term effects" of raising a child with Cerebral Palsy are far greater than having your labor induced.  A lifetime of intensive care and worry that follows like a dark shadow.  That doesn't even account for the mothers who seek a natural childbirth only to find their bodies are so badly damaged that they are left dealing with incontinence, multiple surgeries, and an incredibly long (years) recovery. 

It's ironic then, and more than a little hypocritical, that the people who have agreed to go to this rally (all 14 of them according to their Facebook Invitation) are staunch natural childbirth advocates, and out of hospital birthing families.  How does this group have any right or knowledge base to determine whether or not a cesarean or induction is "necessary"?  Well, they don't, plain and simple.  A more appropriate cause would be addressing the deeply rooted issues in midwifery, those care givers they support themselves instead of the doctors they would never choose for the birth of their babies.  Those of us that choose to birth in the hospital don't need you, or anyone else to rally on our behalf.  Many of us "Wonderbread" moms are grateful for the cesarean that saved our baby's life.   

Truth be told, this group even considered holding their Lansing area rally at Sparrow Hospital, the area's only hospital with a level 3 RNICU.  These are the very doctors and nurses that jump in and try to save lives when things go wrong during out of hospital birth.  The "evidence-based" practices this group is advocating for are things like supporting physiological birth, reducing cesarean rates, reducing induction rates, reducing interventions, and so on.  This is all great and wonderful, but sometimes interventions save lives.  Doesn't it make sense that a hospital that handles the highest of high risk patients, premature labor, mothers who are drug addicts, and everything in between would have births that end in cesarean?  Not to mention this is the same hospital taking great strides to implement collaborative care, bring nurse midwives into their maternity services, and build a doula program to support natural childbirth.  

If you want to really "Improve Birth", lets start with the people causing the greatest amount of harm, the midwives that don't give a damn about risk.  That may not be all midwives, but it is certainly too many midwives in the greater Lansing area offering out of hospital birth.  Improving birth to me means doing everything possible to make sure the mother and baby make it through the experience alive.  If a physiological, "empowering" experience has taken place and your baby dies as a result, what good is that experience?  It's worthless, it's devastating, it becomes your worst nightmare.  I can attest to the fact that there is nothing "empowering" about watching your baby die in your arms.  Why on earth would we rally about cesarean rates that are very much on par with the national average, when we have babies dying preventable deaths because of somebody's refusal to appreciate that sometimes our bodies need help?  Sometimes our babies don't just know how to be born, and they certainly are, "meant to live".  I don't know many mothers who would choose a dead baby over a cesarean, or an induction for that matter.  It does matter how are babies are born.  Alive and undamaged would be preferable.    

I have to believe that people are far more concerned with the practices stated above that are happening in MI and across the country in the out of hospital birth sector, than they are with cesarean and induction rates.  If there is room for improvement on cesarean rates and inductions, that's great.  Rallying at the capitol on a national holiday is not the way to do it.  Nor do I think it's appropriate for home birthing women who would  never have their babies in a hospital anyway, to be leading the way.  

I absolutely support natural childbirth.  I do think the journey is an important one, and certainly the experience spiritual.  That does not mean that those aspirations come at the sacrifice of safety.  Aim for natural child birth, support it, but do not be so arrogant as to think that it works that way for every woman every time.  Nor should you assume it will happen for you.  Birth is complicated, and someone once said, "It's the most dangerous day of your baby's life."  Let's get our priorities straight here, making safety the priority, and improving birth by holding our midwives to higher standards.   

P.S.  No one will be at the capitol on Labor Day, politicians take federal holidays off. 

When a spade is still a spade...

There is a disturbing trend happening across the country, and unfortunately this trend has made its way to Michigan.  Midwives who find themselves in trouble for negligent care are conveniently changing the name of their "birth centers", and continuing to practice without consequence.  How is this possible, and are their practices really changing? 

The Baby Place in Idaho found themselves paying 5 million to three families whose babies died last year.  Less than a month after they were found to be negligent by a civil court, these midwives decided to simply open a new birth center with a new name.  They would now call themselves "New Beginnings Baby Place", and yes, would continue to practice.  

Idaho Midwifery Board Investigating 3 Infant Deaths

Suspended Idaho Midwives Agree to 5 Million Deal

Suspended Midwives' Birth Center Gets A New Name

In Michigan, we now have a new dynamic duo delivering babies.  The first is a former nurse midwife, in trouble for practicing without a license...a license she allowed to lapse in Indiana.  Knowing the laws there state that you must have a valid license to practice midwifery, she continued to deliver babies.   The second is a CPM who is literally out on bail, awaiting trial in fact, for delivering babies in a state that has decided that a CPM credential is not enough education to attend home births (IN).  If being arrested and awaiting trial wasn't a clear enough message, this midwife continues to deliver babies.  These latest additions to the "professional" midwife roster in MI are setting up shop in Sturgis.  Knowing Michigan is a haven for midwives of any kind, (since we have no regulations or laws that require midwives to be licensed, nor do we have any real system of accountability) Jeannie Stanley and Ireena Kesslar have teamed up to to open a brand new birth center, "The Birth Place" to "serve" the women of Michigan.  They aren't advertising much publicly just yet, and I can see why.  Just come to a state where less people know your name, and start a new birth center, why not?  After all, it is God's calling.    

