The American College of Nurse-Midwives’ response to the recently adopted American Medical Association’s resolutions regarding home birth and midwifery may be found here, and it is a delightful read. In particular, the thoroughly documented addenda to the letter is not to be missed.

In the past, medical lobbyists have frequently counted CNMs as allies in opposing state licensure of direct-entry midwives, and the AMA and ACOG have made much of their position that only certification from the ACNM should be considered adequate for midwifery practice. In light of this, the following paragraph from the addenda was of special significance (emphasis in the original):

“It should be noted that Resolution 205 erroneously states that ACNM has defined Certified Professional Midwives (CPMs) as “traditional, independent (of the health care system), non-formally trained and community-based providers of care during pregnancy, childbirth and the post-natal period.” ACNM does not define CPMs in this or any other manner, and will not do so. CPMs have their own professional organizations to represent them and standards which address their education, certification and scope of practice. ACNM is in dialogue with these organizations with the goal of working toward the highest quality midwifery care for women and families in all settings.”

Thank you, ACNM!

The Midwives Alliance of North America (MANA) has released a President’s Editorial in response to the recent American Medical Association resolution condemning home birth.

July 11, 2008

Midwives Alliance of North America
611 Pennsylvania Avenue SE # 1700
Washington, DC
20003-4303

Contact:
Geradine Simkins
president@mana.org
888-923-MANA (6262)
info@mana.org
http://www.mana.org

Doctors Ignore Evidence,
AMA Seeks to Deny Women Choices in Childbirth

One wonders what process the American Medical Association (AMA) House of Delegates used to determine that “Resolution 205 on Home Deliveries” was a prudent and reasonable proposal to adopt. AMA Resolution 205 attempts to outlaw a woman’s choice to birth at home or in a freestanding birth center by calling for legislation to establish hospitals and hospital-based birth centers as the safest place for labor, delivery and postpartum recovery. Further, Resolution 205 seeks to establish that hospital-based midwives who work under the control of physicians are the only safe midwifery practitioners.

The Midwives Alliance of North America, which has represented the profession of midwifery since 1982 and whose members are specialists in homebirth, finds AMA’s Resolution 205 to be arrogant, patronizing and self-serving. We have three major objections to Resolution 2005. First, Resolution 205 patently ignores the vast body of scientific evidence that has documented homebirth to be a safe, cost-effective and satisfying option for women who prefer this alternative to hospital birth. Second, AMA Resolution 205 is seriously out-of-step with the ethical concept of patient autonomy in health care (encompassing both informed consent and informed refusal), which has gained widespread acceptance in the medical community. And third, Resolution 205 distracts from other critical issues in maternity care to which healthcare professionals should be giving substantial attention, including increasing access to care, improving perinatal outcomes, reducing health disparities and fostering client satisfaction. AMA Resolution 205 is anti-homebirth, anti-midwife, anti-choice and is unsupported by scientific evidence.

Why is the American Medical Association not asking the real questions instead of trying to debunk existing research evidence on the safety and efficacy of homebirth and attempting to corner the market on maternity care? For example, why are midwife-attended births far more likely to have fewer interventions, fewer postpartum infections, more successful breastfeeding rates, healthy infant weight gain and result in more satisfied, empowered mothers ready to embrace their newborns and parenting experiences? Why are so many women across the nation left emotionally traumatized by their childbirth experiences in hospitals and consequently why do rates of postpartum depression, anxiety and post-traumatic stress continue to escalate?

It is ironic that the AMA should have a quarrel with a known safe birth option such as homebirth at the same time when the epidemic rise in coerced or elective cesarean sections puts healthy mothers and infants at greater risk than normal vaginal birth and causes excess strain on the limited resources of our healthcare system. The rate of cesarean sections in the United States is unacceptable-one in three pregnancies end in major abdominal surgery-and the decline in availability of vaginal birth after cesarean (VBAC) is deplorable. It is unethical to expect that women and infants should continue to bear the brunt of increasing medical malpractice risks by over-treating them with obstetric technologies such as c-sections while denying them safe evidence-based options such as VBAC. It is past time that the AMA in collusion against homebirth with the American College of Obstetricians and Gynecologists (ACOG) realizes that women and their partners are choosing to labor and deliver at home and in freestanding birth centers to avoid ethically unsupported obstetric interventions.

