Advocates Call on State and Federal Policy Makers to Prioritize Maternal and Infant Safety

WASHINGTON, D.C. (April 28, 2009)-Maternal and infant health advocates are calling on policy makers to take action to ensure that there are enough Certified Professional Midwives (CPMs), who are trained as experts in out-of-hospital delivery, to meet the needs of pregnant women in the event that a flu pandemic makes hospitals unsafe settings for the provision of maternity care.

“Hospitals filled to capacity with flu patients are unsafe and inaccessible places for healthy women to deliver their babies,” said Colette Bernhard, Vice President of Illinois Families for Midwifery. “Fewer than 3 percent of nurse-midwives have undergone the additional training needed to establish out-of-hospital practices, while legal and reimbursement barriers at the state and federal level prevent far too many Certified Professional Midwives, who already have the necessary training and equipment, to utilize their services to the fullest. Given the very real possibility of a flu pandemic, the need to fully incorporate CPMs into our health care system could not be more urgent.”

Certified Nurse-Midwives (CNMs), who are trained to practice in hospital settings, are legally authorized by all 50 states and are federally mandated Medicaid providers. CPMs are the only professional midwives in the United States whose educational and credentialing process requires them to develop the specialized skills necessary to safely deliver babies in private homes and in freestanding birth centers. However, CPMs are legally authorized to practice in just over half the states and are eligible for Medicaid reimbursement in fewer than a dozen states.

Recognizing the need for more midwives with expertise in out-of-hospital maternity care and risk assessment, as well as the ability to safely triage laboring women during a disaster, advocates called on state and federal policy makers to take immediate steps to safeguard maternal and infant health in preparation for a possible flu pandemic.

“First, all states need to get on board and license CPMs to practice legally,” said Russ Fawcett of The National Birth Policy Coalition. “But it is every bit as critical that our federal policy makers require Homeland Security to include CPMs-who function as mobile primary care facilities for pregnant women-in disaster planning at local, regional, and national levels and as eligible providers for the National Health Service Corps.”

In the wake of Hurricane Katrina, members of the White Ribbon Alliance for Safe Motherhood formed the National Working Group for Women and Infant Needs in Emergencies in the United States, and the group’s April 2007 report includes CPMs among those who can educate and train home-based delivery skills to institution-based birth providers.

The Big Push for Midwives is the first initiative of the National Birth Policy Coalition (NBPC), whose mission is to promote the autonomous practice of Certified Professional Midwives and Certified Nurse-Midwives and to ensure the availability of safe, evidence-based care during pregnancy, labor, birth, and postpartum. The Big Push is a nationally coordinated campaign to advocate for regulation and licensure of Certified Professional Midwives (CPMs) in all 50 states, the District of Columbia and Puerto Rico, and to push back against the attempts of the American Medical Association Scope of Practice Partnership
to deny American families access to legal midwifery care.

Through its work with state-level advocates, the Big Push is helping to build a new model of U.S. maternity care built on expanding access to out-of-hospital maternity care and CPMs, who provide affordable, quality, community-based care that is proven to reduce costly and preventable interventions as well as the rate of low-birth weight and premature births.

Media inquiries: Steff Hedenkamp (816) 506-4630, steff@thebigpushformidwives.org.

The BBC News has reported on a a new study from the Netherlands, published in the British Journal of Obstetrics and Gynecology, on the safety of home birth. The study is the largest of its kind to date, including 530,000 births, and compared midwife attended births to low-risk women both at home and in the hospital. The Netherlands has the highest rates of home birth in the industrialized world, with a third of women choosing to give birth at home.

The study determined that there was no difference in the rates of death or serious illness for mothers or babies between the home and hospital groups.

The Concord Monitor just published a lengthy article centered around Jeanne Browne, who offers home and birth center births to New Hampshire moms.

This paragraph was of particular interest:

Through a series of legislative measures, New Hampshire has welcomed and regulated certified midwifery. Midwives like Browne do not have medical or nursing degrees, but they are required to complete coursework and to spend time as apprentices to practicing midwives. They are governed by a state board of midwifery and are required to apply for recertification every two years. Insurance companies are required to reimburse midwives who assist with births outside of the hospital. “New Hampshire is a leader in this area and has been for a long time,” said Ida Darragh, the chairwoman of the North American Registry of Midwives, the group that certifies midwives nationally.

Even when legal, licensed home birth providers are available, many women’s ability to access them is limited by financial considerations. Health insurance providers may use ACOG’s policy on home birth as grounds for systematically denying coverage for home birth, even though the cost of a home birth is substantially less than for a normal hospital delivery. Private insurance providers which do not have an official policy in place on coverage for out-of-hospital maternity services may or may not cover home birth with an unlicensed provider, and usually, the family must pay their midwife out-of-pocket without knowing whether or not their insurance will provide reimbursement until weeks or months after the birth.

However, even Aetna, whose official policy is to refuse coverage for home birth, has to pay up in New Hampshire.