Two Midwives Arrested on Felony Charges

Protest Follows Indiana Midwife's Felony Arrest (Out on Bail)

Most recently, the Greenhouse Birth Center in Okemos, MI has contemplated closing its doors, citing, "emotional and legal stress" as the cause.  The "cause" of their stress is debatable, considering several babies have died there in recent years, and others injured, as reported in March by the Lansing State Journal.  Some might wonder why they didn't close sooner.  Closing their doors will mislead many to believe that these MI midwives will stop practicing, when instead, their approach is to solicit their supporters into "buying in" as part owners in a new "community owned" birth center.  

Greenhouse Birth Center - Letter to Supporters

Greenhouse Birth Center Considers Closing

I have to wonder how transparent these birth centers are really being with their supporters.  I wonder for example if they are explaining that anyone who shares ownership in a facility such as this can be held liable for any negligent situation that occurs there, whether they are present at the time of the birth or not.  As a part owner, one would be responsible for everything that happens, even negligent practices on the part of the midwives working there, including babies that die or are injured. 

Considering the reputation, outcomes, and irresponsible practices of midwives from Idaho to Indiana, to Michigan, I don't know who in their right mind would sacrifice their own family's financial and emotional well being for the sake of providing a haven for these people to practice midwifery.  Furthermore, it is appalling, and unprofessional to say the least, that midwives would ask their supporters to put everything on the line for them, when they know well what their actions have been in recent years, and the "burdens" they carry because of those actions. 

Playing the victim when your own negligence has cost lives doesn't get you very far.  I don't have much empathy for people who drive a laboring mother in trouble 45 minutes further, past a closer hospital to save their own reputation.  Nor do I have empathy for people who "forget" to clamp an umbillical cord, or those whose ego prompts them to take on high risk births that they are no where near capable of handling, or those who wonder why a mother severely hemorrhages after telling her to eat garlic daily leading up to the birth of her baby.  I don't feel badly for those midwives who choose not to follow the law, to use illegal drugs, to abandon their patients, lie on hospital records to void themselves of any responsibility, to practice without a license in a state that has taken great measures to keep its citizens safe.  I would say to these midwives, you are not heroines.  You are not doing "God's" work, not the same God I know and love.  You are not serving women and families, rather you are greatly harming them.  Your dangerous practices and reckless choices got you into these messes, you've made your own bed as they say.  Changing your name, using your supporters to take the next fall, and continuing down the same path is far from repentance, nor is it even close to improving safety. 

Dangerous practices are not only allowed to continue due to lacking regulation in Michigan, our state has become a haven for renegade midwives because of it.  When there is no law stating what "midwife" means, or establishing standards for education and practices, anything goes.  Changing your name instead of playing by the rules, practicing outside the law, or failing to actually improve safety, isn't fooling anyone.  Let's call a spade a spade.  Michigan families deserve responsible midwives.  They deserve options in birth, served by people who are educated, licensed, insured, and accountable, and nothing less. 

When Ideals Fail: CNMs and Collaboration

"Collaboration" in the world of midwives takes many forms.  For some states, midwives are required by law to work under the supervision of an OB, even to the extent that an OB signs off on a midwife's license before they can practice.  In other states midwives function more autonomously, yet still with checks and balances.  In MI, out-of-hospital birth is much like the Wild West. 

National organizations like ACOG and ACNM have issued statements, jointly in fact, that support the notion of collaborative care...meaning that OBs and CNMs come together to offer cohesive, seamless care relative to their expertise and education. 

     “Health care is most effective when it occurs in a system that facilitates 
      communication across care settings and among providers,” according 
      to the joint statement. “Ob-gyns and CNMs/CMs are experts in their 
      respective fields of practice and are educated, trained, and licensed, 
      independent providers who may collaborate with each other 
      based on the needs of their patients. Quality of care is enhanced by collegial 
      relationships characterized by mutual respect and trust, as well as professional 
      responsibility and accountability.”

Collaborative Practice Statement, ACNM, ACOG

It's a noble ideal, and one that maternity care givers should undoubtedly strive for.  The trend toward collaborative care models is growing nationwide.  But what about MI, and specifically, what about the greater Lansing area who has only one nurse midwife delivering babies at one hospital...notably the hospital that doesn't have an RNICU?