Modern medical ethics have evolved to embrace autonomy-patient choices and patient rights-over medical recommendations based on paternalism or physician preference. In almost all areas of modern medicine, except obstetrics, the locus of control rests firmly with the client or patient and not with the medical provider. It is a commonly held principle that it is not appropriate to force medical treatment upon clients or patients against their will, including medications, blood transfusions, chemotherapy or even life-saving surgeries. Informed consent has appropriately become the gold standard in healthcare decision-making. Why then do the AMA and ACOG believe that they can promote legislative efforts to deny women choices in maternity care providers and childbirth settings? In the 21st century this concept is outdated and absurd.

The AMA and its members might consider using their considerable energy, intelligence and resources to focus on promoting the health and well-being of mothers and babies and devote less time to limiting women’s access to midwifery services. All maternity care providers should band together to reduce the unacceptably high rates of maternal and infant mortality and morbidity in the United States, increase access to maternity care for all women, reduce unnecessary cesarean sections, encourage vaginal birth and VBACs for healthy women, reduce health disparities of women and infants in minority populations, and promote increased breastfeeding. These challenging but attainable goals would improve the health of mothers and babies far more impressively than reducing the rates of homebirth.

The Midwives Alliance joins the other individuals and organizations, including individual AMA and ACOG members, who have grave concerns about the AMA taking the stand articulated in Resolution 205, and calls for the AMA to abandon this resolution. Midwives everywhere honor and respect the numerous friendly physicians with whom we already partner and look to the day when midwives and obstetricians will consistently work collaboratively to support women’s choices in childbirth and provide the best possible and most appropriate range of services for every situation.

References

1.. K.C. Johnson, B.A. Daviss, Outcomes of Planned Home Births with Certified Professional Midwives: Large Prospective Study in North America, British Medical Journal 2005; 330: 1416 (18 June).

2.. Royal College of Obstetricians and Gynaecologists and Royal College of Midwives Joint Statement No. 2, April 2007. See http://www.rcog.org.uk/index.asp?PageID=2023

3.. Wiegers TA, Keirse MJ, Van der Zee J, Berghs GA. Outcome of planned home birth and planned hospital births in low risk pregnancies: prospective study in midwifery practices in the Netherlands. BMJ 1996; 313:1309-13.

4.. Olsen O. Meta-analysis of the safety of the home birth. Birth 1997; 24:4-13.

5.. Ogden J, Shaw A, Zander L. Deciding on a home birth: help and hindrances. Br J Midwifery 1997;5:212-15.

6.. Canadian Institute for Health Research Giving Birth in Canada: Regional Trends From 2001-2002 to 2005-2006. http://secure.cihi.ca/cihiweb/en/downloads/Childbirth_AiB_FINAL_E.pdf

7. CMAJ Maternal mortality and severe morbidity associated with low-risk planned Cesarean delivery versus planned vaginal delivery at term. http://www.cmaj.ca/cgi/reprint/176/4/455.pdf 8. Listening to Mothers II Report (2006.) Childbirth Connections, http://www.childbirthconnection.org/

Certified Professional Midwives are now free to practice in Missouri. Check out the Friends of Missouri Midwives’ press release with details about their Missouri State Supreme Court victory reinstating the law which physicians organizations challenged last summer. The Court ruled today that the Missouri State Medical Association and its co-plaintiffs “have no standing to challenge the constitutional validity of section 376.1753, and for that reason, the judgment is reversed.”

Jennifer Block’s Pushed Birth weblog has printed two scathing responses to the American Medical Association’s anti-home birth resolution. The AMA and American College of Obstetricians and Gynecologists (ACOG) bias against autonomous midwifery and home birth is not shared by their colleagues in Canada and Great Britain, both of which have better maternal / child health outcomes than the United States. In both countries, midwifery care and the provision of home birth services is an integrated part of the health care system.