Earlier this month, Childbirth Connection released the results of “New Mothers Speak Out,” their 6-month post-partum follow-up study to the Listening To Mothers II Survey. It made headlines in the Wall Street Journal with some alarming findings:  Nine percent of the women surveyed screened positive for all the criteria of Post Traumatic Stress Disorder,  and twice that many showed some signs of PTSD.  Mothers who had experienced high rates of medical interventions were more likely to report signs of PTSD. These mothers were also more likely to describe their experience of childbirth as “feeling powerless in a threatening environment.”

There are some excellent obstetricians, family doctors, hospital-based midwives, and nurses who are caring for laboring women and new mothers in a way that is gentle, respectful, and empowering. There are also practitioners who are not even aware of the way their customary manner and routine procedures traumatize their patients. Furthermore, the hospital system itself is frequently percieved as a “threatening evironment” in which mothers (and fathers) justifiably “feel powerless.” The result is that mothers and babies are subjected to unnecessary procedures and interventions, and face a significant risk of coming out of their birth experience both physically and emotionally scarred.

Of the 150,784 Ohio births recorded by the Health Department in 2007, 44,860 babies - 29.75% - entered the world through a surgical incision. Cesarean section, like any major surgery, carries physical risks for both the mother and baby. The psychological and sociological implications of having 1/3 of all children born by cesarean - frequently in an atmosphere of tension, fear, and stress - are barely beginning to be explored. But we now know that, contrary to the prevailing view only a few decades ago, newborn and preborn babies are conscious, aware individuals whose early experiences have a significant impact. Though babies have limited means of communicating with their parents and caregivers and may never be able to verbally express or consciously retain the memories of their pre-birth and birth experiences, they are laying down somatic memories during this period which they will carry for the rest of their lives.

An Israeli news report today announced dramatically higher incidence of adult schizoprenia for babies whose mothers were only two months pregnant during the 6-day war in 1967. If exposure to maternal stress hormones so early in gestation has a demonstrable effect, what is the long-term result for the infants of those 9%-18% of mothers whose labor and birth experience makes them feel so powerless and so threatened that they respond in the same way as war and disaster survivors? How do resuscitations and NICU stays (more common in cesarean-born babies), to say nothing of the routine hospital procedures for healthy babies, impact the newborn psyche?

Frederic Leboyer brought to light the question of the newborn’s experience of medicalized childbirth more than thirty years ago, but his work, and subsequent research on newborn consciousness, has done little to change institutionalized newborn care. In 2008, women who seek a gentle birth experience - for their infant as well as for themself - frequently find that the only way to get the birth they want is to avoid the hospital.

Home birth opponents, including the AMA and ACOG, denigrate mothers for placing an “experience” over the health and safety of their baby. (It is ACOG’s official opinion that “Choosing to deliver a baby at home… is to place the process of giving birth over the goal of having a healthy baby,” though all available evidence indicates that planned home birth with a qualified attendant is a safe and reasonable choice for healthy women.) By framing the issue in these terms, pitting the process against the end result, they deny the increasing weight of evidence that the experience matters. Of course the most important goal is a healthy baby - but it is also clear that the process of childbirth profoundly impacts the mental health and well-being of both mothers and their babies. Women and families, no matter where they choose to give birth, need and deserve maternity care that promotes both a safe birth, a healthy mother and baby, and a non-traumatic (or perhaps even positive and empowering?) experience of childbirth.

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.”

Pennsylvania Certified Professional Midwife (CPM_ Diane Goslin, who was fined $11,000 by the State Medical board last year for unlicensed practice, has won her appeal. The court has reversed the Medical Board’s decision and ruled that midwifery is not the practice of medicine and that the medical board’s jurisdiction is only over certified nurse midwives (PA does not currently recognize the CPM credential). Hundreds of Amish families rallied in support of Goslin’s at her trial last year. See this site for more details as they become available.

From Columbus, this WOSU radio story highlights the growing popularity of water birth.

Seems like most of the news stories from the UK picked up by Google alerts are dealing with midwife shortages and preventable tragedies in understaffed maternity units. So it was very refreshing to read this story about the increase in home births.

This is a guest post from a “Post Modern Midwife.” 

21st century midwives who provide out of hospital maternity services are trained, educated primary care providers who often have relationships with physicians and other care providers to offer full scope care. A post modern midwife accesses technology as appropriate and consults in an independent fashion as necessary to provide evidence based care with great outcomes.

As the Big Push garners more and more visibility on a national mainstream level, and OFSB becomes more visible on a state level, there will be more citizens who see our publicity and legislative efforts and have visions of what I call “Little House on the Prairie birthin’”. We need to make clear that midwifery is not tribal woo woo, nor the practice of medicine, but its own independent field grounded in evidence-based practice.

Women with major health problems such as heart disease and type I diabetes which can cause serious complications in pregnancy and labor are not good candidates for out-of-hospital birth and will either self screen out or a midwife would screen them as too high risk for an out-of-hospital birth.

As well, every prenatal visit with a midwife is in fact a screening visit, looking for potential problems that could risk a women out of home birth. Because of this very intense screening process and preventative model of care, families with major problems or risk factors are not tossing the dice on a birth outside of a hospital.