The answer is that people are working toward changing that, slowly but surely.  What's concerning is that the current climate in our area is the exact opposite of collaboration.  Instead, we have a "freestanding" birth center who poses as "collaborative", but has no written agreement that articulates the specifics of that relationship.  When mistakes are made or when midwives have waited too long to get help, families are rushed to the ER in hopes of saving lives.  By then, it's far too late.  The relationship between birth center and hospital are complex to say the least, but it's fair to say the relationship is not working in favor of safety.  We need better options, we need safer care, we NEED a collaborative care model that functions in a healthy way.  No more illusions. 

ACNM states,
     "CNMs and CMs practice in collaboration and consultation with other health care 
      professionals, providing primary, gynecological and maternity care to women in the 
      context of the larger health care system." 

ACNM's document about US Certification Standards

Currently in Michigan, a CNM working in the out-of-hospital birth sector can "collaborate" with an OB as she sees fit, with no guidelines or mandates for such collaboration.  ACNM, a nurse midwife's parent organization does stipulate that care should be limited to low risk births.  Do some nurse midwives risk out appropriately?  Sure.  Are there out of hospital nurse midwives who collaborate seamlessly?  Perhaps.  Do some nurse midwives take chances and attribute high risk situations to "variations of normal"?  Yes they do, it happened to my family, and it's costing lives.  

The problem I have is that we have CNMs painting themselves as, "collaborators within a larger health care system, but nothing that holds them accountable for doing so.  Falsely claiming that you "collaborate" with a local physician, but then failing to do so when it's most obviously needed, should be considered fraudulent...on the part of both the nurse midwife and the "collaborating" physician.  There are many CNMs functioning within a healthy collaborative care model in the hospital setting.  There are not so many functioning in an unregulated, free for all setting of out-of-hospital birth.  There is a distinct difference in what is referred to as "collaboration", and the safety implications are paramount. 

Out of hospital birth practices offer no protocols for risking out or determining when that "collaboration" becomes necessary.  ACNM supports out-of-hospital birth, when attended by a legal, educated midwife for a low-risk birth.  What happens when a nurse midwife fails to risk out, fails to refer her high risk client for OB consultation, fails to see the need for collaboration altogether?  That answer is yet to be revealed.  I hope it is one synonymous with accountability.

The point here is that we must be clear about how we are defining "collaboration", and consistent with how we handle those times that safe collaboration fails to happen.  The women of the greater Lansing area deserve better options, those concurrent with evidence-based, best practices.  We need a collaborative care model we can count on, one who has safety as the utmost priority.  

ACNM on Minimum Educational Standards

ACNM Series, Part 2

With new legislation introduced in Michigan (Senate Bill 1208) that attempts to hold MI midwives to standards for both practice and education, many questions have surfaced. Our post today will focus specifically on educational standards for various midwives.  Here is what a professional midwife organization, the American College of Nurse Midwives, has to say on the subject of minimum educational standards.  I think you will find it to be largely in line with "What We're Seeking" here on the Safer Midwifery for MI blog.  

Midwifery Certification in the US ~ ACNM Position Statement

"This document...clarifies the position of the American College of Nurse-Midwives (ACNM) with regard to midwifery credentials and appropriate qualification for midwifery practice.  ACNM looks forward to the day when there is one unified profession of midwifery, with unified standards for education and credentialing, working toward common goals."

ACNM states that they, "look forward to the day when midwives have unified standards for education."  This is certainly not the case for midwives in Michigan.  Some have graduate degrees, some are advance practice nurses, some have trained through a rudimentary apprenticeship, and some are learning how to be a midwife on You Tube.  Anyone can call herself a "midwife" regardless of educational background in our state, and now CPMs want a license to practice.   

According to ACNM, not just anyone should be calling herself a "midwife." They have established benchmarks for what constitutes appropriate qualifications in order to call oneself a midwife.  What are those qualifications specifically?  What constitutes a "professional" midwife?  

"ACNM supports the following definition of a professional midwife:

“A professional midwife in the United States is a person who has graduated from a formal education program in midwifery that is accredited by an agency recognized by the US Department of Education.

(Please note: a CPM who trained through a MEAC-accredited midwifery school would meet this standard. The problem is that NARM does not require any formal education and therefore CPM credential does not assure that a midwife has been trained through any formal, accredited midwifery program.)

 

"The professional midwife has evidence of meeting established midwifery competencies that accord with a defined scope of practice corresponding to the components and extent of coursework and supervised clinical education completed. In addition, this person has successfully completed a national certification examination in midwifery and is legally authorized to practice nurse-midwifery in one of the 50 states, District of Columbia, or US jurisdictions.”