The first response is from Canadian researcher and physician Andrew Kotaska, who specializes in rural maternity care. He “invites ACOG to join the rest of us in the 21st century” and declares, “If ACOG and the AMA are passive-aggressively trying to coerce women into having hospital births by trying to legally prevent the option of homebirth, then their actions are a frontal assault on women’s autonomy and patient-centered care.”

The second response is from Britain’s National Childbirth Trust (NCT) and Independent Midwives’ Association (IMA). Their statement reads, “The NCT and IMA call on the ACOG to reconsider their position as a matter of urgency. Following the example of its international counterparts it should consider all available evidence on the benefits and risks of home birth… Home birth should be considered a mainstream option and offered as a regular choice for pregnant women using the health service, whichever country they reside in. For a healthy woman with a straightforward, low-risk pregnancy, home birth is a safe option… The views of the NCT and IMA are supported by UK Government policy which seeks to reduce unnecessary interventions in childbirth and increase the numbers of women who experience a normal birth.”

The AMA has adopted three new resolutions concerning home birth and midwifery care. Resolutions 204 and 239 attack home birth midwives, with 239 coming as a direct response to recent legislation in Massachusetts. Resolution 205 condemns home birth, regardless of who provides it, and makes clear that the hope and intent of the AMA is to outlaw the practice:

“RESOLVED, That our AMA develop model legislation in support of the concept that the safest setting for labor, delivery, and the immediate post-partum period is in the hospital…”

The Big Push For Midwives has put out a press release in response to the AMA resolutions.

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

The Big Push press release also notes: “The resolution did not offer any science-based information for the AMA’s anti-midwife or anti-home birth position.”

Indeed, the AMA is following ACOG’s lead in ignoring and discounting the growing body of scientific evidence for the safety of planned home birth with a trained midwife for women with low-risk pregnancies and the excellent outcomes achieved by Certified Professional Midwives. They are also out of step with their colleagues in other countries where midwives providing home birth are a seemlessly integrated part of the health care system. RCOG – the Royal College of Obstetricians and Gynecologists, which is the British equivalent of ACOG – supports the increased provision of the home birth option for women, in
a joint statement with the College of Midwives which begins:

“The Royal College of Midwives (RCM) and the Royal College of Obstetricians and Gynaecologists (RCOG) support home birth for women with uncomplicated pregnancies. There is no reason why home birth should not be offered to women at low risk of complications and it may confer considerable benefits for them and their families. There is ample evidence showing that labouring at home increases a woman’s likelihood of a birth that is both satisfying and safe, with implications for her health and that of her baby.”

Using the same body of scientific information, why do the British doctors come to the conclusion that home birth with a midwife is a safe choice with “considerable benefits” while the American doctors decide it should be outlawed? A possible answer comes from the Big Push Press Release:

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

This is a guest post from Amy Wakeling of the Columbus area OFSB chapter.

Our Lobby Day group on the steps of the Capitol.
On May 6th, 2008, an absolutely beautiful day, midwives and consumers from Akron, Dayton, Heath, Chillicothe, Mount Vernon, and Columbus area joined together at the Ohio Statehouse in honor of International Midwives Day (May 5th). I heard a few people even got up at 5:30 a.m. to come! There was a lot of hard work put into this event by the Columbus OFSB members, specifically, ICAN representative for OFSB, Kathy Skestos; Martha Nieset, Peggy Hutchinson, and Leah Hobbs, the Columbus OFSB Chapter leader. Thank you all for your dedication and all the time you volunteered to make this event a huge success!

Many of us were met with encouraging support for our cause. It was a really fun day, and for those of us that had never done this before, once we got past the first one or two, we realized just how easy this is! The organizers of the event had prepared baby gift bags for us filled with everything we needed, and had a nice talking points sheet ready for us which made it a lot easier. We handed each person we spoke with a fact sheet and some M&M’s (Moms and Midwives) and answered any brief question they may have had.