Midwives monitor mother and baby via intermittent fetal monitoring and other assessment means, just as a hospital does. Problems do not fall out of the sky, they develop with plenty of time for response. The Obstetrical Standard of Care is “Thirty minutes from Decision to Incision”. Out-of-hospital birth with a qualified attendant in relationship with her community health services provides the ability to adhere to this standard.

It is important for the general citizenry to understand that the way to protect families is to provide regulation and mandate minimum standards of training and experience for midwives to ensure public safety. No one is trying to convince anyone who doesn’t want to have a home birth, we are just trying to show policy makers that the best way to protect families who choose out-of-hospital birth is to ensure that their providers are in a regulatory framework.

A powerful medical lobby with strong financial backing opposes legislation which would legalize the autonomous practice of Certified Professional Midwives (CPMs) and protect birth choices for women and families. In many states where the practice of midwifery is not yet legal, midwifery bills are proposed in the state legislature every year. Midwives and parents work hard to gain support with limited resources. When their bills, year after year, fail to pass or even to reach the floor for a vote, the reason given is always the same.

“I understand the choice issue, but the only issue for the Department of Public Health is the safety of the mom and the baby,” Alabama State Health Officer Dr. Don Williamson said in a recent newspaper article. (The article on the Anniston Star website is for subscribers only, but the full text can be found here, after scrolling down past the “daily news” links.)

Safety was also the theme of ACOG’s recent anti-homebirth press release, which warned mothers of dire and catastrophic consequences that might result from birthing outside of the hospital and asserted that “choosing to deliver at home… is to place the process of giving birth over the goal of having a healthy baby.”

No evidence is given to support this claim, because none exists. In fact, the existing evidence overwhelmingly demonstrates the safety and excellent outcomes of home birth with professional midwives for normal, healthy pregnancies. This evidence — including the CPM 2000 study, a prospective study of over 5400 planned home births which was published in the highly respected, peer-reviewed British Medical Journal — is dismissed by ACOG as “limited” and not “scientifically rigorous.” 

Ironically, ACOG’s opposition to out-of-hospital birth and animosity toward midwifery itself poses a great danger to the health and well-being of home-birthing mothers and their babies. ACOG’s statement is not entirely mistaken: obstetricians do offer expertise and surgical interventions that are life-saving for the very few mothers and babies who genuinely need them. While 80-90% of planned home births are safely completed at home, some mothers need to transfer to the hospital in order to access necessary interventions. In the CPM 2000 study, only 3.4% of women experienced a hospital transfer that was considered by the midwife to be “urgent”. But in those rare, urgent cases, professional communication between midwife and obstetrician and smooth and well-orchestrated transfer of care may make a critical difference to the health and safety of both mother and baby.

For this reason, countries such as Great Britain and Canada, where home birth has been well-integrated into the health care system, put a great emphasis on coordination between the home birth midwife, emergency response services, and hospital obstetric departments as a key component of safe out-of-hospital birth. For example, in British Columbia, Canada, a midwife attending a home birth alerts the hospital when she is called to the labor so that hospital staff will be aware and prepared in case their services become necessary. Midwives are trained to use and legally carry stabilizing medications and other emergency equipment to treat the mother or baby until they reach the hospital. If an emergency transfer becomes necessary, the midwife remains the most responsible caregiver during the ambulance transport. Obstetricians and midwives interact as colleagues to achieve the best possible outcome for both mother and baby in an emergency situation.

By contrast, the recent raid of an Ohio midwife’s home described in last week’s City Beat article was the result of a complaint filed against the midwife when she transported a laboring woman to the hospital. The midwife in question has many years of experience and, as a CPM, has obtained a rigorous, national credential which is legally recognized in many other states. The transfer was necessary for the health and safety of the mother and baby; the midwife acted appropriately in bringing them to the hospital; and a good outcome was achieved because of the midwife’s timely transfer. Had the mother been without a skilled attendant monitoring her labor at home, the situaton could have been tragic.

This midwife now faces prosecution, not because of any negligence of action on her part, but because a doctor believed that the birth should not have been attempted at home to begin with. Other women who would have benefitted from her skill and expertise may now face the unwelcome choice of birthing at home unattended because their midwife is barred from practice. Communication between midwife and physician is a vital step when transfer of care is necessary, but now, midwives attending women who need hospital care may be afraid to accompany a laboring woman to the hospital lest they also come under fire.

The prosecution of unlicensed midwives, though undertaken by the State, is initiated and urged on by the same medical interests that work tirelessly to oppose legislation that would enable midwives to practice legally in Ohio and elsewhere. While there are individual physicians who work with midwives in a collegial manner, respect their abilities, and support their continued provision of a much-needed service, the profession as a body seems intent on stamping out the “competition.”

In Ohio, nearly 1000 babies are born at home each year. Despite ACOG’s best efforts, families continue to choose home birth. If the safety of mother’s and babies was truly ACOG’s goal, they would take a position of working with midwives to ensure that no communication gaps or professional animosity prevents access to needed obstetrical expertise for those who cannot safely continue a planned home birth.  ACOG has systemically chosen to place their political agenda and business concerns above “the goal of having a healthy baby.”