Sounds like a formal education by an accredited program isn't asking too much after all.  Neither is a defined scope of practice. 

ACNM supports laws and regulations that include:

(This is a shortened list as it pertains to this topic.  Full list of criteria in the linked document above.)

1. Successful completion of a formal education program accredited by an agency recognized by the US Department of Education.

2. Successful completion of a national certification examination in midwifery.

4. A scope of autonomous practice, recognized by law or regulation, that is consistent with the content of the education process and certification exam.

In an effort to support their "unified" vision for educational standards ACNM's statement specifically addresses an alternative to nursing school.  Senate Bill 1208 proposed an RN requirement as a minimum standard.  Some didn't support requiring midwives to go to nursing school.  ACNM themselves didn't think an RN degree (2 years) was sufficient.  If you continue reading, you'll see that ACNM already has an alternative to nursing school in place, a credential called a CM, Certified Midwife.  This credential includes a bachelor's degree in something other than nursing, then two years of graduate school in and accredited midwifery program.  Perhaps this should be the minimum standard for Michigan midwives. 

The Accreditation and Credentialing Process for CNMs and CMs

"Nurse-midwifery and certified midwifery education programs in the US are currently accredited by an autonomous agency recognized by the US Department of Education, the Accreditation Commission for Midwifery Education (ACME)

"Because ACNM believes that a nursing credential is not the only avenue of preparation for midwives to deliver safe and competent care, we moved to accredit education programs for midwives who do not wish to earn a nursing credential. The American Midwifery Certification Board, Inc. [AMCB, formerly the ACNM Certification Council, Inc. (ACC)] opened its national certification exam to nonnurse graduates of midwifery education programs and issued the first certified midwife (CM) credential in 1997.

"Certified midwives are educated to meet the same high standards that certified nurse-midwives must meet. These are the standards that every state in the U.S. has recognized as the legal basis for nursemidwifery practice. All education programs for CMs, like CNMs, are at the post-baccalaureate level.  Beginning in 2010, a graduate degree will be required for entry into clinical practice for both CMs and CNMs. CMs take the same AMCB certification exam as CNMs and study side-by-side with nurse midwifery students in some education programs. As an organization, ACNM supports efforts to legally recognize CMs as qualified midwifery practitioners granted the same rights and responsibilities as CNMs."

Having minimum standards for education should be a given when defining any "profession".  I have to imagine it becomes even more important for a profession in which lives are directly at stake.  How is it that Michigan has not yet established this for midwives practicing in our state?  How is it that CPMs are actively lobbying for a license, but the focus clearly circumvents any discussion of minimum standards for education?  When a CPM has so many routes to earning her "Certified Professional Midwife" credential, none of which require formal education of any kind, how can that be considered adequate in terms of educational preparation?  Not to mention that it's very clever of NARM to title this certification "Professional" when it doesn't even meet "professional" standards according to ACNM. 

I'd like to leave you with these thoughts...What obligation does ACNM have as a professional organization to speak up on this issue?  Perhaps they should lobby for legislation that would actually make birth safer, no matter where a baby is being born.  Perhaps it's time for them to back up this "position statement" with actions.  We need your help ACNM to protect the integrity of midwifery, and to protect the families "midwives" jointly serve. 

Link to part 1 ~ What ACNM has to say about Senate Bill 1208

For more on this topic, including ACNM's stance at the federal level, visit: 
Confutata: CNMs Don't Want to Play

What ACNM has to say about Senate Bill 1208

Part 1 of 2 series on ACNM:

As the most nationally respected midwifery organization, we had hoped that ACNM would support Senate Bill 1208.  Read more to learn about their concerns with this bill, and what they are hoping for the future of midwifery in our state.

In a recent letter to Safer Midwifery for MI, ACNM's MI Affiliate, President Ruth Zielinski writes:  "We strongly support licensing and regulating midwives as a measure of accountability and safety for the public, if appropriate minimum standards for education have been met."

She continues by writing: 

"The ACNM MI Affiliate does not support Senate Bill 1208 for many reasons: 

• SB 1208 does not meet the International Confederation of Midwives (lCM) minimum standard educationally for professional midwives.  According to the ICM Global Standards for Midwiferv Education "Minimum length of a direct entry midwifery education program is three (3) years Minimum length of a post-nursing/ health care provider program is eighteen (18) months.  SB 1208 does not require any additional midwifery training beyond a nursing education. 
  
  
• The bill deletes the definition of certified nurse midwife and adds a definition of licensed midwife, essentially negating over 30 years history in the state which has established a consistent level of education and mechanisms for licensure for the professionals who are Certified Nurse Midwives.
  