Governor Ted Strickland with OFSB members Amy Wakeling and Kerry Ratcliffe, and Kerry’s daughter Lilly.
The babies were a huge hit;) One of the ladies who called back to the Representative, said “Representative ______, you’ve got to get out here, the babies are here!” They loved them and I think we would be welcomed back any time! We are already brainstorming for ways to improve ourselves for next time! One thing we would really encourage for next time is to make sure we have representation from the entire state. Legislators count on their constituents to provide the information they need to make an informed decision on which position to take. As the consumers, we really need to make sure YOUR Representatives know who you are. If you haven’t done so already, please take a few minutes to write to your representative and tell them just how important this issue is to you!

While our wonderful OFSB Lobby Day organizers in Columbus are passing out goodies to the legislators in honor of International Midwives Day, I wanted to share two excellent articles about the politics of health care in the U.S. and midwifery licensure specifically.

The first one, Midwifery is Messy, by Jennifer Braun, the program director of International Midwife Assistance, tells about her experience lobbying for midwifery legislation in Colorado in the early ’90s:

“I have a friend who was in Viet Nam. He explained to me that while I was working in the legislature, I was at war. I had seen things that I shouldn’t have seen and done things I might not feel that good about doing, but I did those things and saw those things for the good of the mission. It always seemed to me that the legislature was an altogether different world, not so much like a far away land that I’d gone to war in, but more like Narnia — a whole different ecosystem where very little was the same as back in my world.”

The second, a blog post by a naturopathic doctor in Oregon, relates the issue of midwifery licensure to the broader world of health politics:

“The US needs to realize that it should be protecting its citizens, and not big corporations. We protect the financial interests of pharmaceutical companies, while forbidding women to deliver babies in their homes. The health care industry needs to stay focused on life, rather than profit. Life is an unalienable right, not money.”

Chuck Graham, the Missouri State Senator who filibustered a midwifery licensure bill last year, is being challenged in his primary race by pro-home birth OB-GYN Elizabeth Alleman.

Graham says he’s “prepared to defend his stand against midwifery”, calling Alleman a “one-issue candidate.”

(Jefferson City, MO) – The Missouri Supreme Court will hear arguments to reconsider the permanent injunction on the state’s new midwifery law at 9:30 a.m. on Wednesday, March 5 at the Cole County Courthouse, 301 E High Street. A coalition of state and national midwife supporters, midwives and home birth families, led by Friends of Missouri Midwives (FOMM) and mobilized for the appeals process, has learned that the Court has granted their motion to file an amicus curiae (friend of the court) brief, submitted by:

• Citizens for Midwifery (CfM)
• Midwives Alliance of North America (MANA)
• National Association of Certified Professional Midwives (NACPM)
• Our Bodies Ourselves
• The National Birth Policy Coalition (NBPC)

The amicus brief submitted by the coalition (click here for PDF) supports the lifting of the midwives law injunction and makes the case that increasing access to trained and qualified Certified Professional Midwives (CPMs) and out-of-hospital birth is beneficial to Missouri citizens. In seeking to provide such access, Missouri is following the wisdom of a growing number of states recognizing the benefit of authorizing CPMs, who provide safe and high quality care, to practice.

“If the Supreme Court lifts the injunction, this law will permit CPMs to provide high quality, cost-effective care that will benefit Missouri’s citizens and fill some significant gaps in the state health care system,” said Susan Jenkins, legal counsel to the midwives coalition and steering committee member of National Birth Policy Coalition. “Home birth among low-risk women attended by CPMs does not jeopardize the health of mothers or infants, is authorized in 22 states, and is supported by many highly regarded international and professional organizations.”

Mary Ueland, Grassroots Coordinator for Friends of Missouri Midwives, says she hopes the Court will rule to decriminalize Certified Professional Midwives and remove the threat of prosecution to professional midwives who assist families who choose out-of-hospital birth. “Missouri shouldn’t drag its feet when it comes to allowing mothers to have safer and healthier birth options.”