  
• The bill dilutes even further, the educational standards currently in place for Certified Nurse Midwives by not providing for any differentiation between CNMs and CPMs in regard to education or scope of practice. The minimum requirement for Certified Nurse Midwifery education is a graduate degree post baccalaureate nursing education: Comparison of Certified Nurse-Midwives, Certified Midwives, and Certified Professional Midwives (ACNM document) 
  
  
• SB 1208 limits a midwife's scope of practice to birth, whereas the scope of practice for a Certified Nurse Midwife includes primary and well woman care. The services provided by CNMs includes "primary care, gynecologic and family planning services, preconception care" ACNM Definition of Midwifery and Scope of Practice,of Certified Nurse-Midwives and Certified Midwives"

In a nutshell, it appears that ACNM doesn't think this bill requires enough educational training in the area of midwifery, citing International Standards as being more appropriate. ACNM also notes the "redefining" of nurse midwives as licensed midwives, and limiting their scope of practice for Certified Nurse Midwives is concerning.  It also appears that they don't much like being limited to the same scope of practice as CPMs, and I can see why.  Their concerns are valid considering they have earned licenses in every state, are overseen by the board of nursing, have graduate degrees as advanced practice nurses, and have worked hard to earn respectable professional recognition.  

So, now what?  ACNM has met with Senator Whitmer's team about their suggested revisions.  Senator Whitmer's team has acknowledged the concerns regarding nurse midwives.  They have expressed their willingness to amend the language to represent a bill that would not limit the scope of practice or dilute the respected credentials of CNMs.  They have also explained that while International Standards may be more desirable and appropriate, schools that offer such training are not available in MI.  Establishing the RN degree as a minimum for formal education is something that is readily available to people who want an alternative route to becoming a midwife.  Senator Whitmer's team is steadfast in their commitment to work in appropriately regulating and establishing minimum educational standards for anyone who is not a CNM or CM, but wants to call herself a "midwife".  

In the closing of her letter to Safer Midwifery about ACNM's position on SB 1208, Ruth writes: 

The Michigan Affiliate supports the position that,  "ACNM looks forward to the day when there is one unified profession of midwifery, with unified standards for education and credentialing, working toward common goals.  In the meantime we continue to maintain our standards for academic preparation and clinical practice." 

ACNM Midwifery Certification in the United States: Position Statement 

We, at Safer Midwifery for Michigan, will look forward to that day too.  A " unified profession of midwifery, with unified standards for education and credentialing."  Sounds like a dream, and I often wonder why that is not already the case in today's world.  The truth is it's a deeply divided, broken profession, with some practicing well and others who are slipping through the cracks at the expense of precious lives.  I hope ACNM can back up their goals and statements by actively seeking the change women need and deserve. 

The language of Senate Bill 1208 may need to change slightly in areas, but the larger issues Senator Whitmer is attempting to address are spot on.  Thank you Senator for stepping forward to improve the safety & professional practices of midwifery, and thank you ACNM for your valid concerns and constructive feedback.  

More about what ACNM says about educational standards, and the definition of "professional midwife" next week on the blog!

For more information on International Standards, see the following links: 

International Confederation of Midwives (ICM)

ICM's Core Documents

ICM's Educational Standards & Legislation Suggestions

A Democratic Citizen

A friend recently shared a radio show called On Being. This is part of a quote from Jacob Needleman.  It is relevant to the conversation in our state about midwifery, and people who constantly sling hurtful comments in various conversations, causing a tailspin of noise, but no real progress: 

"A democratic citizen is not a citizen who can do anything he wants; it's a citizen who has an obligation at the same time. And just to give you an example, if I may, the freedom of speech...what is the duty associated with it? Well, if you ponder that a little bit, you'll come to the conclusion very clearly that the right of free speech implies the duty of allowing others to speak. If I have the right to speak, I have the duty to let you speak.

Now, that's not so simple. It doesn't mean just to stop my talking and wait till you're finished and then come in and get you. It means I have an obligation inwardly — and that's what we're speaking about, is the inner dimension. Inwardly, I have to work at listening to you. That means I don't have to agree with you, but I have to let your thought into my mind in order to have a real democratic exchange between us. And that is a very interesting work of the human being, don't you think?"

The question is not how do we protect midwives.  It's not even how do we preserve choice, although that is important too.  The real question is HOW do we make out-of-hospital birth as safe as it can possibly be?  What expectations need to change?  What guidelines are fair and balanced?  Who holds what responsibilities?  What measures of safety and outcomes can be employed?  None of this can be answered without closely & honestly examining the glaring problems that are pervasive in midwifery today, and the impact they are having on families.  If we can clearly identify those problems, we can in turn, talk about solutions that will move us forward.  

PS.  It is not democratic conversation to respond to questions about improving midwifery by sharing how great your home birth was, and how your midwife is infallible.  Nor is it democratic to threaten people who see room for improvement within the profession itself.  The point is a) recognizing there are problems being expressed, and b) getting to work at solving them.  Pretending that there are none gets us no where.   

The Problems with Michigan Midwifery
(Note, this primarily refers to out of hospital midwives in MI.  Those practicing in hospital affiliated birth centers have graduate degrees, an advanced practice nursing license, most have insurance, and a board of oversight.)

1)   No accountability

2)   No minimum standards for education, not consistently educated/trained

3)   No mandates or system for reporting outcomes, that would in turn help to evaluate 

       safety

4)   No license required

5)   No insurance required

6)   No consistent requirements for informed consent

7)   No oversight by a balanced and fair board (or anyone at all for that matter) = no 
       analysis of practice, no improving upon practices, no accountability for dangerous  
       practices

8)   No defined risking out criteria or screening standards

9)   No defined scope of practice

10) No transfer of care protocols or models for collaboration outside the hospital

11)  A "sisterhood" that would defend a negligent midwife before helping her improve upon 

       her practices

Let me sum it up by again stating that ANYONE in MI can wake up tomorrow and call herself a "midwife".  She can open a "birth center" in her garage, without one bit of oversight. Babies can be injured or die in her care, and there isn't a damn thing anyone can do about it.  The midwife doesn't have to report it to anyone either, so the next unsuspecting family won't have a clue about her prior history.  No regulation = a walk in the park for negligent midwives.  Unacceptable.  Time to start talking about real solutions that will protect families, and save lives.  The people of Michigan deserve excellent midwives and responsible care. 

Upset with SB 1208? Call Upon Your Midwife

If Senate Bill 1208 has your stomach in knots, call upon your midwife.  If you're concerned for CPMs and their future in Michigan, call upon NARM and the organizations that support them.  

Ask them why there are not consistent standards for education.  Ask them why there is no defined scope of practice.  Ask them why those among them who like to take on risky births, and brag about them later are worshiped.  Ask them why dead babies are ignored and the "allegations" department offers only "peer review" with NO mandatory changes in practice.  In fact, NARM doesn't even ask that the "notes" be turned in after a peer review.   Ask them why midwives who carry and use illegal drugs are not sanctioned or monitored.  Ask them why they don't report their outcomes.  Ask them what their risking out criteria is.  

Call upon your midwives to make their standards for education consistent and in line with international standards at the very least.  Tell them you care about midwifery and its future and you'd like the option of home birth to be as safe as it possibly can be.  Tell them you want safer options and a higher standard of care.  Tell your midwives  you want a licensed, insured, accountable care giver to serve the women of Michigan.  

If midwives were doing their jobs well enough, there wouldn't be a need for any bill, Senate or House.  Problems need to be addressed and women who value midwifery need to have higher expectations.  Midwifery as a profession needs to hold themselves to higher standards.  Ladies, we can do better.  

Perhaps consumers should take a moment to consider what midwifery looks like in other countries, and then start to ask more questions.  

"I have to thank the home birthers for trumpeting the Netherlands study results constantly. Once I asked and discovered what the standards of care were in the Netherlands, it gave a fantastic contrast to how home births are handled in the United States. It also gave us a model of care to use in asking for change. After all, the MIDWIVES like the results so obviously they would be more than happy to support the process, right? 

Maybe we need to start asking: Why don't we have two midwives at a home birth? Why don't we have better trained midwives? Why don't midwives work with OBs so that transfer of care can happen smoothly whether it's at 20 weeks or 41 weeks? Why don't midwives carry insurance to protect themselves and their patients?

Why are we using the Lone Ranger model of midwifery care where the midwife can ride off into the sunset at any time, for any reason?" ~ Anj Fabian

I leave you with these questions, Why is our current model of midwifery in Michigan acceptable?  If there really is a need for excellent midwives and a crisis in maternity care, why aren't our CPMs and lay midwives filling that gap with appropriate training and standards for practice?  Why do we tolerate sub standard care that would literally be unacceptable in any other first world country?  Why is it wrong to ask more of our midwives?  Time to raise our standards Michigan, and demand ethical, responsible practices of our midwives.  

NARM

Friends of MI Midwives

Michigan Midwives Association

Ask an OB: "You can't grow a baby too big . . ."

"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. 