The new Missouri Midwifery law was supposed to take effect Aug. 28, 2007, but the Missouri State Medical Association (MSMA) organized a well-financed challenge to the new law and was granted a temporary restraining order on July 3. Then on Aug. 8, Circuit Court Judge Patricia Joyce, who serves on the Board of Directors for St. Mary’s Health Center in Jefferson City, disallowed the Certified Professional Midwives provision contained within HB818 regarding portability and accessibility of health insurance.

Judge Joyce ruled the provision was unconstitutional and unrelated to health insurance, despite hearing from Assistant Attorney General John K. McManus and Midwifery Coalition attorney Jim Deutsch that decriminalizing midwifery does indeed relate to health insurance as they recalled that the Missouri Supreme Court has already ruled health insurance is interdependent on health services, and the two subjects are related.

During the Circuit Court appeal to Judge Joyce on Aug. 2, Deutsch cited nine other states where Medicaid covers home births attended by Certified Professional Midwives and many others where CPMs receive private insurance reimbursement. Both McManus and Deutsch argued that families obviously cannot get health insurance reimbursement for their midwives if their providers are considered felons by the state. They agreed that legalizing Certified Professional Midwives is a first step to home birth families being able to have their maternity care providers covered by insurance. They also cited the lower cost of midwifery care, which in turn could encourage insurance companies to lower their rates for healthy women.

“We’re seeing a strong shift in support of professional midwives as families become more aware of the benefits of CPMs, as well as more alert to skyrocketing c-section rates,” Laurel Smith, President of Friends of Missouri Midwives, said. “Beyond the additional risks for mothers and babies that c-sections create, what effect does a c-section rate of more than 30percent have on our insurance premiums, and how reliant are doctors and hospitals on these increasing revenues?”

Missouri is part of The Big Push for Midwives Campaign, a nationally coordinated campaign to advocate for regulation and licensure of Certified Professional Midwives (CPMs) in all 50 states, the District of Columbia and Puerto Rico, and to push back against the attempts of the American Medical Association Scope of Practice Partnership to deny American families access to legal midwifery care.The case defendants and midwifery supporters who are listed on the appeal to the Missouri Supreme Court include:

• Friends of Missouri Midwives (FoMM). A nonprofit organization representing the interests of Missouri families who choose to have safe, alternative, out-of-hospital childbirth options. FoMM was created to support, promote and protect the rights of Missouri families to make choices about how, where, and with whom their babies will be born and to promote access to the midwifery model of care. Contact: Laurel Smith 636-209-1033.
• Kelly Dallion Rehm, and Eric & Jessica Kerr. Two families that were expecting babies to be born after Aug. 28, 2007, the day the new law was to take effect. They were planning home births with legal, well-trained CPMs. When the new law was struck down, they had to choose between breaking the law, birthing at home without a trained attendant or the expense and interventions of a hospital birth. Contact: Kelly & Dallion Rehm 417-777-8005, Eric & Jessica Kerr 314-962-1143 or 314-248-0952
• Columbia Community Birth Center, Kim James, CPM; Ivy White, CPM; and Dr. Elizabeth Allemann, MD. Columbia Community Birth Center is the only licensed birth center in the state of Missouri. The Center is a place where families give birth in a comfortable home-like setting. James and White received their CPM credentials in 1995. Ivy White says, “As a natural childbirth specialist and professional, to have the freedom and recognition to legally practice in my state is a dream that I share with my midwife colleagues in Missouri. It wrenches my heart that there are families who long for midwifery care, and I cannot give it to them.” Contacts: CCBC 573-447-2700; Ivy White 573-356-1059; Kim James 573-424-9115; Elizabeth Allemann 573-268-6946.
• Missouri Midwives Association. An organization dedicated to promotion, protection, support and education for midwives in Missouri. “Generally, parties who want to join a suit want to be on the plaintiff’s side. We are an unusual group with an unusual dedication to our cause. We have joined the State of Missouri as co-defendants so we can have a say in what evidence the court will consider, and ensure our victory,”says Debbie Smithey, President of the Missouri Midwives Association. Contact: Mary Ueland 417-543-4258.