What do you think of the statement, "You can't grow a baby too big for your body to birth."  Can you also talk about the importance of Gestational Diabetes screening?  What danger is there in skipping that test?  Is there a weight gain at which a pregnant woman would be suspected for Gestational Diabetes?  For example if she has gained 60-90lbs and is craving sugar toward the end of her pregnancy, would that be a warning sign? - Lansing Mom

“You can’t grow a baby too big for your body to birth” is a completely false statement.  The latest worldwide statistics on maternal mortality show that 8% of pregnancy related deaths in women are due to “obstructed labor” – in other words, baby actually WAS too big and mom DIED trying to deliver it. So let’s not spend any time debating the validity of this statement – it’s nuts.
 
The thing I really hate about this statement is that it implies that if you have a C section for this reason, you just didn’t try hard enough. If only you had been stronger, tougher, more deserving – a better person – you would have been able to do it. You’re a quitter, a wimp, a weakling, not deserving of respect. And the opposite is familiar as well isn’t it? Somehow those lucky women who blast 10 pound babies out in 3 hours with 1 push are proud and self-satisfied, revered and rarified. Let’s just accept the fact that some women have big pelvises and others don’t, and that babies vary in size and shape. Usually mother nature puts the right sized baby in the pelvis – 90% of the time babies fit in moms over 5’1” tall. In moms under 5’1” 80% of babies fit! Make sure your contractions are strong enough and be patient – if your pelvis is big enough the baby will come. If not, you will have a well deserved and life saving cesarean section – personally, I think you deserve MORE credit for that delivery than the 3 hour, 1 push delivery!

Diabetes is related to this question of bigger babies. Gestational diabetes mellitus is increasing in frequency, mostly due to increasing obesity rates in moms, now occurring in about 7% of all pregnancies. Even in moms of normal weight, GDM is present about 5% of the time. So the chances are small that you will be affected – 95% of the time you will be fine. Why do we care in that case? Well, we care because if you do have uncontrolled GDM it can greatly increase the chance for complications in you or in your baby.  Look at this data from a 1998 study of about 800 women, which remained significant after controlling for maternal age, race, parity, body mass index, pregnancy weight gain, and gestational age at delivery.
 

	Uncontrolled GDM	Controlled GDM	No GDM
Baby over 8.5#	44%	9%	5%
Shoulder dystocia	19%	3%	3%
Birth trauma	25%	0.3%	0%

(Am J Obstet Gynecol 1998;178:1321-32)

Note that you won’t give yourself diabetes by gaining too much weight, but that pre-pregnancy obesity IS related to developing GDM. “Sugar craving” is unrelated to GDM as far as I can tell. Bottom line: even though your risk of having GDM is small, if you do have it and don’t control it, the chance for problems is quite high. In the interest of as many vaginal deliveries as possible, let’s control GDM so we can reduce babies that are too big to fit out vaginally and safely.

You can read more about Dr. Maude "Molly" Guerin, MD, FACOG, right here. 

Self Inflicted Controversy: CPMs Under Fire

I found profound insight from a fellow Michigan mom and blogger that expresses the reason CPMs have no one to blame but themselves for being under scrutiny.  Her post also notes many double standards running amok in conversations about birth.  

The links below are an accurate observation of where NARM has led its midwives.  This is precisely why regulations are needed for those pretending to regulate themselves.  Please also see the related post entitled, What We're Seeking Defined Scope of Practice, to hear from midwife apprentices about the need for improved standards.  

Sara Savel: Make Midwifery Safer Now! 

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

The links below represent a collection of resources where you can learn more about proposed bills currently in MI's legislature.  I encourage you to become familiar with the issues at hand and take action to ensure safer practices and improved standards for all Michigan Midwives.  

Next week Wed, look for a post entitled: Tell me about this credential: "CPM or Certified Professional Midwife" for more on this topic from student midwives.

Other Related Links:
Why HB 5070 Would do More Harm Than Good

Actions Speak: Senate Bill 1208

The Marriage Between Legislation and Choice
The Big Bill Debate: HB 5070 & SB 1208
The Big Push Back
Upset with Senate Bill 1208?  Call Upon Your Midwife
www.michiganmidwifebill.org

Home Birth Story: Women deserve not to be their own midwives

I feel compelled to share the perspective of an Ex-CPM student and her experience(s) with home birth.  Please note the inconsistency in practice or standards of care among CPMs.  

"I had two home births attended by certified professional midwives (CPMs). I gave birth to my children amidst my own training to become a CPM. I apprenticed with a number of CPMs and was enrolled in a MEAC accredited midwifery program. I add these details because I was not the average pregnant and laboring mother – I had experience witnessing and participating in home births, and I had knowledge of midwifery and standards of care for pregnancy and birth.

I value and cherish that I’ve given birth my babies at home. I had no unusual reason for birthing at home: I wanted woman-centered, family-centered care,  I wanted to avoid drugs or procedures in absence of complications, I believed my body knew how to give birth, and I wasn’t afraid of the pain. I appreciate the midwifery model of care – I personally selected and knew my midwife, and knew she specifically would attend me during labor and follow up with me postpartum.