Media inquiries about the Missouri Supreme Court case should be directed to Mary Ueland at (417) 543-4258, better_birth@yahoo.com. Media inquiries about The Big Push for Midwives Campaign should be directed to Steff Hedenkamp at (816) 506-4630, RedQuill@kc.rr.com.#####

This past Saturday, midwives, apprentice midwives, and consumer activists gathered in Columbus for a workshop with Ida Darragh, chair of the North American Registry of Midwives (NARM). Ida’s experience working with groups in other states that have recently passed midwifery licensure laws, as well as those who are attempting to get licensure laws passed but have not yet reached that goal, was a valuable resource to those in Ohio who hope to see direct-entry midwifery established as a legally recognized option for birthing families.

Ida shared stories about successful and not-so-successful strategies and tactics for educating and lobbying legislators. She explained the steps we would need to take to create an organized and effective grassroots effort to get a midwifery bill passed in Ohio. She guided us through role-playing practice at answering difficult questions and emphasized the importance of preparation, practice, eye contact, and body language in leaving legislators with the message we want them to hear. And she encouraged us to leave with an action plan for working together to send a unified message to our representatives: Ohio families want safe, legal, professional midwives.

The group of workshop participants included not only midwives and mothers who have given birth at home but also a nursing student who hopes to have a home birth in the future, a mother who birthed in the hospital but believes the home birth option should be available, and a home birth dad. Ida explained that this kind of diversity of voices would be extremely helpful in showing a broad base of public support for a midwifery licensure bill. Legislators have no reason to pass a law that will only benefit or protect a small “special interest group.” That is why our first task is to identify potential supporters beyond the obvious pool of home birth families. The names and contact information of friends, family, and neighbors who agree that women who want to birth at home should be able to choose a licensed, professional midwife to attend them and are willing to write or visit with a legislator to communicate their support for our bill need to be compiled in a database so that we can coordinate our efforts and show legislators that this issue is important to their constituents all across the state.

Ida also emphasized the importance of supporting and encouraging the core group of activists who will need to bear the lion’s share of work in getting a bill passed. To be successful, she explained, we will need to have someone at the Capitol every day that the legislators are in session, ready to seize any opportunity to inform, educate, and win support for our bill. This is a task that requires dedication, time, energy, and money and has a high potential for burnout. Appreciation and recognition of the sacrifice made by the primary players in the lobbying effort will mean a lot to them, especially if — as is frequently the case — it takes more than one season’s effort to get a bill passed.

2008 will be a year of preparation for the legislative effort, as we hope to introduce our bill in the 2009 legislative session. The key players: the Ohio Midwives Alliance (Ohio midwives’ professional organization), Ohio Friends of Midwives (a consumer group established in 1996 but largely inactive in recent years) and Ohio Families for Safe Birth (established last year and envisioned as a coalition group which could combine the efforts of all parties interested in midwifery legislation and other initiative supportive of the midwives’ model of care). The leadership of these groups needs to determine who will take responsibility for the various necessary organizational tasks as we work together for our common cause.

Meanwhile, everyone can be identifying potential supporters in their social networks. And for those who are able, this election year is a great time to establish a relationship with your representatives. Can you volunteer an hour or two to help with your house representative or senator’s re-election campaign? If your current legislator’s term is expiring, find out who is running to replace them. The Ohio State Legislature web page is the place to start to find your legislators’ names and contact information and whether they are up for re-election this fall. Take a minute to find out who your senator and house representative are if you don’t know already, see what bills they’ve sponsored in the past, and try to find a point of contact. When our midwifery bill comes up for a vote it will be our goal to have every legislator hear from as many as possible of his or her own constituents asking for their vote. So we need you and anyone else who is willing to help, and if you can start building bridges with your representatives now so that they remember you next year, so much the better!

If you missed the workshop and want more detailed information about the covered topics, you should definitely check out The North American Registry of Midwives Planninf for Legislation Handbook. Ida had spiral-bound copies available for $10 at the workshop,many of which went home with OMA and OFSB members, but the handbook is also available as a PDF file from NARM’s website.