I have a lot of conflicting thoughts on home birth due to my experience with it in many different roles. As having been a doula, an apprentice, a home birth assistant and a midwifery client I am intimately aware of the many shortfalls of home birth and “professional” midwifery.

Recently I learned the term “black hole” used to describe what is lacking in midwives’ training. It is so perfect to describe what is missing – it is a black hole – and because no light escapes a black hole – no one is really aware of the lack in knowledge or skill. It’s just missing. Absent.

I had knowledge and experience with many area midwives, but choosing my midwife was quite hard. Because as much as they provided “woman-centered” care, they also provided care that was based on their own personal fears and biases and superstitions. Maybe these weren’t black holes, per se, but there were voids in my care that I knew I would have to fill somewhere else.

For instance one of my midwives did not use the Doppler during prenatal care. (I believe she had one for waterbirths, I’m not certain). Because I knew many midwives in my community, I could ask a friend to meet me in a parking lot and get heart tones in the first trimester of my pregnancy. Which is what I did. 

One of my midwives sort of eschewed routine prenatal blood work. So I found a friend (a midwife) who would do my prenatal blood panel and 28 week blood work.  I was filling in the holes in my care – to create the care I wanted.

Neither of my midwives made any recommendation about finding a back-up hospital provider during my pregnancy. I did this. Twice. With two different area physicians. Both physicians were willing to come in to take over my care during labor if a transport to the hospital was necessary. Both physicians were agreeable to backing up my home birth plans and ordering any tests (BPP or U/S) if there became reason  to do so during my pregnancy. I would not have given birth at home without this arrangement – though neither CPM during either pregnancy ever mildly suggested that I do this.

The CPMs I hired for my care had very different postpartum follow up care than the care that was provided in one of my apprenticeships. There was virtually no postpartum instruction regarding how to care for my baby, myself, or warning signs that would necessitate immediate medical attention. I couldn’t tell if these things were being omitted because they assumed I knew them already as a student midwife, or if it wasn’t a part of their routine care at all. I knew postpartum instructions and things to look for because the midwife I apprenticed under did this quite thoroughly. But again, this created another hole I had to fill.

I go back to how much I appreciate that home birth was an option for me – but I don’t know that I can recommend home birth with either of these midwives to anyone – and for various reasons.

And after working with many midwives, and being attended by two different CPMs for my own births, it has really struck me how there is NO STANDARD of care by these “professionals.”

If anyone were to ask me to recommend midwife “A” or midwife “B” as their maternity care provider, I would feel obligated to give a list of things that they don’t do: “You’ll have to find someone to do your prenatal lab work.” “They’re superstitious about vaccines/GBS screening/hospital back-up. “ “She won’t use a Doppler during prenatal appointments, so you might not hear the heartbeat.” “She doesn’t work with trained assistants.” “She won’t recommend any physician to provide back up, but Dr Y and Dr Z are two who will back up home births.”

It is hard for me to think that this type of care was OK for me, but not for anyone else. The only reason why it was OK for me is because I knew how to fill the holes. Maybe I’m just justifying it in hindsight. But in both circumstances – and for different reasons – I felt I had to midwife myself at some point during each pregnancy and labor and postpartum. This was substandard care. And, it was the best I could get.

Women seeking midwives deserve to *not* have to be their own midwife. They deserve to have all the holes filled, and all the care provided. Even if that care goes against the midwife’s personal beliefs. (And to be clear, we’re not talking pro-life/pro-choice/religious beliefs – we’re talking about things like routine blood testing , routine lab specimens, hospital back-up arrangements , and auscultation of fetal heart tones with a Doppler.)

If I could have hired a certified nurse-midwife (CNM) to attend my home birth, I think would have. It is legal in my state for CNMs to practice out-of-hospital, it is just very rare. It is also legal in the nearby neighboring state for CNMs to practice out-of-hospital. Again, it is very rare. There was no CNM practice providing home birth services within a hundred of miles of me. There were at least two dozen CPMs or “other” midwives in my area who would attend my home birth.  CPMs are legal in my state. And I was training to become a CPM. Naturally, I chose a CPM to attend each of my homebirths.

Both of my home births went well. And every issue that came up in labor was handled in a sufficient manner.

But I cannot recommend these midwives.  And I have not.

And I have a hard time recommending home birth with a CPM to anyone these days." 


Someone recently described the gaps in a CPM's training and education to be much like Swiss cheese.  Depending on the program of study and your preceptor, skills slip through the cracks.  Safer Midwifery for Michigan is advocating for consistent standards for education and training of midwives.  Clients can be informed, but using the term "midwife" to describe your profession should stand for something we all can count on.